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Perioperative care of the surgical patient with neurologic disease

Geno J Merli, MD, FACP, FHM
Rodney D Bell, MD
Section Editor
Michael J Aminoff, MD, DSc
Deputy Editors
Janet L Wilterdink, MD
Marianna Crowley, MD


Perioperative care of the patient with neurologic disease is a challenge for the medical consultant. The most important considerations are the management of medications used to treat neurologic disorders, an understanding of the pathophysiologic mechanism of these disorders, and evaluation of new neurologic changes that occur perioperatively. The more commonly encountered neurologic disorders and their perioperative management are reviewed here.


At least one million people in the United States have recurrent seizures or epilepsy [1]. Most patients with epilepsy are managed with antiepileptic drugs (AEDs). (See "Overview of the management of epilepsy in adults".)

People with epilepsy appear to be at significant risk of postoperative complications, some of which are attributed to epilepsy and some to comorbidities associated with epilepsy. In one retrospective database study, 13,103 patients with epilepsy had a higher rate of postoperative complications compared to those without epilepsy (OR = 2) [2]. Stroke was identified as the most significant postoperative complication in patients with epilepsy.

Causes of seizures in perioperative patients — Seizures can occur during the perioperative period due to a number of causes:


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Literature review current through: Sep 2017. | This topic last updated: Sep 10, 2014.
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  1. Hauser WA, Kurland LT. The epidemiology of epilepsy in Rochester, Minnesota, 1935 through 1967. Epilepsia 1975; 16:1.
  2. Chang CC, Hu CJ, Lam F, et al. Postoperative adverse outcomes in surgical patients with epilepsy: a population-based study. Epilepsia 2012; 53:987.
  3. Evans DE. Anaesthesia and the epileptic pateint. A review. Anaesthesia 1975; 30:34.
  4. Bell RD. Perioperative seizures in decision making. In: Anesthesiology, Bready LL, Smith RB (Eds), BC Decker, Toronto 1987. p.224.
  5. Modica PA, Tempelhoff R, White PF. Pro- and anticonvulsant effects of anesthetics (Part I). Anesth Analg 1990; 70:303.
  6. Benish SM, Cascino GD, Warner ME, et al. Effect of general anesthesia in patients with epilepsy: a population-based study. Epilepsy Behav 2010; 17:87.
  7. Sampliner R, Iber FL. Diphenylhydantoin control of alcohol withdrawal seizures. Results of a controlled study. JAMA 1974; 230:1430.
  8. Bell R, Merli G. Perioperative assessment and management of the surgical patient with neurologic problems. In: Medical Management of the Surgical Patient, Merli G, Weitz H (Eds), Saunders Elsevier, Philadelphia 2008. p.535.
  9. Lee ST, Lui TN, Chang CN, et al. Prophylactic anticonvulsants for prevention of immediate and early postcraniotomy seizures. Surg Neurol 1989; 31:361.
  10. Shaw MD, Foy PM. Epilepsy after craniotomy and the place of prophylactic anticonvulsant drugs: discussion paper. J R Soc Med 1991; 84:221.
  11. Epilepsy Foundation of America. Origins and classification of epilepsia. In: Basic statistics on the epilepsia, FA Davis, Philadelphia 1975. p.16.
  12. Penry JK, Newmark ME. The use of antiepileptic drugs. Ann Intern Med 1979; 90:207.
  13. Seizure Disorders. A Pharmacological Approach to Treatment, Wilder BJ, Bruni M (Eds), Raven Press, New York 1981.
  14. AHFS Drug Information 2000, American Society of Health-System Pharmacists Inc. Bethseda, MD, 2000.
  15. Goetz CG, Lutge W, Tanner CM. Autonomic dysfunction in Parkinson's disease. Neurology 1986; 36:73.
  16. Mutch WJ, Strudwick A, Roy SK, Downie AW. Parkinson's disease: disability, review, and management. Br Med J (Clin Res Ed) 1986; 293:675.
