Journal of neurosurgical anesthesiology最新文献

The selection of anesthetic agents during aneurysm repair may have an impact on the prognosis of patients with aneurysmal subarachnoid hemorrhage (SAH). In this systematic review and meta-analysis, we compared the effects of volatile-based anesthesia with those of total intravenous anesthesia (TIVA) on perioperative outcomes in SAH patients. A comprehensive literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library through December 2024, yielding 9 studies (comprising 4 randomized controlled trials [RCTs] and 5 cohort studies) with a total of 1459 participants. Data pooled from the cohort studies indicated that volatile-based anesthesia was associated with a lower risk of postoperative cerebral vasospasm (risk ratio [RR]=0.72; 95% CI: 0.62-0.83; I2 =22%) and delayed cerebral ischemia (RR=0.63; 95% CI: 0.51-0.80; I2 =22%). In contrast, analyses of the RCTs showed no significant differences between the 2 anesthetic techniques regarding cerebral vasospasm (RR=1.04; 95% CI: 0.35-3.06; I2 =60%), infarction (RR=1.51; 95% CI: 0.76-3.00; I2 =0%), or intraoperative brain swelling (RR=1.14; 95% CI: 0.83-1.58; I2 =0%). The Egger regression test did not reveal any evidence of publication bias. Overall, these findings suggest that although cohort studies point to a potential benefit of volatile-based anesthesia in reducing the incidence of postoperative vasospasm and delayed cerebral ischemia, the pooled results from RCTs do not corroborate these differences. Thus, further large-scale, high-quality randomized trials are warranted to better elucidate the comparative effects of these anesthetic approaches in aneurysmal SAH repair procedures.

Background: Recent studies show that levels of the brain injury biomarkers glial fibrillary acidic protein (GFAP) and neurofilament light (NfL) are elevated postoperatively in infants undergoing surgery for craniosynostosis. The aim of this study was to investigate the relationship between intraoperative hypotension and blood loss on biomarker levels.

Methods: This retrospective study included all consecutive patients undergoing surgery for metopic synostosis at our institution from January 2019 to September 2020 who were included in a previous trial. We extracted data from the medical record on intraoperative blood pressure, heart rate, and intraoperative blood loss. Pre- and postoperative GFAP and NfL levels were measured in stored blood samples. Hypotension was defined as the area under the curve (AUC) of mean arterial blood pressure (MAP) at 4 threshold levels (35, 40, 45, and 50 mm Hg, respectively). This AUC and intraoperative blood loss were used to identify correlations with postoperative changes in baseline GFAP and NfL levels.

Results: A total of 20 patients [age: 190±65 d (mean±SD); and weight: 8.0±1.0 kg] undergoing an open cranial vault procedure for metopic synostosis repair were included. Intraoperative blood loss was 27±11 mL/kg, and we did not identify significant association between plasma NfL or GFAP level and any MAP threshold (NfL AUC40 rs =0.08, AUC45 rs =0.15, AUC50 rs =0.30. GFAP AUC40 rs =-0.17, AUC45 rs =0.01, AUC50 rs =-0.06) or blood loss parameter [NfL rs =0.26, GFAP rs =-0.15].

Conclusion: We did not identify a relationship between MAP, blood loss, and markers of brain injury. Our findings suggest that other factors (eg, mechanical manipulation) may explain the observed elevations in brain injury biomarkers after craniosynostosis surgery. This study is limited by its sample size and further investigation is needed.

Intraoperative electroencephalography (EEG) is increasingly used to monitor the depth of anesthesia and a range of other perioperative indications. While processed EEG indices offer a convenient numerical representation, exclusive reliance on these values can obscure clinically significant findings. Discordance between the numerical index and the raw EEG or density spectral array (DSA) may arise due to artifacts, patient-specific neurophysiology, or pharmacologic effects. This article highlights common sources of such discordance, illustrated through clinical examples, and emphasizes the importance of integrating raw EEG interpretation and DSA analysis into routine intraoperative monitoring.

Background: Opioid-free anesthesia (OFA) offers potential benefits of smoother recovery and reduced complications, compared with conventional opioid-based approach. We aimed to evaluate the use of OFA as an alternative approach to conventional opioid-based anesthetic regimen in patients undergoing supratentorial brain tumor surgery.

Methods: Adult patients (>18 y) with supratentorial tumors undergoing elective craniotomy under general anesthesia (Aug 2022 to Dec 2023) were randomized into Dexmedetomidine (group D) or Fentanyl (group F) group. Primary outcome included emergence and extubation times and secondary outcomes were hemodynamic responses, pain scores, rescue analgesic use, and complications.

Results: A total of 44 patients were randomized (22 per group). Of these, 33 patients completed the study. Demographic variables were comparable, except for age and body mass index. Emergence (8.2±3.3 min vs. 6.8±2.6 min [ P =0.18]; Mean Difference [MD], 95% CI: 1.42, -0.69 to 3.55) and extubation times (12.7±4.2 min vs. 11.2±3.9 min [ P =0.27]; MD, 95% CI: 1.58, -1.31 to 4.46) were comparable between the groups, respectively. Group D demonstrated better hemodynamic stability during Mayfield pin application and tracheal extubation. Postoperative pain scores were similar, except at 12 hours, where group D reported lower Numerical Rating Scale. Postoperative Richmond Agitation-Sedation Scale at different time points was comparable between the groups.

Conclusion: Our preliminary data suggest that OFA may provide better hemodynamic stability and improved pain control at 12 hours compared with opioid-based anesthesia, while maintaining similar emergence and extubation times.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition characterized by high morbidity and mortality. Electroencephalography (EEG) is often used in the management of critically ill patients in the intensive care unit (ICU). Its role in the management of aSAH is not well known. The objective of this study is to evaluate the role of EEG in the management of aSAH patients by determining the association between EEG and outcomes and resource utilization.

Methods: The National Inpatient Sample (NIS) 2012 to 2017 was queried for adult patients with aSAH. Patients were classified as having received EEG during the hospitalization or not. The NIS-SAH severity score (NIS-SSS) was used to account for illness severity. Weighted multivariable regression models were used to estimate the association between the use of EEG and outcome of interest (total cost of care, length of stay (LOS), in-hospital mortality, and home discharge) adjusting for demographic, comorbidities, and other clinical characteristics.

Results: Among 41,896 patients with SAH (mean age 61.3 years, 41.8% male), 3.8% received EEG monitoring and had higher NIS-SSS (11.2 vs. 7.3, P <0.001). In multivariable models, the use of EEG was associated with higher cost of care (β=$113,740, 95% CI: $101,109-126,371) and longer LOS (β=6.21, 95% CI: 5.57-6.85). Patients with EEG had significantly lower risk of death in hospital (ARR=0.86, 95% CI: 0.77-0.96) but lower likelihood of home/self-care discharge (ARR=0.79, 95% CI: 0.70-0.89).

Conclusion: EEG monitoring was used in a minority of critically ill patients with aSAH. Although associated with increased cost of care and longer LOS, EEG likely averts adverse outcomes in patients with high severity and improves the chance of survival.