A stroke is a serious medical emergency in which blood supply to the brain is blocked or there is sudden bleeding in the brain. The first type of stroke, which occurs due to the blockage of blood flow to the brain, is called an ischemic stroke and accounts for just under 90% of all strokes. In an ischemic stroke, the brain is no longer able to get oxygen and nutrients from the body’s blood, and brain cells begin to die within minutes. The second type of stroke, caused by bleeding in the brain, is called a hemorrhagic stroke. When blood leaks into the brain, it puts pressure on brain cells and damages them.1 Rapid recognition and treatment of a stroke has a significant impact on patient outcomes, with research showing that patients treated 0 to 90 minutes after onset have increased odds of favorable outcomes compared to patients treated after that window.1,2 Treatment may also involve longer term rehabilitation and adjustments, with one important component being the delay of surgery after stroke to reduce the risk of complications.
There are many factors to keep in mind during the stroke recovery process: patients and their medical teams should consider the severity of the physical and cognitive effects of the patient’s stroke as well as the emotional and social support necessary for the patient as they undergo rehabilitation.3 For most patients, one crucial element of recovery is delaying any planned elective surgeries. In 2021, the American Heart Association (AHA) recommended in a statement that individuals should wait at least 6 months—and possibly as long as 9 months—after a stroke to undergo any non-urgent surgical procedure. This delay can reduce the risk of recurrent stroke perioperatively, or during and after the surgery.4
Ischemic or hemorrhagic stroke which occurs during or closely after surgery is a devastating complication that can severely negatively impact the outcome of the surgery. According to a primer published in Nature Reviews, the 30-day mortality rates of patients who experience perioperative strokes are, at 16–26%, about ten times higher than those of patients who did not experience a perioperative stroke. Furthermore, the stroke itself can have much more damaging results, with perioperative strokes being associated with longer hospital stays, increased likelihood of discharge to long-term care, greater risk of cognitive impairment 1 year after the stroke, and a higher rate of disability than strokes unrelated to a surgical procedure.5 Therefore, it is critical for survivors of a stroke to delay surgery and recover appropriately.
However, some recent research has complicated our understanding of the 2021 AHA recommendations about how long to wait after a stroke to undergo elective surgery. Specifically, Laurent G. Glance, M.D., and colleagues found through a cohort study in 2022 of surgery patients 66 years and older that the risk of recurrent stroke and death leveled off once 90 days had elapsed between a previous stroke and the surgery. Based on their data, the authors suggested that the 6 months prescribed by the AHA may be too conservative.6 This is important to consider because delaying a surgery may present its own risks. Many conditions for which surgery is needed as a treatment are progressive, meaning waiting to perform the surgery can increase the probability of worse outcomes and mortality.7 Physicians should help patients with a planned surgery who have recently experienced a stroke weigh the potential benefits and costs of putting off their procedure and assist them in planning an appropriate amount of time by which to delay their surgery to minimize risk of complications.
References
(1) Stroke – What Is a Stroke? | NHLBI, NIH. https://www.nhlbi.nih.gov/health/stroke (accessed 2025-05-05).
(2) Marler, J. R.; Tilley, B. C.; Lu, M.; Brott, T. G.; Lyden, P. C.; Grotta, J. C.; Broderick, J. P.; Levine, S. R.; Frankel, M. P.; Horowitz, S. H.; Haley, E. C.; Lewandowski, C. A.; Kwiatkowski, T. P.; for the NINDS rt-PA Stroke Study Group. Early Stroke Treatment Associated with Better Outcome: The NINDS Rt-PA Stroke Study. Neurology 2000, 55 (11), 1649–1655. https://doi.org/10.1212/WNL.55.11.1649.
(3) Stroke rehabilitation: What to expect as you recover – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke-rehabilitation/art-20045172 (accessed 2025-05-05).
(4) Kleindorfer, D. O.; Towfighi, A.; Chaturvedi, S.; Cockroft, K. M.; Gutierrez, J.; Lombardi-Hill, D.; Kamel, H.; Kernan, W. N.; Kittner, S. J.; Leira, E. C.; Lennon, O.; Meschia, J. F.; Nguyen, T. N.; Pollak, P. M.; Santangeli, P.; Sharrief, A. Z.; Smith, S. C.; Turan, T. N.; Williams, L. S. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021, 52 (7). https://doi.org/10.1161/STR.0000000000000375.
(5) Fanning, J. P.; Campbell, B. C. V.; Bulbulia, R.; Gottesman, R. F.; Ko, S.-B.; Floyd, T. F.; Messé, S. R. Perioperative Stroke. Nat. Rev. Dis. Primer 2024, 10 (1), 3. https://doi.org/10.1038/s41572-023-00487-6.
(6) Glance, L. G.; Benesch, C. G.; Holloway, R. G.; Thirukumaran, C. P.; Nadler, J. W.; Eaton, M. P.; Fleming, F. J.; Dick, A. W. Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery. JAMA Surg. 2022, 157 (8), e222236. https://doi.org/10.1001/jamasurg.2022.2236.
(7) Fu, S. J.; George, E. L.; Maggio, P. M.; Hawn, M.; Nazerali, R. The Consequences of Delaying Elective Surgery: Surgical Perspective. Ann. Surg. 2020, 272 (2), e79–e80. https://doi.org/10.1097/SLA.0000000000003998.