Journal of neurosurgical anesthesiology最新文献

This focused review explores the current literature on anesthetic care of pregnant patients requiring intracranial intervention. Neuropathology in pregnancy is rare, and existing evidence for management remains limited by the ethical complexities surrounding maternal and fetal research-related risks; pregnant women are typically excluded from randomized controlled trials. Physiological changes during pregnancy, combined with additional fetal considerations, alter pharmacodynamics and complicate the safety profile of maternal interventions. This review highlights the complex interplay between the physiological changes of pregnancy and common neuropathologies in this patient population. Up-to-date strategies for managing elevated maternal intracranial pressure, appropriate timing of delivery relative to neurosurgical intervention, and key medications in neuro-interventional and obstetrical care are described. The appropriateness of imaging, current evidence in stroke management, and consideration for neuraxial anesthesia and awake surgery in pregnant patients are also addressed. Emphasis is placed on the importance of multidisciplinary collaboration to ensure safe, patient-centered care tailored to neuropathology, gestational age, and clinical status. Despite recent advances, significant gaps in evidence persist. Further research from large retrospective or observational data sets is recommended to improve evidence-based approaches for managing this complex and uncommon patient population.

After intracranial surgery, sympathetic overdrive and increased blood catecholamine levels can contribute to postoperative hypertension, a significant clinical problem. The objective of this review was to summarize, quantify, and assess the epidemiological perspective of post-craniotomy hypertension and its association with adverse outcomes. This PROSPERO-registered systematic review was conducted following PRISMA guidelines. We searched electronic databases for studies that investigated adult patients who had elective craniotomy for any indication and reported hypertension within 72 hours postoperatively. Study quality was assessed using the Newcastle-Ottawa scale. Twenty-one studies, including 2602 patients, were identified for inclusion in this review. Multiple thresholds and criteria for defining post-craniotomy hypertension were used across studies. The pooled incidence of post-craniotomy hypertension from 13 studies (2279 patients) was 30% [95% CI, 15%-50%]. Post-craniotomy hypertension was associated with a 2.6 times higher risk of having an intracerebral hemorrhage within 72 hours after surgery (pooled risk ratio, 2.63; 95% CI, 1.16-5.97). There were insufficient data to investigate the quantitative association of post-craniotomy hypertension with 30-day adverse events. In summary, 1 out of 3 patients exhibited hypertension post-craniotomy, and this was associated with a significantly higher risk of having intracranial hemorrhage within 72 hours post-procedure. A generally accepted and clinically relevant criteria for post-craniotomy hypertension should be defined.

Background: Strict blood pressure control can be used to prevent or treat cerebral hyperperfusion syndrome. This study investigated whether scalp nerve block (SNB) is associated with a reduced risk of postoperative symptomatic cerebral hyperperfusion syndrome (SCHS) by reducing postoperative blood pressure in adult patients who underwent combined revascularization surgery for moyamoya disease.

Methods: Patients were retrospectively divided into the SNB (n=167) and control (n=221) groups depending on whether SNB was performed immediately before placement of wound dressings at the end of surgery. Postoperative SCHS was defined as new-onset postoperative neurological deficits with a focal increase in cerebral blood flow at the perianastomosis site in the absence of infarction or hemorrhage on postoperative brain imaging. Inverse probability of treatment weighting was used to balance preoperative variables between the 2 groups.

Results: The incidence of postoperative SCHS did not differ between the SNB and control groups (61 [36.5%] vs. 102 [46.2%], P=0.072), but its duration was shorter in the SNB group (4 [2-6] vs. 5 [3-7] days, P=0.021). Although of limited clinical relevance, the SNB group had lower postoperative pain scores and systolic blood pressures at postoperative days 0 to 1 and a shorter intensive care unit stay.

Conclusions: Despite some potential benefits, SNB was not associated with a reduced incidence of postoperative SCHS in adult patients who underwent combined revascularization surgery for moyamoya disease.

Intubation of patients requiring cervical spine immobilization can be challenging. Recently, the use of C-MAC video laryngoscopes (VL) has increased in popularity over direct laryngoscopy (DL). We aimed to conduct a systematic review and meta-analysis to evaluate the efficacy of C-MAC VL as compared with DL for intubation in C-spine immobilized patients. A systematic search of electronic databases, including PubMed, Cochrane Library, Embase, and Web of Science was performed. Time taken to intubate was the primary outcome whereas the use of optimization maneuvers, laryngoscopy view, first-pass success rates, and difficulty of intubation were secondary outcomes. Seven trials involving 490 patients were included in the analysis. There was no significant difference between the 2 groups in terms of time taken to intubate, standardized mean difference 0.65 (95% CI, -2.55, 3.86). The certainty of evidence for the primary outcome, time taken to intubate, was low, with high heterogeneity (I2=97%). The C-MAC VL group had higher first-pass success rates (odds ratio 2.92 [95% CI, 1.14, 7.49]) and a lower incidence of a poor laryngoscopy view (odds ratio 0.21 [95% CI, 0.07, 0.66]). There was no difference in terms of the difficulty of intubation and the use of optimization maneuvers. Overall, C-MAC VL did not reduce the time taken to intubate, although the strength of this finding is limited by wide confidence intervals. C-MAC VL significantly improved laryngoscopy views and first-pass success rate as compared with DL.

