Preoperative Evaluation of Neurosurgical Patients

All patients undergoing noncardiac surgery are exposed to a risk of adverse surgical, anesthesia, and medical complications. Unlike procedural risk, the medical risks are often modifiable, and therefore stratification of patient medical risk prior to surgery forms the basis of reducing postoperative morbidity, mortality, and length of hospital stay. Patients undergoing neurosurgical procedures pose several unique challenges and require special focus. This patient subgroup also carries a high risk for thrombotic events from immobilization and interruption of pharmacological prophylaxis. Cardiovascular events occurring in the postoperative period are the primary focus of risk assessment in noncardiac surgery, and this is also true for neurosurgical procedures, many of which are performed emergently or urgently. The authors discuss cardiovascular risk stratification based on a patient’s functional status, exercise capacity, and prior cardiac history. They review risk assessment scales to aid decision-making and how to select patients for further testing. Bleeding complications can be devastating and are of great concern in neurosurgery; the chapter discusses assessment of bleeding risk using an approach that combines basic laboratory testing with a thorough history and physical exam. The authors address the risk of thromboembolic events in neurosurgery patients and provide recommendations for preoperative assessment and postoperative prophylaxis. This chapter covers a broad approach from the point of view of a hospitalist physician evaluating a patient preoperatively, including a review of current guidelines, recommendations, and future directions on risk stratification for cardiac, thrombotic, and bleeding complications.