Journal of neurosurgical anesthesiology最新文献

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.

Background: Some anesthetic drugs reduce the amplitude of transcranial electrical motor-evoked potentials (MEPs). Remimazolam, a new benzodiazepine, has been suggested to have little effect on MEP amplitude. This prospective, preliminary, dose-escalation study aimed to assess whether remimazolam is associated with lower MEP amplitude in a dose-dependent manner.

Methods: Ten adult patients scheduled for posterior spinal fusion were included in this study. General anesthesia was induced with a continuous infusion of remifentanil and remimazolam. After the patient lost consciousness, the infusion rate of remimazolam was set to 1 mg/kg/h, and the patient underwent tracheal intubation. Baseline MEPs were recorded under 1 mg/kg/h of remimazolam in a prone position. Thereafter, the infusion rate of remimazolam was increased to 2 mg/kg/h, with a bolus of 0.1 mg/kg. Ten minutes after the increment, the evoked potentials were then recorded again. The primary endpoint was the MEP amplitude recorded in the left gastrocnemius muscle at 2 time points.

Results: There was no difference in MEP amplitude recorded from the left gastrocnemius muscle before and after increasing remimazolam (median [interquartile range]: 0.93 [0.65 to 1.25] mV and 0.70 [0.43 to 1.26] mV, respectively; P =0.08). The average time from the cessation of remimazolam administration to neurological examination after surgery was 4 minutes using flumazenil.

Conclusions: This preliminary study suggests that increasing remimazolam from 1 to 2 mg/kg/h might have an insignificant effect on transcranial electric MEPs.

In this review article, we explore the implementation and outcomes of enhanced recovery after spine surgery (spine ERAS) across different World Bank country-income levels. A systematic literature search was conducted through PubMed, Embase, Scopus, and CINAHL databases for articles on the implementation of spine ERAS in both adult and pediatric populations. Study characteristics, ERAS elements, and outcomes were analyzed and meta-analyses were performed for length of stay (LOS) and cost outcomes. The number of spine ERAS studies from low-middle-income countries (LMICs) increased since 2017, when the first spine ERAS implementation study was published. LMICs were more likely than high-income countries (HICs) to conduct studies on patients aged ≥18 years (odds ratio [OR], 6.00; 95% CI, 1.58-42.80), with sample sizes 51 to 100 (OR, 4.50; 95% CI, 1.21-22.90), and randomized controlled trials (OR, 7.25; 95% CI, 1.77-53.50). Preoperative optimization was more frequently implemented in LMICs than in HICs (OR, 2.14; 95% CI, 1.06-4.41), and operation time was more often studied in LMICs (OR 3.78; 95% CI, 1.77-8.35). Implementation of spine ERAS resulted in reductions in LOS in both LMIC (-2.06; 95% CI, -2.47 to -1.64 d) and HIC (-0.99; 95% CI, -1.28 to -0.70 d) hospitals. However, spine ERAS implementation did result in a significant reduction in costs. This review highlights the global landscape of ERAS implementation in spine surgery, demonstrating its effectiveness in reducing LOS across diverse settings. Further research with standardized reporting of ERAS elements and outcomes is warranted to explore the impact of spine ERAS on cost-effectiveness and other patient-centered outcomes.