Journal of neurosurgical anesthesiology最新文献

Background: Continuous, wearable-based vital sign monitoring can enhance patient safety and reduce intensive care demands but is not routinely used on standard neurosurgical wards. This study assessed alarm events and technology acceptance during the implementation of such a system for postoperative patients in a university hospital's neurosurgical ward.

Methods: In this pilot feasibility study, selected patients were continuously monitored for 12 to 24 hours after elective neurosurgery on a 44-bed ward. Phase 1 (June to December 2019) used 12 mobile units with manual alarm documentation; Phase 2 (August 2023 to January 2024) used 44 fixed bedside units with automatic documentation. Alarm patterns and nurse-rated technology acceptance (4-point Likert scale) were analyzed.

Results: Vital signs were monitored in 214 patients (median age: 58, IQR: 42 to 70) in Phase 1 and 290 patients (median age: 60, IQR: 43 to 77) in Phase 2. Procedures included cranial, spinal, and peripheral nerve surgeries. Phase 1 recorded 30 nonclinical alarms and no clinical alarms. In contrast, Phase 2 registered 14,500 clinical and 185,744 nonclinical alarms, mostly from detached sensors (177,989/185,744; 96%). Clinical alarms were mainly due to hypoxia (8305/14,500; 57%) and tachycardia (3487/14,500; 30%). Most alarms were acknowledged within 30 seconds (clinical: 12,969/14,500; 90% and nonclinical: 181,447/185,744; 98%), with delayed responses mostly for nonclinical events (3625/4189; 87%). Nurses reported improved convenience, usability, and system connection in Phase 2.

Conclusions: Wearable-based vital sign monitoring is feasible on neurosurgical wards, but high nonclinical alarm rates highlight the need to refine alarm management strategies for effective clinical integration.

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: 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.

There is still no clear evidence of the efficacy of the application of neuroprotective agents (NPAs) for acute ischemic stroke (AIS) patients receiving reperfusion therapies. This meta-analysis aimed to determine the effects of NPAs versus placebo on functional and safety outcomes as an adjunctive treatment to intravenous thrombolysis (IVT) or endovascular therapy (EVT) in AIS patients. The primary outcome was neurological functional independence, as evaluated by the proportion of patients whose modified Rankin Scale scores were 0 to 2 at 90 days after treatment. Thirteen randomized controlled trials with a total of 3736 patients were included. The application of NPAs was associated with greater odds of functional independence (odds ratio [OR]: 1.28; 95% CI: 1.12 to 1.46; P < 0.001; I2 = 0.0%) within 90 days. However, subgroup analysis of reperfusion therapy type (IVT, EVT, or both) revealed that only the EVT subgroup showed a significant association between NPAs or placebo and functional independence at 90 days (EVT group, OR: 1.43; 95% CI: 1.05 to 1.94; P = 0.022; I2 = 0.0%; IVT group, OR: 1.51; 95% CI: 0.93 to 2.46; P = 0.099; I2 = 39.8%; IVT plus EVT group, OR: 1.17; 95% CI: 0.94 to 1.45; P = 0.157; I2 = 16.0%). This meta-analysis revealed that NPAs could increase the possibility of AIS patients undergoing reperfusion therapies achieving functional independence within 90 days of onset; however, with the limited number of studies on each drug, further evidence is still needed to demonstrate the efficacy of each individual agent as an adjunctive therapy for different means of reperfusion.

Background: The perioperative management of chronic aspirin therapy in patients undergoing elective brain surgery is challenging due to the risk of bleeding and thromboembolic events. Although aspirin discontinuation reduces the bleeding risk, it can increase thrombotic complications, particularly in patients at high risk of cardiovascular complications. This Delphi study aimed to develop consensus-based guidelines to address these clinical challenges.

Methods: A 2-round Delphi survey was conducted among an international panel of 42 experienced anesthesiologists and neurosurgeons. Participants assessed the risks and benefits of perioperative aspirin management, including bleeding risk, thrombotic risk, timing of cessation and resumption, and the utility of platelet function testing. Consensus was defined as ≥80% agreement in round 2.

Results: Round 1 highlighted significant variability in practice patterns. In round 2, consensus was reached on several key areas. Most experts (84%) agreed that continuing aspirin increases perioperative bleeding risk in high-risk procedures, with 87% recommending discontinuing aspirin 5 to 7 days before surgery. Nearly all experts (97%) supported continuing low-dose aspirin in high-thrombotic-risk patients. Conversely, for low-thrombotic-risk patients, only 65% agreed on aspirin continuation, reflecting an ongoing debate. No consensus was reached regarding routine platelet function testing.

Conclusions: This Delphi study provides experience-based recommendations for managing chronic aspirin therapy in neurosurgical patients. The panel strongly supports aspirin continuation in high-thrombotic-risk patients, with cessation 5 to 7 days before high-bleeding-risk surgeries. Individualized management is advised for low-bleeding-risk procedures and low-thrombotic-risk patients. Future research should further clarify aspirin management in these groups and explore the role of platelet function testing in neurosurgical settings.

Background: Postoperative delirium is a common complication in older adults, associated with poor outcomes, morbidity, mortality, and higher health care costs. Older age is a strong predictor of delirium. Intraoperative burst suppression on the electroencephalogram (EEG) has also been linked to postoperative delirium and poor neurocognitive outcomes.

