Journal of neurosurgical anesthesiology最新文献

Background: Intraoperative neuromonitoring (IONM) is used to detect neurological complications during carotid endarterectomy (CEA), and current data show mixed results in clinical outcomes. This study aimed to examine health care utilization metrics and outcomes relating to the use of IONM in CEA using a large national database in the USA.

Methods: Data were abstracted from the 2016 to 2021 Nationwide Readmissions Database. The primary aim was to evaluate whether adverse neurological events, hospital costs, length of stay (LOS), and routine discharge differed by the presence of IONM. We additionally evaluated whether all-cause 30-day and 90-day readmissions, and in-hospital mortality differed by IONM. We adjusted outcomes to control for age, comorbidity burden, left-sided surgery, and elective admission.

Results: There were an estimated 283,045 hospitalizations for CEA, of which 13,469 (4.79%) had IONM. IONM was associated with 12% longer adjusted stays, 16% higher adjusted costs and 35% lower odds of routine discharge ( P <0.001). In addition, IONM was associated with increased odds of an adverse neurological event, which included ischemic and hemorrhagic cerebrovascular complications (IONM: 19.40% vs. 12.65%, aOR: 1.31, 95% CI: 1.18-1.45, P <0.001). Lower income quartiles and rural/nonteaching facilities were associated with lower odds of IONM use. There were no differences in mortality or all-cause readmissions.

Conclusions: Our findings showed worse outcomes associated with IONM use during CEA. IONM is typically utilized in high-surgical-risk patients, largely accounting for our findings. The higher costs, longer hospital stays, and lower odds of routine discharge associated with IONM use need to be balanced with potential benefits. We also found significant disparities based on facility type and income. Detailed procedural risk factors, which are lacking from this data, limit the results of this study.

Objective: Beta-blockers have been studied for their impact on traumatic brain injury (TBI). We aimed to examine the association of preinjury beta-blocker exposure with early brain injury biomarker levels and outcomes following TBI.

Methods: We retrospectively studied adults (≥40 y) participating in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. The exposure was preinjury beta-blocker utilization. Primary outcome was blood-based brain injury biomarker levels on day 1 following injury. Secondary outcomes included biomarkers on days 3 and 5, hospital mortality, and the 6-month Glasgow Outcome Scale-Extended. Inverse probability-weighted models assessed the association between preinjury beta-blocker exposure, biomarker levels, and outcomes, stratified by TBI severity.

Results: A total of 1185 patients were included, with 101 on preinjury beta-blockers (BB+): 21 in the moderate/severe group and 80 in the mild TBI group. BB+patients were older than BB- in both mild (67 vs. 57 y, P<0.001) and moderate/severe TBI (64 vs. 56 y, P=0.003). Hypertension was more common in BB+patients (78% mild, 67% moderate/severe, P<0.001). Preinjury beta-blocker use was not associated with day 1 biomarker levels. The 6-month GOSE scores in the BB+ moderate/severe TBI were lower, but the effect was marginal (B= -1.20, 95% CI: -2.39 to -0.01, P=0.049).

Conclusion: Our study did not find a clear association between preinjury beta-blocker exposure and day 1 blood-based brain injury biomarkers or clinical outcomes. These findings warrant confirmation in future studies with larger cohorts.

Background: Carotid blowout syndrome (CBS) is a life-threatening emergency involving the rupture of the carotid arteries and/or branches, often following surgery and radiotherapy for head and neck cancer. Our case series aimed to describe airway management strategies, endovascular and surgical approaches, perioperative resuscitation management, and clinical outcomes in a cohort of patients with CBS at a tertiary referral academic health center.

Methods: We retrospectively identified patients presenting with CBS between 2017 and 2021. Airway management, procedural treatment techniques, perioperative management, and clinical outcomes were extracted from the chart for each CBS occurrence.

Results: We identified 76 total cases among 62 patients (n=20 [26.3%] female; median age: 61.5 [IQR: 56 to 67]). Three cases were type I (threatened), 18 were type II (impending), 53 were type III (active bleed), and 2 were undeterminable. The most common airway management strategies were a pre-existing airway (n=37 [48.7%]), oral awake bronchoscopic intubation (n=14 [18.4%] occurrences), or nasal awake bronchoscopic intubation (n=8 [10.5%] occurrences). Resuscitation per case included intravenous crystalloid (mean: 1484 mL, SD: 791 mL), red blood cells (mean: 272 mL, SD: 906 mL), fresh frozen plasma (mean: 49 mL, SD: 400 mL), and platelets (mean: 11 mL, SD: 94 mL). Perioperative mortality was 16.1%. Thirty-nine patients (62.9%) died by the time of review (median: 157 mo, IQR: 92 to 205 mo).

Conclusions: Perioperative management of CBS is challenging, particularly airway management, in which awake bronchoscopic intubation was common. Endovascular interventions were commonly performed. The investigation highlights the importance of advanced airway management strategies for patients with CBS.

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: 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.

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.