Authors: Bright M et al.
Journal of Neurosurgical Anesthesiology. 38(1):3–9, January 2026. 10.1097/ANA.0000000000001073
Summary
This focused narrative review examines the relationship between perioperative blood pressure management and the development of perioperative neurocognitive disorders (pNCD) and stroke following noncardiac surgery. Although intraoperative hypotension has long been considered a modifiable contributor to cerebral hypoperfusion and neurologic injury, recent high-quality evidence challenges the assumption that targeting higher arterial pressures reduces neurocognitive complications.
The authors synthesize data from large randomized controlled trials, including POISE-3 and the CogPOISE substudy, which demonstrated that strategies aimed at maintaining higher mean arterial pressures did not reduce delirium, long-term cognitive decline, or perioperative stroke in unselected surgical populations. Observational studies linking hypotension to pNCD or stroke were inconsistent, suggesting that hypotension may often act as a marker of patient vulnerability rather than a direct causal mechanism.
The review emphasizes that perioperative brain injury is multifactorial, involving neuroinflammation, autonomic dysfunction, vascular injury, mitochondrial impairment, anesthetic depth, and patient-specific vulnerabilities such as frailty and impaired cerebral autoregulation. Cerebral hypoperfusion may contribute in select individuals, but population-wide blood pressure thresholds are physiologically unsound given wide interindividual variability in autoregulatory limits.
The authors argue for a paradigm shift away from universal blood pressure targets toward personalized, physiology-guided perioperative care. Emerging strategies include autoregulation-guided hemodynamic management, multimodal neuromonitoring integrating cerebral oxygenation and EEG, and targeted protection of high-risk patients. Future research should focus on individualized brain protection strategies rather than population-based arterial pressure goals.
What You Should Know
Large randomized trials show no benefit of targeting higher perioperative blood pressure to prevent delirium or long-term cognitive decline.
Perioperative neurocognitive disorders arise from multifactorial mechanisms beyond cerebral hypoperfusion alone.
Universal mean arterial pressure targets fail to account for wide variability in cerebral autoregulation.
Future neuroprotection strategies should emphasize personalized, physiology-guided monitoring and care.
Key Points
Question: Does maintaining higher perioperative blood pressure reduce neurocognitive disorders or stroke after noncardiac surgery?
Findings: Randomized trials demonstrate no reduction in delirium, cognitive decline, or stroke with higher blood pressure targets in unselected patients.
Meaning: Neurocognitive protection requires a shift from uniform blood pressure thresholds to individualized, multimodal, physiology-based strategies.
Thank you to the Journal of Neurosurgical Anesthesiology for allowing us to summarize this article.