INTRODUCTION: Transcranial electrical stimulation-motor evoked potential (TES-MEP) is used during neurosurgical procedures to assess motor pathway integrity. TES-MEP-associated unexpected movement may compromise surgical...INTRODUCTION: Transcranial electrical stimulation-motor evoked potential (TES-MEP) is used during neurosurgical procedures to assess motor pathway integrity. TES-MEP-associated unexpected movement may compromise surgical precision and anesthetic management. This study aimed to evaluate the incidence of unexpected movements and compare neuroendovascular procedures (NE) versus conventional neurosurgery (CV). METHODS: We conducted a retrospective observational study of patients undergoing TES-MEP monitoring. The primary outcome was the occurrence of TES-MEP-associated unexpected movements. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline differences. Multivariable logistic regression was used to identify factors associated with unexpected movements. Sensitivity and bootstrap analyses were performed to confirm the stability of findings. RESULTS: A total of 252 patients (NE: 63, 25.0%; CV: 189, 75.0%) were included. Overall, unexpected movements occurred in 20 patients (7.9%), with a higher incidence in the NE group (n = 11, 17.5%) compared with the CV group (n = 9, 4.8%). After IPTW adjustment, covariate balance was achieved between the two groups, and NE remained associated with higher odds of movements (weighted OR: 3.78, 95% CI: 1.23 to 11.64). Multivariable analysis showed that earlier MEP initiation and higher total charge per stimulation were independently associated with increased odds of unexpected movements (OR: 0.96 per minute delay, 95% CI: 0.93 to 0.99; OR: 1.04 per µC/phase, 95% CI: 1.03 to 1.06), respectively. CONCLUSION: TES-MEP-associated unexpected movements were more frequent during NE procedures. Procedural timing and total stimulation charge, rather than patient baseline characteristics, were associated with the odds of movement. Future studies should investigate potential interventions to reduce unexpected movements, such as the optimization of MEP stimulation parameters and initiation timing, to enhance intraoperative safety.
BACKGROUND: Variable systemic oxygenation may affect mortality in critically ill patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: In this multicenter retrospective cohort study, data were extracted from...BACKGROUND: Variable systemic oxygenation may affect mortality in critically ill patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: In this multicenter retrospective cohort study, data were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database. Adult patients with aSAH admitted to an intensive care unit (ICU) between January 2018 and June 2024 were included. The arterial oxygen tension during the initial 24 hours in ICU (D1 PaO2), which yielded the highest Acute Physiology and Chronic Health Evaluation III-J oxygenation subscore, was the primary exposure variable. The primary outcome was in-hospital mortality. A multivariable mixed-effects logistic regression model was constructed to determine the adjusted probability of in-hospital mortality based on D1 PaO2. RESULTS: A total of 6446 patients were included. The median D1 PaO2 was 92 mm Hg (IQR: 74 to 138), in-hospital mortality was 20.0% (n=1291), and 12-month mortality was 25.6% (n=1647). A U-shaped multivariable relationship was observed between D1 PaO2 and in-hospital mortality, with 79 mm Hg being associated with a nadir of 16.2%. This varied according to age (65 y and over: 69 mm Hg; below 65 y: 83 mm Hg), admission type (medical: 77 mm Hg; surgical: 89 mm Hg), intubation status (not intubated: 90 mm Hg; intubated: 143 mm Hg), and Glasgow Coma Score (GCS) (GCS 15: 75 mm Hg; GCS 13 to 14: 65 mm Hg; GCS 7 to 12: 96 mm Hg; GCS 3 to 6: 131 mm Hg). CONCLUSIONS: In critically ill patients with aSAH, a U-shaped relationship was noted between D1 PaO2 and in-hospital mortality. This varied according to patient demographics and illness severity.
BACKGROUND: Hyperlactatemia is common during brain tumor craniotomy, although the pathophysiology and association to outcome are unclear. We prospectively investigated prevalence and risk factors for perioperative hyperl...BACKGROUND: Hyperlactatemia is common during brain tumor craniotomy, although the pathophysiology and association to outcome are unclear. We prospectively investigated prevalence and risk factors for perioperative hyperlactatemia (S-lactate ≥2.2 mM) as well as its association with short-term outcomes in patients undergoing elective brain tumor craniotomy. METHODS: In 450 patients, arterial lactate was measured hourly from the first surgical incision until 6 hours postoperatively. The primary outcome was a change in the level of neurological disability, measured by the modified Rankin Scale preoperatively and at 30 days after surgery. Secondary outcomes were length of hospital stay, new neurological deficits at discharge, days alive and out of hospital at 30 days, and 30-day mortality. Hyperlactatemia was analyzed both as a dichotomous (≥1 measurement of S-lactate ≥2.2 mM) and as a continuous variable (lactate load). We used both a multivariable regression and a backward stepwise regression analysis to identify risk factors for hyperlactatemia and factors associated with postoperative outcomes. RESULTS: Hyperlactatemia was seen in 66% of the study participants. No association was found between hyperlactatemia and modified Rankin Scale change from baseline to 30 days or any other clinical outcome. Independent factors associated with hyperlactatemia were mean perioperative glucose (0.14; 95% CI: 0.09-0.18; P<0.001), preoperative glucocorticoid dose (0.09; 95% CI: 0.06-0.12, P<0.001), malignant CNS-derived tumor type (0.25; 95% CI: 0.08-0.42; P=0.004), and inverse noradrenaline dose (-0.02; 95% CI: -0.04 to -0.006, P=0.006). CONCLUSIONS: We did not find an association between perioperative hyperlactatemia and short-term outcomes in patients undergoing brain tumor craniotomy. Preoperative glucocorticoids, perioperative glucose, malignant CNS tumor, and noradrenaline dose were independently associated with hyperlactatemia.
