Cerebrovascular Events in Aortic Stenosis: From Native Valve Disease to TAVR-Specific Risk and Prevention

Aortic stenosis (AS) is associated with a heightened burden of cardiovascular comorbidities, atrial fibrillation (AF), and progressive valvular calcification, all of which may contribute to cerebrovascular events across the disease continuum. However, true epidemiologic evidence establishing AS as an independent stroke risk factor remains limited, and much of the contemporary concern regarding stroke has shifted toward interventional management. Transcatheter aortic valve replacement (TAVR) has become the dominant therapy for severe AS, but periprocedural and early postprocedural stroke remain among its most clinically significant complications. This review integrates current knowledge on stroke pathways in native AS, AF, calcific embolization, hemodynamic alterations, and places them in context with procedural mechanisms unique to TAVR. We summarize evidence comparing stroke rates in TAVR versus surgical aortic valve replacement and examine anatomic, procedural, and patient-level drivers of embolic risk. Building on these mechanisms, we highlight contemporary stroke mitigation strategies including multimodality imaging for preprocedural planning, optimization of access and device selection, cerebral embolic protection devices, antithrombotic therapy tailored to individual indications, and structured postprocedural neurologic and rhythm monitoring. By integrating the natural history of AS with TAVR-specific embolic pathways, this review provides a comprehensive framework for understanding and minimizing stroke risk in patients across the spectrum of AS.