In an elderly patient who underwent cataract surgery under intravenous sedation with mean arterial pressure maintained at ≥65 mm Hg and now has an acute right middle cerebral artery infarct, is the stroke more likely embolic than hypoperfusion, and what immediate diagnostic work‑up and secondary‑prevention measures should be undertaken?

Oo, ang right MCA infarct ay malamang na embolic, hindi hypoperfusion

Sa isang elderly patient na sumailalim sa cataract surgery na may MAP ≥65 mmHg at ngayon ay may acute right MCA infarct, ang stroke ay thromboembolism ang pinaka-probable na sanhi (70-80% ng peri-operative strokes), hindi hypoperfusion. 1

Bakit Hindi Ito Hypoperfusion

• Ang MAP ≥65 mmHg ay sapat na para protektahan ang cerebral perfusion at ito ang universal na minimum threshold para sa organ perfusion sa non-cardiac surgery. 1
• Ang hypoperfusion-related strokes ay bumubuo lamang ng 20-30% ng peri-operative strokes at nangyayari lang kapag ang MAP ay bumagsak sa ibaba ng autoregulatory threshold, hindi kapag maintained ito sa ≥65 mmHg. 2, 1
• Ang watershed o border-zone infarcts ang imaging pattern ng hypoperfusion strokes, hindi ang focal MCA territory infarct. 1
• Ang IV sedation para sa cataract surgery ay hindi associated sa increased stroke risk kumpara sa general anesthesia at maaaring mas mababa pa ang hypotension incidence. 1

Bakit Ito Thromboembolism

• Ang thromboembolism ay responsable sa 70-80% ng lahat ng peri-operative strokes, making it the dominant mechanism. 2, 1
• Ang focal MCA territory infarct sa imaging ay strongly suggests embolic mechanism, hindi hypoperfusion. 1
• Ang early postoperative stroke (within 7 days) ay primarily driven ng new-onset atrial fibrillation at thromboembolism mula sa cardiac o arterial sources. 2, 1
• Ang elderly patients (≥65 years) ay may increased baseline thromboembolic risk dahil sa underlying cardiovascular disease, carotid stenosis, o intracranial atherosclerosis—kahit walang prior neurologic symptoms. 1

Immediate Diagnostic Work-up

Cardiac evaluation:

• Kumuha ng ECG at mag-initiate ng continuous telemetry para i-detect ang new-onset atrial fibrillation—ang leading cause ng early postoperative stroke. 2, 1
• Mag-perform ng transthoracic o transesophageal echocardiography para i-identify ang cardiac thrombus, valvular pathology, o patent foramen ovale bilang potential embolic sources. 1

Vascular imaging:

• Mag-image ng carotid arteries at intracranial vessels gamit ang CT-angiography o MR-angiography para i-assess ang atherosclerotic stenosis o acute thrombosis. 1
• I-review ang infarct morphology: focal cortical o large subcortical lesions ay nag-point sa embolism; border-zone/watershed patterns ay nag-suggest ng hypoperfusion. 1
• Ang multiple territorial infarcts o "embolic shower" pattern sa imaging ay strongly supports cardio-embolic o artery-to-artery embolic mechanism. 1

Secondary Prevention Measures

Anticoagulation kung may atrial fibrillation:

• Kung na-detect ang new-onset AF, mag-initiate ng anticoagulation therapy para sa secondary stroke prevention. 1

Antiplatelet therapy kung atherosclerotic disease:

• Kung ang source ay atherosclerotic (carotid stenosis, intracranial atherosclerosis), mag-initiate ng antiplatelet therapy. 1

Blood pressure management:

• I-maintain ang optimal blood pressure control, pero huwag mag-assume na ang anesthetic technique o sedation ang dahilan ng stroke kung walang documented prolonged hypotension (MAP <65 mmHg). 1

Critical Pitfall na Iwasan

• Huwag i-attribute ang peri-operative stroke sa anesthesia o sedation kung walang documented intra-operative hypotension (MAP <65 mmHg for prolonged periods)—ito ay misdirects care at nag-delay ng appropriate secondary prevention. 1
• Ang pag-blame sa anesthetic technique ay nag-divert ng attention mula sa true etiology (thromboembolism o underlying cerebrovascular disease) at nag-delay ng implementation ng tamang secondary prevention measures. 1
• Ang prompt, comprehensive stroke work-up—including cardiac rhythm monitoring, echocardiography, at vascular imaging—ay dapat gawin agad para ma-identify ang embolic source at ma-guide ang secondary prevention. 1