The role of an internal medicine physician in the perioperative setting includes the assessment of peri-operative risk, optimization of modifiable risk factors to decrease this risk and management of post-operative medical complications that may occur. Every patient undergoing surgery is at risk for procedural and anesthesia complications, in addition the patient is at risk of developing adverse medical events. Unlike surgical risk which is related to the procedure being performed and the risk of anesthesia, the factors affecting the medical risk are often modifiable. These modifiable risk factors form the principal basis of risk stratifying patients prior to surgery.

Neurosurgical patients pose certain unique challenges in the peri-operative setting and the pre-operative assessment forms a starting point in the prevention of not just post-operative cardiac complications but also thrombotic events and in reducing the overall morbidity and length of hospital stay.

In this chapter, we summarize our approach to the cardiac risk stratification of patients undergoing neurosurgery. We review recommendations from accepted guidelines and provide a step wise approach to the cardiac risk assessment of a patient undergoing elective surgery.