Walking the Hemostatic Tightrope in Stroke, VTE, and Orthopedic Surgery: A Scoping Review

Patients with prior stroke undergoing orthopedic surgery face elevated risks of recurrent stroke and venous thromboembolism, while thromboprophylaxis must be balanced against hemorrhage. Evidence is fragmented across subspecialties. To map the epidemiology, risk stratification, timing, anesthesia and thromboprophylaxis evidence for this population, labeling each recommendation by evidence type. Following PRISMA-ScR and Joanna Briggs Institute guidance, we searched PubMed, Embase and the Cochrane Library from inception through December 2025, with supplementary identification to the final search date of 23 January 2026. No protocol was registered, 76 sources met inclusion criteria, and formal critical appraisal was not undertaken. Deferring elective arthroplasty at least 3 months after stroke is reasonable, but 3 to 6 months is individualized rather than optimal, derived largely from noncardiac surgery; one arthroplasty cohort suggests longer. Hip fracture surgery should proceed within 24 to 48 h after ischemic or remote hemorrhagic stroke; after recent hemorrhagic stroke timing is unestablished, with no fixed delay supported because delay is itself harmful. Mortality advantages of neuraxial anesthesia are observational, randomized trials including REGAIN are null, and technique is individualized. No randomized trial has compared prophylactic agents here, so preferring low-molecular-weight heparin or a direct oral anticoagulant over aspirin is extrapolation, not established standard. Factor XIa inhibition remains investigational: phase 2 trials with venographic endpoints that largely excluded patients with stroke. Management requires individualized, multidisciplinary assessment, not uniform rules; most positions rest on indirect or inferential evidence. Only 8 of 76 charted sources report stroke subtype or the interval since stroke.