Perioperative stroke - NYSORA

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Perioperative stroke

Learning objectives

  • Describe the definition and risk factors of perioperative stroke
  • Diagnose perioperative stroke
  • Manage perioperative stroke


  • Perioperative stroke is a devastating complication of surgery
  • Defined as an ischemic or hemorrhagic brain infarction that occurs during surgery or within 30 days of surgery
  • Overt stroke: Acute brain infarct with clinical manifestation lasting longer than 24 hours
  • Covert stroke: Infarct that is not recognized at the time of onset
  • Incidence 0.1-1.9%
  • Higher morbidity and mortality rates compared to stroke unrelated to surgery

Risk factors

Patient factorsSurgical factors
Increasing ageThoracic surgery
History of prior stroke or TIATransplant surgery
HypertensionEndocrine surgery
History of atrial fibrillationBurn surgery
Valvular diseaseOtolaryngology surgery
Cardiovascular diseaseHemicolectomy
Renal disease
Diabetes mellitus
Smoker or COPD
Patent foramen ovale
Migraine with or without aura


perioperative stroke, carotid stenosis, carotid endarterectomy, carotid stenting, anticoagulation, warfarin, atrial fibrillation, aspirin, beta-blocker, electrolyte, blood pressure, hypotension, metropolol, hypoglycemia, hyperglycemia, statin, hypocarbia

Postoperative evaluation

  • The modified National Institutes of Health Stroke Scale (NIHSS) can be used to assess patients with suspected perioperative stroke
    • 0 = no stroke
    • 1–4 = minor stroke
    • 5–15 = moderate stroke
    • 15–20 = moderate/severe stroke
    • 21–42 = severe stroke

Level of consciousness questions0 = Answers both correctly
1 = Answers one correctly
2 = Answers neither correctly
Level of consciousness commands0 = performs both tasks correctly
1 = performs one task correctly
2 = perform neither task
Gaze0 = Normal
1 = Partial gaze palsy
2 = Total gaze palsy
Visual fields0 = No visual loss
1 = Partial hemianopsia
2 = Bilateral hemianopsia
Left arm0 = No drift
1 = Drift before 10 s
2 = Fails before 10 s
3 = No effort against gravity
4 = No movement
Right armSame scoring as left arm
Left legSame scoring as left arm
Right legSame scoring as left arm
Sensory0 = Normal
1 = Abnormal
Language0 = Normal
1 = Mild aphasia
2 = Severe aphasia
3 = Mute
Neglect0 = Normal
1 = Mild
3 = Severe


  • Early diagnosis is key (<25 min after symptom onset)
    • Emergency non-contrast CT scan to discriminate between ischemic stroke from intracranial hemorrhage and nonvascular causes of neurologic symptoms (e.g., tumors)
    • Multimodal CT and MRI may provide additional information
  • Emergency treatment (<60 min after symptom onset):
    • Move patient to acute stroke unit
    • Correction of postoperative causes of hypotension (volume depletion, blood loss, myocardial ischemia, arrhythmias)
    • Treat fever 
    • Cardiac monitoring and treatment of arrhythmias should they occur
    • Intravenous thrombolysis may be beneficial 
    • Intraarterial thrombolysis can be administered within 6 hours of symptom onset, either alone or in conjunction with intravenous thrombolysis
    • Aspirin can be used when deemed safe
    • Mechanical thrombectomy in patients with large vessel occlusion, between 6 and 24 hours after symptom onset

Suggested reading

  • Ng JLW, Chan MTV, Gelb Adrian W, Warner David S. Perioperative Stroke in Noncardiac, Nonneurosurgical Surgery. Anesthesiology. 2011;115(4):879-90.
  • Lindberg AP, Flexman AM. Perioperative stroke after non-cardiac, non-neurological surgery. BJA Educ. 2021;21(2):59-65.
  • Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, et al. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation. 2021;143(19):e923-e46.

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