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Perioperative stroke

Nature Reviews Disease Primers volume 10, Article number: 3 (2024) Cite this article

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Abstract

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1–0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1–5% range in patients undergoing cardiac surgery and in the 1–10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

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Fig. 1: Incidence (%) of 30-day postoperative stroke according to surgical category.
Fig. 2: Forest plot and adjusted odds ratio of predictors for 30-day postoperative stroke complication.
Fig. 3: Aetiologic contributions to perioperative stroke.
Fig. 4: Neuroimaging of two patients with large postoperative intracerebral haemorrhages.
Fig. 5: Clinical pathways for suspected perioperative stroke.
Fig. 6: Neuroimaging of a large postoperative thromboembolic stroke of the left middle cerebral artery territory managed with mechanical thrombectomy.

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Author information

Authors and Affiliations

  1. Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia

    Jonathon P. Fanning

  2. Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia

    Jonathon P. Fanning

  3. Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia

    Jonathon P. Fanning

  4. The George Institute for Global Health, Sydney, New South Wales, Australia

    Jonathon P. Fanning

  5. Nuffield Department of Population Health, University of Oxford, Oxford, UK

    Jonathon P. Fanning & Richard Bulbulia

  6. Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia

    Bruce C. V. Campbell

  7. Department of Medicine, University of Melbourne, Parkville, Victoria, Australia

    Bruce C. V. Campbell

  8. Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia

    Bruce C. V. Campbell

  9. Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK

    Richard Bulbulia

  10. National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA

    Rebecca F. Gottesman

  11. Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea

    Sang-Bae Ko

  12. Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA

    Thomas F. Floyd

  13. Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

    Steven R. Messé

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  2. Bruce C. V. Campbell
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  6. Thomas F. Floyd
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  7. Steven R. Messé
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Contributions

J.P.F. performed the literature search, wrote the first draft, designed the figures, and finalized and submitted the Primer. All authors discussed and approved the strategy of the Primer, its overall content and organization, and carefully assessed and revised the entire manuscript, when appropriate, including its figures, tables and references.

Corresponding author

Correspondence to Jonathon P. Fanning.

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Competing interests

S.R.M. is co-founder of Neuralert Technologies, which is developing a continuous non-invasive monitor to detect stroke rapidly. He is on the patient selection committee for the Terumo RelayBranch trial, the steering committee for the Boston Scientific PROTECT-TAVR trial, the data safety monitoring board for the WL Gore REDUCE PFO closure post-marketing study and receives research support from WL Gore for a prospective study of outcomes from ascending aortic repair. T.F.F. is founder of NFOSYS, Inc., which is involved in the development of minimally invasive devices for the monitoring of spinal cord and brain blood flow and oxygenation. The other authors declare no competing interests.

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Nature Reviews Disease Primers thanks C. Benesch, D. Dippel, A. Flexman and P. Thirumala for their contribution to the peer review of this work.

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Fanning, J.P., Campbell, B.C.V., Bulbulia, R. et al. Perioperative stroke. Nat Rev Dis Primers 10, 3 (2024). https://doi.org/10.1038/s41572-023-00487-6

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