BACKGROUND: Electrocorticography is a valuable technique for guiding resective epilepsy surgery, yet there is heterogeneous literature regarding its efficacy and the influence of anesthetic agents. We examined the anesth...BACKGROUND: Electrocorticography is a valuable technique for guiding resective epilepsy surgery, yet there is heterogeneous literature regarding its efficacy and the influence of anesthetic agents. We examined the anesthetic and neurological outcomes of patients undergoing electrocorticography-guided procedures to characterize our current practice within the pediatric population. METHODS: With ethical approval, we gathered prospective observational data from 24 patients aged 0 to 18-years-old undergoing electrocorticography procedures at British Columbia Children's Hospital. We collected (i) preoperative patient information, (ii) intraoperative anesthetic and neuromonitoring details, (iii) immediate postoperative outcomes, and (iv) Engel Class 1-year postsurgery. RESULTS: Of 24 patients, 63% were male with a median (range) age of 12 (2 to 18) years. Sevoflurane, dexmedetomidine, and remifentanil were the most common maintenance agents, with sevoflurane minimized during electrocorticography recording. Almost all recordings were subjectively rated by the neurologist/neuromonitoring technicians as "good" or "excellent" quality. One procedure was abandoned as the seizure focus area overlapped the eloquent cortex and would have left the patient with a motor deficit. No anesthetic or electrocorticography-related complications were found. One year postoperatively, 68% of patients had complete seizure freedom (Engel class I), 16% had rare disabling seizures (Engel class II), and 12% had worthwhile improvement (Engel class III). CONCLUSIONS: Our team implemented an anesthetic protocol that supports quality electrocorticography recordings and contributes to good postresection seizure outcomes without complications. Future research may identify and explore modifiable factors to improve outcomes in the subset of patients who did not see worthwhile improvement in seizure control (Engel class IV).
BACKGROUND: Intracranial hypertension is a life-threatening complication of acute brain injuries such as traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). In low-income and m...BACKGROUND: Intracranial hypertension is a life-threatening complication of acute brain injuries such as traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). In low-income and middle-income countries (LMICs), limited resources can delay timely neurocritical interventions. Smartphone-based quantitative pupillometry offers a scalable solution for early detection of elevated intracranial pressure (ICP). Here, we assessed its ability to (1) detect raised optic nerve sheath diameter (ONSD), a noninvasive surrogate for elevated ICP, and (2) classify severe TBI. METHODS: Thirty-eight Nepali ICU patients with TBI (n=16), SAH (n=10), or ICH (n=12) underwent daily sonographic ONSD and pupillary light reflex (PLR) assessments through the PupilScreen app (Apertur Inc., Seattle, WA) over 7 days. Machine learning classifiers were trained on PLR features to detect elevated ONSD (>6.0 mm). To identify severe TBI (Glasgow Coma Scale [GCS] ≤8 on admission), classifiers were trained on PLR features, ONSD, or both. RESULTS: For ONSD >6.0 mm, a random forest model achieved an AUC of 0.66, with a sensitivity of 0.31 and specificity of 0.80. For identifying severe TBI, the optimal classifier was a random forest model incorporating ONSD and a subset of PLR metrics, with a sensitivity of 0.93, specificity of 1.00, and AUC of 0.96. CONCLUSION: In this pilot study, smartphone-based pupillometry showed modest ability for detecting elevated ONSD. However, its high performance in severe TBI classification warrants further evaluation. Larger, multicenter studies evaluating triage utility in prehospital and resource-limited settings are warranted to validate and extend these findings.
