All types of health care providers may be called on to evaluate the risk of ischemic stroke related to an upcoming surgical procedure, particularly in patients with established cerebrovascular disease. We outline possible mechanisms contributing to perioperative stroke, summarize available data on the stroke risk associated with selected surgeries, and highlight recognized risk factors. We then provide recommended answers to some of the questions commonly encountered at the preoperative cerebrovascular consultation: What is the appropriate time interval between a stroke and elective surgery? What is the perioperative stroke risk for patients with established carotid or vertebrobasilar large artery stenosis, and what are the cardiac implications of detecting a cerebrovascular large artery stenosis? Should patients with a large artery stenosis undergo prophylactic revascularization procedures before undergoing general surgery? What treatment is appropriate for patients with both coronary artery and carotid or vertebrobasilar large artery stenosis? What is the appropriate perioperative management of antiplatelet and anticoagulant medications with respect to stroke risk?
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