The following are key points to remember about a Scientific Statement from the American Heart Association/American Stroke Association on perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, non-neurological surgery:

1. Perioperative stroke is a devastating complication in patients undergoing noncardiac, non-neurological surgery. This scientific statement reviews established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke.
2. Perioperative stroke can be defined as any embolic, thrombotic, or hemorrhagic cerebrovascular event with motor, sensory, or cognitive dysfunction lasting at least 24 hours, occurring intraoperatively or within 30 days after surgery.
3. All patients undergoing evaluation before surgery should be assessed for perioperative stroke risk in terms of key risk factors (age, renal disease, and history of transient ischemic attack/stroke) with additional emphasis on timing of surgery relative to prior stroke, overall cardiovascular risk, and type of surgery planned. The presence of a patent foramen ovale may also be associated with higher perioperative stroke risk. Clinicians should use the web-based American College of Surgeons surgical risk calculator https://riskcalculator.facs.org/RiskCalculator to identify patients with elevated risks of perioperative stroke.
4. If history of stroke exists, consider delaying elective surgery at least 6 months and preferably 9 months from time of incident stroke. Consider nonsurgical treatment in discussion with the patient and caregivers as an alternative to surgery in patients with elevated risk of stroke.
5. It is recommended to perform carotid revascularization (carotid endarterectomy vs. carotid artery stenting) in patients with symptomatic (stroke or transient ischemic attack within last 6 months) carotid artery stenosis (>70%) before planned surgery. Perioperative management of patients with high-grade asymptomatic carotid stenosis is uncertain but should be informed by existing guidelines for carotid revascularization and contemporary medical treatment in this population.
6. Use or adjustment of medications such as statins, beta-blockers, and antithrombotic agents should be based on existing guidelines but tailored to individual patient characteristics. In particular, aspirin should be held unless patients have had a prior percutaneous coronary intervention. Patients with a mechanical heart valve receiving a vitamin K antagonist may need to be bridged with low molecular weight heparin (LMWH) or intravenous heparin. Patients at high risk for thromboembolism taking a vitamin K antagonist (e.g., atrial fibrillation with high CHA₂DS₂-VASc score, recent venous thromboembolic disease) may be bridged with full-dose (therapeutic) LMWH or intravenous heparin.
7. Intraoperatively, consider maintaining a mean arterial pressure >70 mm Hg, especially in patients who are at moderate or high risk for perioperative stroke. Hypocarbia should be generally avoided in patients at high risk for perioperative stroke.
8. It is reasonable to consider a transfusion threshold of 8 g/dl for patients with a history of recent stroke or significant cerebrovascular disease (e.g., carotid or intracranial stenosis >70%). Clinicians may consider a transfusion threshold of 8–9 g/dl in patients with an acute perioperative stroke, ongoing bleeding, hemodynamic instability, and known cerebrovascular insufficiency attributable to stenosis or occlusion.
9. All centers performing surgery should consider establishing algorithms for the evaluation and treatment of patients with perioperative stroke by stroke code teams, with protocols in place for immediate treatment or transfer to hospitals capable of providing advanced care.
10. Restoring blood flow to the injured brain is critically important. Patients with a perioperative stroke should be strongly considered for evaluation for mechanical embolectomy and intravenous thrombolysis because both interventions have been shown to be safe in select patients. Mechanical thrombectomy is preferable to intravenous thrombolysis alone in large vessel occlusion strokes. Obtaining more advanced imaging initially, including computed tomography angiography and perfusion studies, should be considered for patients with more severe stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score >6 or cortical deficits) to determine eligibility for mechanical thrombectomy. The risk of bleeding at the surgical site must be considered in relation to intravenous thrombolytic treatment.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Nonstatins, Novel Agents, Statins, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Anticoagulants, Aspirin, Atrial Fibrillation, Carotid Stenosis, Cerebrovascular Disorders, Coronary Angiography, Constriction, Pathologic, Embolectomy, Endarterectomy, Carotid, Fibrinolytic Agents, Foramen Ovale, Patent, Heart Valve Diseases, Heparin, Low-Molecular-Weight, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Ischemic Attack, Transient, Myocardial Revascularization, Percutaneous Coronary Intervention, Perfusion Imaging, Risk Factors, Secondary Prevention, Stroke, Surgical Procedures, Operative, Thrombectomy, Thromboembolism, Thrombolytic Therapy, Vascular Diseases, Vitamin K

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