BACKGROUND: Static or averaged electroencephalography (EEG) metrics may fail to capture dynamic cerebral changes during surgery. We assessed the EEG features during aortic arch surgery with cardiopulmonary bypass (CPB) a...BACKGROUND: Static or averaged electroencephalography (EEG) metrics may fail to capture dynamic cerebral changes during surgery. We assessed the EEG features during aortic arch surgery with cardiopulmonary bypass (CPB) and total circulatory arrest (TCA) to identify key EEG predictors of postoperative delirium (POD). METHODS: This retrospective study analyzed intraoperative EEG data from 233 patients across 5 phases: pre-CPB, CPB initiation, TCA, post-TCA, and post-CPB. The predictive potential of EEG parameters was assessed using logistic regression, and phase-specific nomogram models were developed. The primary analysis included emergency cases; elective cases were included in sensitivity analyses. RESULTS: POD occurred in 78 patients (44.8%). Phase-specific models showed high predictive performance. Independent predictors of POD included reduced alpha power during the post-CPB phase (odds ratio [OR]=0.76, 95% CI: 0.67-0.87, P <0.001) and lower delta power during TCA (OR=0.87, 95% CI: 0.79-0.96, P =0.031). In addition, elevated BSR during CPB initiation (OR=1.53, 95% CI: 1.24-1.89, P <0.001) and post-TCA (OR=1.37, 95% CI: 1.11-1.70, P =0.008) predicted increased POD incidence. A similar, but nonsignificant, observation for alpha power was observed during the pre-CPB phase ( P =0.103). Calibration plots showed strong agreement between predicted and observed outcomes. CONCLUSIONS: Phase-specific EEG monitoring reliably predicted POD during aortic arch surgery. Predictive factors varied across intraoperative phases, underscoring the dynamic sensitivity of EEG to physiological changes. Comprehensive, phase-specific EEG assessment may improve risk stratification and perioperative management, though large prospective studies are needed to confirm these findings.
The optimal anesthetic technique during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) remains uncertain. General anesthesia (GA) provides airway protection and procedural stability, whereas conscious se...The optimal anesthetic technique during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) remains uncertain. General anesthesia (GA) provides airway protection and procedural stability, whereas conscious sedation (CS) offers faster workflow and the ability to monitor neurological status. This updated systematic review and meta-analysis (SRMA) aims to summarize and update the existing literature from randomized controlled trials (RCTs) to guide the selection of the most appropriate anesthetic technique during EVT for AIS. We searched the electronic databases of PubMed, ProQuest, and Scopus from their inception to October 17, 2025. No time or language restrictions were applied. Only RCTs were included. The SRMA protocol was registered with PROSPERO (ID: CRD420251170612) on 18th October 2025. Statistical analysis was performed using Review Manager software. Risk of bias (RoB) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were assessed. Of the 348 records screened, ten eligible RCTs were included. GA was associated with a significantly higher rate of successful reperfusion, but there was no difference in 90-day functional independence on modified Rankin scale (mRS) score, or mortality compared with CS. GA increased the risk of hypotension and prolonged the door-to-puncture time, but not other complications or process times. The RoB was low for most included studies. The certainty of evidence for study outcomes was moderate on GRADE. To conclude, GA has superior recanalization rates than CS, but functional outcomes and mortality are similar. Conversely, hypotension occurs more frequently with GA, while CS provides a faster workflow.
BACKGROUND: Cervical spine fusion causes limited neck mobility, a known risk factor for increased difficulty of endotracheal intubation. Cervical spine fusion surgeries are increasingly performed. The objective of this s...BACKGROUND: Cervical spine fusion causes limited neck mobility, a known risk factor for increased difficulty of endotracheal intubation. Cervical spine fusion surgeries are increasingly performed. The objective of this study was to determine the relationship between previous cervical spine fusion and subsequent endotracheal intubation. MATERIALS AND METHODS: This retrospective study included adult patients undergoing elective surgery requiring endotracheal intubation between 2015 and 2023. We used multivariable logistic regression to identify variables independently associated with the primary outcome: requiring more than one intubation attempt. Sensitivity analyses examined the outcome within only fusion patients. RESULTS: We identified 938 patients, 436 with a history of cervical fusion, with 493 intubation attempts, and 502 nonfusion patients with 543 intubation attempts. The majority of the sample (91.5%) had fusion involving C3 or below, with 6.2% having a C1/C2 fusion(2.3% were missing the level of fusion). The success of the first attempt was 89.2% versus 92.6%, 8.5% versus 6.6% second attempt, and 2.3% versus 0.8% third attempt for fusion versus nonfusion patients, respectively. Requiring more than one attempt was associated with short thyromental distance, using multiple laryngoscopes, mouth trauma, and trainee status, but not with spinal fusion status (OR=1.29; 95% confident interval=079-2.12; P=0.312). CONCLUSION: Patients with a history of cervical spine fusion undergoing elective intubation experience similar rates of first intubation attempt failure compared with those without fusion when controlling for provider experience. Requiring more than one intubation attempt was associated with short thyromental distance, using multiple laryngoscopes, a trainee provider, and mouth trauma, but not a history of cervical fusion.