Perioperative Stroke: Mechanisms, Risk Stratification, and Management

Perioperative stroke, defined as a cerebrovascular event occurring during surgery or within 30 days postoperatively, remains a devastating complication associated with substantial morbidity, disability, mortality, and increased healthcare utilization. Although overall incidence is relatively low—up to 1% in most surgical populations—it is significantly elevated in cardiac, major vascular, and neurosurgical procedures, often exceeding 5%. The rising prevalence of perioperative stroke, primarily driven by an aging surgical population burdened by multiple chronic vascular conditions and increasingly eligible for high-risk surgical interventions, underscores the urgency of optimizing preventive and management strategies. This review synthesizes insights into patient- and procedure-related risk factors, highlighting the intricate interplay of embolic, thrombotic, and hypoperfusion mechanisms underpinning perioperative ischemic strokes. Key patient-specific risks include advanced age, recent cerebrovascular events, atrial fibrillation, carotid stenosis, and chronic cardiovascular comorbidities. Procedural factors, such as the type and complexity of surgery, intraoperative hypotension, and vascular manipulations, further modulate stroke risk. Emphasizing an evidence-based approach to risk mitigation, this review examines preoperative risk stratification, intraoperative techniques designed to minimize cerebral embolization and preserve adequate perfusion, and structured postoperative protocols aimed at rapid stroke detection. Acute management complexities are also discussed, with careful consideration of intravenous thrombolysis and mechanical thrombectomy in the postoperative setting. Finally, gaps in current guidelines and promising areas for future research are identified, advocating a multidisciplinary approach involving neurology, surgery, anesthesiology, and allied specialties to enhance patient outcomes and reduce the perioperative stroke burden.