Methods: In this a secondary analysis of data from the Perioperative Anesthesia Neurocognitive Disorder Assessment-Geriatric (PANDA-G) observational study, the raw EEGs of 239 spine surgery patients were evaluated. Associations between delirium and age, device-generated burst suppression ratio, and visual detection of the raw EEG were compared.

Results: Demographics and anesthesia durations were similar in patients with and without delirium. There was a higher incidence of burst suppression identified by analysis of the raw EEG in the delirium group than in the no delirium group (73.45% vs. 50.9%; P =0.001) which appeared to be driven largely by a higher incidence of burst suppression during maintenance of anesthesia (67.2% vs. 46.3%; P =0.004). Burst suppression was more strongly associated with delirium than with age; estimated linear regression coefficient for burst suppression 0.182 (SE: 0.057; P =0.002) and for age 0.009 (SE: 0.005; P =0.082). There was no significant interaction between burst suppression and age (-0.512; SE: 0.390; P =0.190). Compared with visual detection of burst suppression, the burst suppression ratio overestimated burst suppression at low values, and underestimated burst suppression at high values.

Conclusion: Intraoperative burst suppression identified by visual analysis of the EEG was more strongly associated with delirium than age in older adults undergoing spine surgery. Further research is needed to determine the clinical importance of these findings.

Background: Propofol is widely used in neurosurgery, with its dosage typically based on patient weight and variability. While factors like age, sex, and cognitive function are known to influence propofol requirements, the impact of preoperative hearing function remains underexplored. This study investigates the relationship between hearing loss and propofol sensitivity in vestibular schwannoma surgery patients.

Methods: This retrospective study analyzed 475 patients who underwent vestibular schwannoma resection between May 12, 2020, and February 28, 2024. Total intravenous anesthesia (TIVA) with propofol and remifentanil was used, maintaining BIS values between 40 and 60. Hearing impairment was defined as a pure tone average (PTA) ≥20 dB. Multivariable linear regression was used to assess the relationship between preoperative hearing function and propofol requirements.

Results: The hearing-impaired group was older (51.7±10.5 vs. 42.9±10.5 y, P <0.001) and required lower median (IQR) propofol doses (96.7 [85.2 to 115.2] vs. 109.0 [91.4 to 126.9] μg·kg -1 ·min -1 , 95% CI: 5.511-15.016, P <0.001). In unadjusted analysis, hearing loss (PTA ≥20 dB) was associated with reduced propofol requirements (OR: -10.4, P <0.001). This association remained significant in multivariable analysis adjusting for age, sex, ASA, BMI, and anesthesia provider (ORadj: -5.0; 95% CI: -9.8 to -0.2; P =0.040).

Conclusion: Hearing loss is associated with increased propofol sensitivity in vestibular schwannoma surgery, highlighting its potential relevance in anesthesia management.

Perioperative neurocognitive disorder (pNCD) and stroke are frequent and serious complications following noncardiac surgery, leading to increased mortality and healthcare expenditure. While intraoperative hypotension has long been considered a potentially modifiable risk factor through its impact on cerebral perfusion, a direct role in causing pNCD is now challenged. Large randomized controlled trials, including the recent CogPOISE trial, have demonstrated that strategies targeting higher perioperative mean arterial pressure do not reduce the incidence of delirium, long-term cognitive decline, or major vascular events in the surgical population. These findings suggest that the "one size fits all" approach to blood pressure management is insufficient. The pathophysiology of perioperative brain injury is multifactorial, and the role of cerebral hypoperfusion remains uncertain. Future research must shift from population-based blood pressure thresholds towards investigating the impact of personalized, multimodal, neurophysiology-guided care for vulnerable patients, including cerebral autoregulation and metabolic markers to protect against pNCD and stroke.

Antiplatelet and anticoagulant medications are widely prescribed to the general population for therapeutic and prophylactic purposes in a wide range of diseases, mainly of cardiovascular interest, spanning from acute events such as acute coronary syndromes (ACS), strokes, and thromboembolic disorders to chronic conditions like atrial fibrillation (AF) and peripheral vascular diseases. The management of such therapies is expected to escalate over time due to the aging population, which has a growing need for these medications, and the rising demand for surgical procedures. The management of anticoagulants and antiplatelets still represents a tough challenge for clinicians in elective neurosurgical procedures, where the balance between preventing thromboembolic events and an increased bleeding risk plays a crucial role in all phases of the perioperative setting. Managing antiplatelet and anticoagulant drugs in elective neurosurgery is complex and requires a tailored and multidisciplinary approach. Careful assessment of patient factors, surgery type, and potential risks and benefits is essential. POC testing can be valuable in optimizing therapy management and bleeding risk assessment. This narrative review for clinicians aims to provide an updated overview of the management of these drugs in the perioperative setting of elective neurosurgical procedures. We explored coagulation abnormalities commonly found in neurosurgical patients, the pharmacological profile of each class of drugs, the appropriate management according to the type of procedure (brain or spinal), and the available diagnostic tests, focusing on the application of point-of-care (POC) coagulation testing.