Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study – The Lancet

Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study – The Lancet



In non-surgical settings, covert stroke is more common than overt stroke and is associated
with cognitive decline. Although overt stroke occurs in less than 1% of adults after
non-cardiac surgery and is associated with substantial morbidity, we know little about
perioperative covert stroke. Therefore, our primary aim was to investigate the relationship
between perioperative covert stroke (ie, an acute brain infarct detected on an MRI
after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive
decline 1 year after surgery.


NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries,
in which we assessed patients aged 65 years or older who underwent inpatient, elective,
non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology
experts, masked to clinical data, assessed each MRI for acute brain infarction. Using
multivariable regression, we explored the association between covert stroke and the
primary outcome of cognitive decline, defined as a decrease of 2 points or more on
the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up.
Patients, health-care providers, and outcome adjudicators were masked to MRI results.


Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study,
78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed
the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%)
of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants
who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20,
absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased
risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute
risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year
follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019).


Perioperative covert stroke is associated with an increased risk of cognitive decline
1 year after non-cardiac surgery, and perioperative covert stroke occurred in one
in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is
needed to establish prevention and management strategies for perioperative covert


Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented
Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and
Medical Research Fund, Government of the Hong Kong Special Administrative Region,
China; and The Neurological Foundation of New Zealand.

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Article Info

Publication History

Published: August 15, 2019




© 2019 Elsevier Ltd. All rights reserved.


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