Perioperative Blood Pressure and Neurocognitive Disorders After Noncardiac Surgery: A Focused Review

Perioperative neurocognitive disorder (pNCD) and stroke are frequent and serious complications following noncardiac surgery, leading to increased mortality and healthcare expenditure. While intraoperative hypotension has long been considered a potentially modifiable risk factor through its impact on cerebral perfusion, a direct role in causing pNCD is now challenged. Large randomized controlled trials, including the recent CogPOISE trial, have demonstrated that strategies targeting higher perioperative mean arterial pressure do not reduce the incidence of delirium, long-term cognitive decline, or major vascular events in the surgical population. These findings suggest that the "one size fits all" approach to blood pressure management is insufficient. The pathophysiology of perioperative brain injury is multifactorial, and the role of cerebral hypoperfusion remains uncertain. Future research must shift from population-based blood pressure thresholds towards investigating the impact of personalized, multimodal, neurophysiology-guided care for vulnerable patients, including cerebral autoregulation and metabolic markers to protect against pNCD and stroke.