Top Things to Know: Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations

Published: August 26, 2020

  1. This statement identifies pre-operative, intraoperative, and postoperative strategies aimed at reducing the risk of perioperative stroke and improving outcomes for patients who experience a perioperative stroke.
  2. Perioperative stroke is associated with an increased length of hospital stay, a 5 to 10-fold greater likelihood of in-hospital mortality and increased risk of cognitive decline at 1 year after surgery.
  3. Stroke is a feared complication of cardiac surgery, and data has shown that approximately 81% of patients would sacrifice longevity for freedom from stroke.
  4. Age, hypertension, hyperlipidemia, diabetes, smoking, heart failure, renal disease, atrial fibrillation, and prior stroke, or transient ischemic attack, are all factors that put a patient at risk for perioperative stroke.
  5. Many factors can increase risk for perioperative stroke; information on incidence, mechanisms, diagnosis, and treatment help minimize neurological risk for patients.
  6. Intra-operative stroke occurs during surgery and is diagnosed upon emergence from anesthesia, while post-operative stroke occurs in the early (first week after surgery) or late post-operative period after a variable period of normal neurological function.
  7. Thromboembolism accounts for 70-80% of intra-operative strokes and is considered to result from surgical aortic manipulation from proximal anastomosis.
  8. To help reduce intra-operative stroke, pre- and intra-operative screening strategies can help guide surgical techniques.
  9. The risk of post-operative atrial fibrillation (POAF) is 27-40% following cardiac surgery. Typically, anticoagulation should be started within 12-48 hours after surgery in patients with POAF.
  10. If neurological changes occur, indicating a possible post-operative stroke, a code stroke should be called to activate the team of experts in stroke care to facilitate immediate imaging and urgent medical or endovascular interventions as appropriate for the patient.


Gaudino M, Benesch C, Bakaeen F, DeAnda A, Fremes SE, Glance L, MesseĢ SR, Pandey A, Rong LQ; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; Stroke Council; and Council on Cardiovascular and Stroke Nursing. Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a scientific statement from the American Heart Association [published online ahead of print August 26, 2020]. Circulation. doi: 10.1161/CIR.0000000000000885.