Stroke in Surgical Patients: A Narrative Review

Phillip E. Vlisides, M.D.; Laurel E. Moore, M.D.


Anesthesiology. 2021;134(3):480-492. 

In This Article

Abstract and Introduction


Stroke is associated with substantial morbidity and mortality. The aim of this review is to provide an evidence-based synthesis of the literature related to perioperative stroke, including its etiology, common risk factors, and potential risk reduction strategies. In addition, the authors will discuss screening methods for the detection of postoperative cerebral ischemia and how multidisciplinary collaborations, including endovascular interventions, should be considered to improve patient outcomes. Lastly, the authors will discuss the clinical and scientific knowledge gaps that need to be addressed to reduce the incidence and improve outcomes after perioperative stroke.


Postoperative stroke is associated with delayed recognition, infrequent intervention, and high rates of mortality and disability.[1,2] In fact, the risk of death or major disability at discharge exceeds 80% for noncardiac surgery patients, and long-term care is frequently required.[1] Epidemiologic data also suggest that the incidence of perioperative stroke may be increasing.[3] The risk of stroke ranges from approximately 0.1 to 2% depending on risk factors,[4] although clinically unrecognized (i.e., covert) stroke may occur in 7% of noncardiac surgery patients 65 yr and older.[5] Furthermore, those with clinically unrecognized stroke demonstrate an increased risk of long-term cognitive impairment, similar to cognitive declines observed after clinically detected stroke.[5,6] As such, perioperative stroke occurs with considerable frequency and is associated with substantial morbidity and mortality.

Our understanding of perioperative stroke has advanced over recent years. Details regarding stroke etiology and anatomical distributions have been reported,[7–10] and multiple risk prediction models have been developed.[11] Strategies for preoperative optimization have been identified,[12,13] and the role of endovascular thrombectomy has been clarified for patients with large-vessel occlusion.[14–18] Such advances in knowledge have informed and motivated changes to perioperative guidelines, particularly with respect to surgical timing,[19] anticoagulation strategies,[19–21] and acute stroke management.[22] The purpose of this narrative review is to provide evidence-based updates with respect to perioperative stroke, with a focus on the noncardiac surgery setting. Because the majority of perioperative strokes appear to be ischemic,[7–10] ischemic perioperative stroke will be the primary focus of this review. We will also describe the public health consequences of perioperative stroke and areas in need of continued study to aid in the prevention, identification, and optimization of treatment after perioperative stroke to improve patient outcomes.