  17. Meir, M. Mechanism leading to hypoventilation in extrapyramidal disorders with special reference to Parkinson's disease. J Am Geriatr Soc 1976; 15:230.
  18. Paulson GD, Tafrate RH. Some "minor" aspects of parkinsonism, especially pulmonary function. Neurology 1970; 20:14.
  19. Abel M, Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med 2002; 69:31.
  20. Wittbrodt ET. Drugs and myasthenia gravis. An update. Arch Intern Med 1997; 157:399.
  21. Gronert GA. Malignant hyperthermia. Anesthesiology 1980; 53:395.
  22. Sundt TM, Sandok BA, Whisnant JP. Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc 1975; 50:301.
  23. Jørgensen ME, Torp-Pedersen C, Gislason GH, et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA 2014; 312:269.
  24. Bell R, Merli G. Perioperative assessment and management of the surgical patient with neurologic problems. In: Medical Management of the Surgical Patient, Merli G, Weitz H (Eds), W. B. Saunders, Philadelphia 1998. p.283.
  25. Hart R, Hindman B. Mechanisms of perioperative cerebral infarction. Stroke 1982; 13:766.
  26. Kartchner MM, McRae LP. Carotid occlusive disease as a risk factor in major cardiovascular surgery. Arch Surg 1982; 117:1086.
  27. Evans BA, Wijdicks EF. High-grade carotid stenosis detected before general surgery: is endarterectomy indicated? Neurology 2001; 57:1328.
  28. Ropper AH, Wechsler LR, Wilson LS. Carotid bruit and the risk of stroke in elective surgery. N Engl J Med 1982; 307:1388.
  29. Kartchner MM, McRae LP. Guidelines for noninvasive evaluation of asymptomatic carotid bruits. Clin Neurosurg 1981; 28:418.
  30. David TE, Humphries AW, Young JR, Beven EG. A correlation of neck bruits and arteriosclerotic carotid arteries. Arch Surg 1973; 107:729.
  31. Rea T. The role of carotid bruit in screening for carotid stenosis. Ann Intern Med 1997; 127:657.
  32. Heyman A, Wilkinson WE, Heyden S, et al. Risk of stroke in asymptomatic persons with cervical arterial bruits: a population study in Evans County, Georgia. N Engl J Med 1980; 302:838.
  33. Wolf PA, Kannel WB, Sorlie P, McNamara P. Asymptomatic carotid bruit and risk of stroke. The Framingham study. JAMA 1981; 245:1442.
  34. Reed GL 3rd, Singer DE, Picard EH, DeSanctis RW. Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits. N Engl J Med 1988; 319:1246.
  35. Jones EL, Craver JM, Michalik RA, et al. Combined carotid and coronary operations: when are they necessary? J Thorac Cardiovasc Surg 1984; 87:7.
  36. Hines GL, Scott WC, Schubach SL, et al. Prophylactic carotid endarterectomy in patients with high-grade carotid stenosis undergoing coronary bypass: does it decrease the incidence of perioperative stroke? Ann Vasc Surg 1998; 12:23.
  37. Gott JP, Thourani VH, Wright CE, et al. Risk neutralization in cardiac operations: detection and treatment of associated carotid disease. Ann Thorac Surg 1999; 68:850.
  38. Blacker DJ, Flemming KD, Wijdicks EF. Risk of ischemic stroke in patients with symptomatic vertebrobasilar stenosis undergoing surgical procedures. Stroke 2003; 34:2659.
  39. Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med 1986; 315:860.
  40. Graor RA, Hetzer NR. Management of coexistent carotid artery and coronary artery disease. Stroke 1988; 19:1441.
  41. Whisnant JP, Sandok BA, Sundt TM Jr. Carotid endarterectomy for unilateral carotid system transient cerebral ischemia. Mayo Clin Proc 1983; 58:171.
  42. Francis J, Kapoor WN. Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc 1992; 40:601.
  43. Levkoff SE, Evans DA, Liptzin B, et al. Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992; 152:334.
  44. Murray AM, Levkoff SE, Wetle TT, et al. Acute delirium and functional decline in the hospitalized elderly patient. J Gerontol 1993; 48:M181.
  45. Rockwood K. Delays in the discharge of elderly patients. J Clin Epidemiol 1990; 43:971.
  46. Cole MG, Primeau F, McCusker J. Effectiveness of interventions to prevent delirium in hospitalized patients: a systematic review. CMAJ 1996; 155:1263.