Processed electroencephalography (pEEG) is increasingly used to titrate the depth of anesthesia. Whether such intra-procedural pEEG monitoring can offer additional information on cerebral perfusion or acute focal or global cerebral ischemia is unknown. This scoping review aimed to provide a narrative analysis of the current literature reporting the potential role of pEEG in adults with acute cerebral ischemia. In keeping with the scoping review methodology, a broad search strategy was defined, including descriptions of encephalography in acute ischemic stroke, carotid endarterectomy, cardiac surgery, and cardiac arrest. Additional screening of citations was conducted by 2 independent assessors. From 310 records, 28 full-text articles met inclusion criteria. Most identified studies were observational in design, and described the diagnostic ability of pEEG to identify cerebral hypoperfusion or its prognostic sensitivity after stroke or carotid surgery. No studies were identified that evaluated pEEG in the specific setting of endovascular therapy for acute ischemic stroke. Low sensitivity associations between pEEG indices and cerebral blood flow were highlighted, which may be influenced by cerebral autoregulatory thresholds. Despite the associations reported in observational studies, this review identified significant uncertainty in the role of pEEG during cerebral ischemia. There is a paucity of high-level observational (cohort or case-control) or randomized trial research examining the possible role of pEEG for the detection and management of cerebral ischemia during acute stroke, including during endovascular therapy, or in other common scenarios of acute cerebral ischemia.

Background: We implemented a quality improvement project to transition from routine cerebrospinal fluid (CSF) sampling to indication-based sampling in aneurysmal subarachnoid hemorrhage (aSAH) patients with an external ventricular drain (EVD).

Methods: Forty-seven patients were assessed across 2 epochs: routine (n=22) and indication-based (n=25) CSF sampling. The primary outcome was the number of CSF samples, and secondary outcomes included cost reductions and ventriculostomy-associated infections.

Results: Patient characteristics were similar in the routine and indication-based sampling groups, as was the mean (SD) EVD duration (13.86 [5.28] days vs. 12.44 [4.78] days, respectively; P=0.936). One hundred eight CSF samples were collected during the quality improvement project; 81 in the routine sampling period and 27 in the indication-based sampling period. The median (interquartile range) CSF sampling rate reduced from 4 (3 to 4) per patient during routine sampling to 1 (0 to 2) during indication-based sampling (odds ratio: 0.19; 95% CI: 0.08-0.46; P<0.001), representing a 73% reduction in the number of samples after the transition to indication-based sampling. Each CSF sample cost $723, resulting in total sampling costs in the routine and indication-based sampling periods of $58,571 and $19,524, respectively. Therefore, the mean cost per patient was significantly higher in the routine sampling period than in the indication-based period ($2772 [$615] vs. $889 [$165], respectively; P=0.007). There were no ventriculostomy-associated infections in either period.

Conclusion: Transitioning from routine to indication-based CSF sampling in aSAH patients with an EVD reduced sampling frequency and associated costs without increasing infection rates.

Background: Predictors of difficult fiberscopic intubation have not been fully elucidated. This study focused on identifying radiographic predictors of difficult fiberscopic intubation during general anesthesia in patients with a cervical collar.

Methods: This retrospective study included unconscious patients who underwent orotracheal intubation using a flexible fiberscope while wearing a cervical collar to simulate a difficult airway. Easy fiberscopic intubation was defined as successful fiberscopic intubation within 120 seconds on the first attempt without desaturation below 90%. The patients were divided into easy (n=133) and difficult (n=24) fiberscopic intubation groups. Demographic, mask ventilation-related, upper airway-related, and radiographic variables measured on sagittal images of preoperative cervical x-ray and magnetic resonance imaging were analyzed.

Results: The difficult fiberscopic intubation group had a smaller oral cavity area (2.1 [1.2-2.5] vs. 2.9 [2.1-3.7] cm2, P<0.001), higher tongue area divided by oral cavity area (9.3 [6.5-13.3] vs. 6.4 [4.6-8.3], P<0.001), smaller epiglottis angle (33±10° vs. 37±8°, P=0.02), and longer skin-glottis distance (1.3 [1.1-1.6] vs. 1.1 [1.0-1.3] cm, P=0.004). Tongue area/oral cavity area (odds ratio per 1 [95% CI]: 1.24 [1.09-1.40]) and skin-glottis distance (odds ratio per 1 cm [95% CI]: 13.0 [2.69-62.4]) were independently associated with the difficulty in fiberscopic intubation.

Conclusions: High tongue area/oral cavity area and long skin-glottis distance were predictive of difficult fiberscopic intubation during general anesthesia in patients with a cervical collar.

Background: An anesthesia information management system (AIMS) can be used to assess operating room utilization. The aim of this study was to assess neurosurgery OR utilization patterns using an AIMS.

Methods: This retrospective audit was performed at a tertiary neurosciences university hospital over a 1-year period. The time taken for various OR activities were identified from the timestamps recorded in the AIMS and used to assess whether the type of surgical procedure, patient's American Society of Anesthesiologists (ASA) physical status score, case schedule order, or surgeons' experience impacted operating room utilization.

Results: Data from 1800 patients were available for analysis. Utilization times for various operating room activities were different based on the type of surgery, ASA grade, case order, and surgeon seniority. The main differences were found in the durations of surgery and anesthesia, and the time from the arrival of a patient into the operating room and the start of surgery, which were significantly impacted by the type of surgery, case order, and surgeon seniority (P<0.001), but not by ASA score.

Conclusions: AIMS can effectively track and identify operating room utilization patterns by analyzing the durations of various operating room activities. Prospective multicenter studies are required to validate these findings in different surgical populations and centers.