Stroke in Pediatric Cardiac Surgery: Incidence, Risk Factors, and Management Strategies

Stroke is among the most consequential neurologic complications of cardiac surgery for congenital heart disease, occurring in 1% to 5% of the general pediatric cardiac surgical population and rising above 7%, extracorporeal membrane oxygenation-supported patients, and cardiac transplant recipients. Most events are clinically silent; systematic postoperative MRI detects 2 to 3 times more strokes than clinical examination alone, which means that centers without a neuroimaging protocol are systematically undercounting. The congenital heart disease brain arrives at surgery already compromised: preoperative white matter injury is present in up to 50% of neonates, driven by placental insufficiency, impaired cerebrovascular autoregulation, and delayed cortical maturation. Embolic, hemodynamic, thrombotic, and cerebral venous sinus thrombosis mechanisms converge in a brain rendered vulnerable before any surgical insult. This narrative review synthesizes contemporary evidence on incidence; risk stratification across the preoperative, intraoperative, and postoperative periods; pathophysiology; neuroimaging; acute management; and long-term outcomes, incorporating the dual perspective of pediatric cardiac surgery and clinical neurology. Mechanical thrombectomy has emerged as a potentially transformative intervention for large vessel occlusion in this population, with superior results in the cardioembolic subtype. Anticoagulation decisions remain the most difficult acute management challenge, requiring individualization by procedure type, hemorrhagic risk, and timing. Early structured neurorehabilitation, initiated within the neuroplasticity window of the developing brain, is an essential and frequently under-resourced component of recovery. Systematic neuroimaging protocols, multimodal neuromonitoring, thrombectomy where feasible, and early neurorehabilitation are achievable interventions that most centers can implement without awaiting further trial data.