Neurological complications: prevention and management

Perioperative neurological complications are common and potentially devastating, resulting in life-changing and life-limiting sequelae. Delirium is the most commonly encountered complication; pre-emptive pharmacological intervention has not been shown to consistently prevent delirium, and research findings are mixed. Postoperative cognitive dysfunction is a controversial diagnosis of subtle cognitive decline with no agreed treatment. Stroke risk is generally low in most surgical settings but can rise 20-fold in patients with a previous stroke. Clinical dilemmas arise when balancing improving stroke-risk profile by delaying surgery against the risk of deleterious outcomes from such delays. Parkinson disease's treatment must continue throughout the perioperative period as abrupt cessation risks the development of the life-threating neuroleptic malignant-like syndrome. The enteral route for dopaminergic therapy is preferred where possible. Myasthenia gravis management should be optimized in partnership with a patient's neurologist before surgery. Neuromuscular blocking agents should be used with care. Anti-seizure medication should be continued perioperatively and be given parentally if required, particularly as surgery can lower the seizure threshold. Perioperative peripheral nerve injuries can result in significant morbidity and are a common source of litigation.