title: Perioperative stroke.
abstract: OBJECTIVE
  Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. In this review, we examine the significance, pathophysiology, risk factors, and evidence-based recommendations for the prevention and management of perioperative stroke.
  
  
  METHODS
  This is a narrative review based on literature from the PubMed database regarding perioperative stroke across a broad surgical population. The Society for Neuroscience in Anesthesiology and Critical Care recently published evidence-based recommendations for perioperative management of patients at high risk for stroke; these recommendations were analyzed and incorporated into this review.
  
  
  RESULTS
  The incidence of overt perioperative stroke is highest in patients presenting for cardiac and major vascular surgery, although preliminary data suggest that the incidence of covert stroke may be as high as 10% in non-cardiac surgery patients. The pathophysiology of perioperative stroke involves different pathways. Thrombotic stroke can result from increased inflammation and hypercoagulability; cardioembolic stroke can result from disease states such as atrial fibrillation, and tissue hypoxia from anemia can result from the combination of anemia and beta-blockade. Across large-scale database studies, common risk factors for perioperative stroke include advanced age, history of cerebrovascular disease, ischemic heart disease, congestive heart failure, atrial fibrillation, and renal disease. Recommendations for prevention and management of perioperative stroke are evolving, though further work is needed to clarify the role of proposed modifiable risk factors such as perioperative anticoagulation, antiplatelet therapy, appropriate transfusion thresholds, and perioperative beta-blockade.
  
  
  CONCLUSIONS
  Perioperative stroke carries a significant clinical burden. The incidence of perioperative stroke may be higher than previously recognized, and there are diverse pathophysiologic mechanisms. There are many opportunities for further investigation of the pathophysiology, prevention, and management of perioperative stroke.
authors.affiliation: Department of Anesthesiology, University of Michigan Health System, University Hospital 1H247, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109, USA.
authors.forename: Phillip
authors.initials: P
authors.lastname: Vlisides
authors.affiliation: Department of Anesthesiology, University of Michigan Health System, University Hospital 1H247, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109, USA. gmashour@med.umich.edu.
authors.forename: George A
authors.initials: GA
authors.lastname: Mashour
mesh_terms: D000818:Animals; D019317:Evidence-Based Medicine; D006801:Humans; D059035:Perioperative Period; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology / Q000517:prevention & control; D012307:Risk Factors; D020521:Stroke / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000379:methods; D013927:Thrombosis / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control