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Hypertension is considered a potential risk factor for perioperative ischemic stroke (PIS). However, the association between elevated first systolic blood pressure measured in the operating room (first-OR-SBP) and the incidence of PIS has not been well documented. We conducted a single-center retrospective cohort study including patients who underwent elective non-brain, non-cardiac surgery at Peking University First Hospital between January 1, 2018, and December 31, 2024. Data were extracted from a perioperative database, and patient demographics, intraoperative and perioperative variables-particularly the relationship between first-OR-SBP and PIS-were analyzed. Multivariate logistic regression was performed before and after propensity score matching to adjust for perioperative confounders. The minimum p value approach was used to identify a potential threshold of first-OR-SBP independently associated with PIS risk. We found that, among 105 059 surgeries, 195 patients (0.19%) experienced PIS. The threshold for first-OR-SBP associated with PIS was identified as 186 mm Hg. The adjusted odds ratios for PIS were 1.69 (95% CI, 1.12-2.55; p = 0.013) before matching and 1.62 (95% CI, 1.03-2.54; p = 0.036) after propensity score matching. We conclude that a first-OR-SBP≥186 mm Hg was significantly associated with an increased risk of perioperative ischemic stroke in patients undergoing elective non-brain, non-cardiac surgery.