Delaying Surgery After Stroke

Recent guidelines from the American Heart Association (AHA) and the American Stroke Association (ASA) recommend a significant delay in elective non-neurological and non-cardiac surgery after a stroke. This strategic delay aims to reduce the risk of recurrent stroke, which can have devastating health consequences. The scientific statement, published in 2022, recommends a waiting period of at least six months and possibly up to nine months after a stroke before undergoing such procedures. The period immediately following a stroke is one of increased vulnerability to further cerebrovascular events. Additionally, research suggests that surgical procedures may increase physiological stress and inflammatory responses, potentially triggering recurrent stroke. Therefore, delaying elective surgery after a stroke is believed to provide the brain with the necessary time to recover and reduce the risk associated with surgery (1).


The AHA and ASA recommendations are based on a comprehensive review of recent studies linking surgery to an increased risk of stroke recurrence. In particular, a comprehensive analysis by Glance et al. (2022) using Medicare data showed that patients who underwent surgery within six months of a stroke had a significantly increased risk of recurrent stroke compared with those who delayed surgery (1). In addition, Christiansen et al. (2017) also examined the impact of emergency non-cardiac, non-intracranial surgeries on patients with a history of stroke and found that these surgeries led to a high occurrence of major adverse cardiovascular events and mortality when performed within nine months of a stroke (2).


However, some experts argue that delaying surgery after stroke for so long may be unnecessarily conservative and could potentially lead to other health complications or deterioration in quality of life. For example, delaying surgeries such as hip replacement or hernia repair could lead to decreased mobility, increased pain, and other adverse outcomes, which in turn could lead to hospital admissions (3). These concerns suggest that a more flexible, personalized approach may be needed, where the timing of surgery is tailored to the individual patient’s risk profile and the type of surgery.


Healthcare providers must rigorously evaluate the risks and benefits of proposed elective surgery for patients with stroke. This includes careful consideration of the patient’s recovery after experiencing a stroke, the urgency of the surgery, and the potential risks of delaying treatment. Patient management strategies must also be adapted to ensure that those at risk are closely monitored during the extended post-stroke period. In addition, these guidelines require a collaborative approach among healthcare teams. Neurologists, cardiologists, and surgeons must work together to optimize the timing of surgeries to prioritize patient safety and outcomes. This interdisciplinary coordination is essential for effective implementation of the AHA and ASA guidelines (4).


While the AHA and ASA recommendation of delaying elective surgery for at least six to nine months after stroke is well-intentioned, emerging perspectives suggest that patient-specific factors and the type of surgery should more strongly guide decision-making. This balanced approach helps ensure both the safety and overall well-being of stroke survivors and adapts to medical research and patient needs. Ongoing research and tracking of patient outcomes are essential to further refine these guidelines and ensure that they remain in line with best clinical practice.




  1. Glance LG, Dick AW, Mukamel DB, et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology. 2011;114(2):283-292. doi:10.1097/ALN.0b013e3182054d06
  2. Christiansen MN, Andersson C, Gislason GH, et al. Risks of Cardiovascular Adverse Events and Death in Patients with Previous Stroke Undergoing Emergency Noncardiac, Nonintracranial Surgery: The Importance of Operative Timing. Anesthesiology. 2017;127(1):9-19. doi:10.1097/ALN.0000000000001685
  3. Vikatmaa P, Sairanen T, Lindholm JM, Capraro L, Lepäntalo M, Venermo M. Structure of delay in carotid surgery–an observational study. Eur J Vasc Endovasc Surg. 2011;42(3):273-279. doi:10.1016/j.ejvs.2011.04.021
  4. Rantner B, Kollerits B, Auer J, et al. Carotid stenosis and clinical recurrence after ischemic stroke or transient ischemic attack in the European Carotid Surgery Trial. J Vasc Surg. 2006;44(4): 792-796