Your next patient in the preoperative clinic is a 68-year-old woman scheduled to undergo an L4-5 laminectomy for chronic back pain. She had a stroke one week ago, and you are considering how long to delay this elective surgery. A recent study of older adult patients showed the risk of perioperative stroke was increased when the stroke occurred closer to the time of surgery. According to this study, which of the following is MOST likely the minimum amount of time this elective surgery should be delayed to decrease the risk of perioperative stroke?

  • □ (A) 3 months
  • □ (B) 6 months
  • □ (C) 1 year

The number of patients experiencing a stroke is increasing in the United States, and the annual cost of stroke care is projected to be $240 billion by 2030. The risk of perioperative stroke is estimated to be between 0.1% and 1% for patients undergoing noncardiac surgery and is approximately 16 times higher when a patient has had a prior stroke. The risk is even higher when the surgery occurs in close temporal proximity to the stroke. The perioperative risk of stroke may remain high for the lifetime of a patient with a prior stroke, but it is important to determine the time after which the risk of perioperative stroke levels off, such that waiting any longer for elective surgery would not confer any additional safety. The American Heart Association and American Stroke Association issued a scientific statement in 2021 based on clinical expert consensus recommending that elective surgery be postponed at least six months after a stroke, possibly nine months. This recommendation was based on the results of a single Danish study of patients aged 20 years or older, which may not be generalizable to other populations; the American population has higher rates of obesity, diabetes, and hypertension, and lower life expectancy than the Danish population. A recent study used data from the Medicare Provider Analysis and Review files and included American patients aged at least 66 years to determine whether the six-month cutoff applied to this at-risk population.

This was a retrospective study of 5,841,539 patients aged 66 years or older who underwent noncardiac, nonneurologic surgeries from 2011 to 2018. Patients were divided into seven cohorts based on the time since their stroke (Table). Importantly, the reference group (n = 5,787,506) consisted of patients with no stroke history and those who had a stroke more than two years prior to surgery; a total of 54,033 patients had a stroke within two years of surgery. The primary outcome was the rate of 30-day perioperative stroke. Secondary outcomes included all-cause mortality, 30-day composite of stroke and mortality, and postoperative discharge to a nursing home or skilled nursing facility. The authors also analyzed data according to surgical risk, categorizing surgeries based on postoperative 30-day mortality rate: low (≤0.5%), intermediate (>0.5%-1%), and high (>1%).


The adjusted odds ratio for perioperative stroke was found to be higher in the two cohorts of patients with a previous stroke within 30 days and 30 to 60 days prior to surgery (Table). The risk of stroke in patients who had a stroke 61 to 90 days prior to surgery (adjusted odds ratio, 5.01; 95% CI, 4.00-6.29) was not found to be different from the longer wait periods. The 30-day mortality risk results were similar to these 30-day stroke results. Therefore, the authors recommended that patients wait three months after a stroke to have elective noncardiac, nonneurologic surgery.

In the surgical risk subanalysis, patients undergoing high-risk surgeries (>1% mortality rate), the risk of perioperative stroke leveled off in patients who had a stroke three months prior to surgery, similar to the overall cohort. Interestingly, in patients undergoing intermediate- or low-risk surgeries, the risk of stroke continued to decline; there was no period up to two years beyond which the stroke risk leveled off.

In conclusion, this U.S.-based study of older adult patients found that the risk of perioperative stroke or death was not substantially reduced after three months since experiencing an ischemic stroke. This finding differs from the recommendations of the American Heart Association and American Stroke Association scientific statement, which recommends postponing elective surgery at least six months after a stroke.