Perioperative Evaluation and Care of Patients With Mild to Moderate Cerebrovascular Disease: It’s Time to Develop Treatment Guidelines!
For patients undergoing noncardiac surgery, clear recommendations for the perioperative evaluation and care of cardiovascular disease are defined in the guidelines of the American College of Cardiology/American Heart Association and the European Society of Cardiology/European Society of Anesthesiologists.1,2 These clinical practice guidelines include directives to manage preexisting severe cerebrovascular disease (eg, stroke), but specific guidelines how to best treat patients with mild or moderate cerebrovascular disease (eg, mild cognitive impairment, onset Alzheimer’s disease) are missing so far.
Cerebrovascular disease is associated with sclerosis of the cerebral vasculature, reduced cerebrovascular elastance, reduced cerebral perfusion (particularly respecting the watershed regions such as the cerebral white matter), and potentially disturbed cerebrovascular autoregulation.3 The observation that patients with cardiovascular disease have a high risk for myocardial mortality and morbidity suggests that patients with cerebrovascular disease may share an increased risk for adverse cerebral outcomes (eg, postoperative cognitive decline, delirium, stroke). The main purpose is to identify patients in early stages of cerebrovascular disease. Although clinical stages of heart failure are already established (eg, New York Heart Association classification, echocardiography, angiography, biomarkers), the evaluation of the onset of cerebrovascular dysfunction still remains difficult. For instance, the minimental state examination or the Mini-Cog may allow the assessment of cognitive function preoperatively; however, such investigation as part of the clinical routine remains a challenge.4
Recent research of cerebrovascular disease shows that preexisting cerebral white matter damage may have a major impact on the pathogenesis of age-dependent and postoperative cognitive dysfunction.5 Various modern techniques of cerebral monitoring (eg, transcranial Doppler ultrasound, near-infrared spectroscopy, and electroencephalography) further suggest that preexisting cerebrovascular disease may reduce cerebral perfusion, impair cerebrovascular autoregulation, increase cerebral resistance, decrease cerebral regional hemoglobin oxygen saturation, and may alter cerebral baseline electrical activity. Subsequent research in the field of neuroanesthesia and neurocritical care may allow us to implement guidelines for the perioperative care of patients with cerebrovascular disease to improve cerebral and overall patient outcome.