INTRODUCTION: Postanesthesia Care Unit delirium (PACU-D) is associated with significant morbidity, including longer hospital length of stay and postoperative delirium. Identifying at-risk individuals may help mitigate lo...INTRODUCTION: Postanesthesia Care Unit delirium (PACU-D) is associated with significant morbidity, including longer hospital length of stay and postoperative delirium. Identifying at-risk individuals may help mitigate long-term consequences. We sought to determine if there was an association between performance on a preoperative 5-minute visual paired comparison task (VPC) or maximum constriction velocity (automated pupillometry) with the development of PACU-D. METHODS: This was a prospective, observational study. Patients undergoing elective surgery under general anesthesia were eligible if PACU recovery was anticipated. All patients underwent VPC testing and pupillometry measurements in the preoperative clinic. Postoperatively, the patients were screened for delirium on 3 scales at 15 and 60 minutes following PACU admission. RESULTS: Two hundred forty-eight subjects completed preoperative testing, with complete pupillometry and VPC data in 199 subjects. A positive delirium screen was found in 39.5% of 200 subjects at 15 minutes and 21% of 196 subjects at 60 minutes. At 15 and 60 minutes, 30% and 22% of subjects had concordant positive delirium screens on all 3 scales, respectively. VPC ≤ 0.75 was associated with PACU-D on the Confusion Assessment Method for the Intensive Care Unit screen at 60 minutes ( P =0.043, Fisher Exact Test). Continuous VPC (odds ratio [OR] 0.84 per change of 0.05, 95% CI: 0.73-0.98 at 15 min; OR 0.84 per change of 0.05, 95% CI: 0.71-0.98 at 60 min) was associated with PACU-D. Maximum constriction velocity was not associated with PACU-D. CONCLUSIONS: Our study showed that a VPC < 0.75 may be associated with PACU-D.
BACKGROUND: Cerebral venous thrombosis (CVT) is a major cause of stroke in young adults, but existing prognostic scores rely only on clinical and radiologic data and may not reflect brain function. We evaluated the use o...BACKGROUND: Cerebral venous thrombosis (CVT) is a major cause of stroke in young adults, but existing prognostic scores rely only on clinical and radiologic data and may not reflect brain function. We evaluated the use of noninvasive multimodal brain monitoring (MBM) in moderate-to-severe CVT and its added prognostic value over the Cerebral Venous Thrombosis-Grading Scale (CVT-GS). MATERIALS AND METHODS: In this prospective observational study, 53 patients with moderate-to-severe CVT admitted to a tertiary neurosciences center (September 2021 to March 2023) underwent bedside MBM within 24 hours of admission. Tools included transcranial Doppler (TCD) for flow velocities, pulsatility index (PI), and autoregulation (transient hyperemic response ratio [THRR]); ultrasound for optic nerve sheath diameter (ONSD); bispectral index (BIS); and regional cerebral oxygen saturation (rSO₂). Neurological outcome was assessed at 1 month using the modified Rankin Scale (mRS). Predictors were analyzed using correlation and logistic regression. ROC curves were compared with the DeLong test. RESULTS: At 1 month, 27 patients (50.9%) had a poor outcome (mRS ≥3), including 12 deaths (22.6%). Raised ONSD, elevated PI, impaired autoregulation (THRR ≤1.02), and reduced BIS were significantly associated with poor outcome and mortality, while rSO₂ and most TCD velocities were not. Adding MBM to CVT-GS improved accuracy: for mortality: adding ONSD and PI increasedAUC from 0.74 to 0.91; for poor outcome: addingTHRR and BIS increasedAUC from 0.76 to 0.92 (both P<0.05). CONCLUSIONS: Noninvasive MBM can be used in patients with CVT. Integrating noninvasive surrogates of ICP, autoregulation, and brain electrical activity with CVT-GS improves outcome prediction.
Prior ischemic stroke is a strong risk factor for perioperative mortality and morbidity, including recurrent stroke and other major adverse cardiovascular events. These risks are highest in the months after stroke and de...Prior ischemic stroke is a strong risk factor for perioperative mortality and morbidity, including recurrent stroke and other major adverse cardiovascular events. These risks are highest in the months after stroke and decline over time. Increasing the interval between stroke and surgery may decrease the risk of perioperative complications. The benefits of delay must be weighed against the risks of postponing surgery. In this focused review, we examine 5 major studies of the timing of surgery after ischemic stroke. On the basis of this evidence, we provide a framework to guide the appropriate scheduling of surgery after stroke.
BACKGROUND: Studies on oxygenation in acute ischemic stroke (AIS) mainly focus on the prehospital care and during endovascular therapy (EVT). This study aimed to explore the association between arterial oxygenation level...BACKGROUND: Studies on oxygenation in acute ischemic stroke (AIS) mainly focus on the prehospital care and during endovascular therapy (EVT). This study aimed to explore the association between arterial oxygenation levels within the first 24 hours of intensive care unit (ICU) admission and neurological recovery, as well as pulmonary complications in AIS patients after EVT. METHODS: We conducted an exploratory analysis of the multicenter RESCUE-RE registry, including 532 AIS patients who underwent EVT at 18 comprehensive stroke centers in China from January 2019 to June 2024. Patients were categorized by arterial blood gas measurements within 24 hours post-ICU admission into hypoxemia (PaO2 <80 mm Hg), normoxemia (PaO2 80 to 120 mm Hg), and hyperoxemia (PaO2>120 mm Hg) groups. The primary outcome was functional independence (modified Rankin Scale [mRS] score 0 to 2) at 90 days. Secondary outcomes included other mRS thresholds, 90-day all-cause mortality, neurological improvement/deterioration, and pulmonary infection incidence. Multivariable regression adjusted for confounders assessed associations between PaO2 levels and outcomes. RESULTS: Functional independence rates at 90 days did not differ significantly among hypoxemia (26.8%), normoxemia (27.2%), and hyperoxemia (24.5%) groups (P=0.788). Adjusted analyses showed no significant association between PaO2 levels and neurological outcomes or mortality. Secondary outcomes, including neurological changes, were also comparable across groups. Notably, normoxemia and hyperoxemia were associated with significantly lower pulmonary infection risk compared with hypoxemia (adjusted ORs: 0.48 to 0.63). CONCLUSIONS: In AIS patients undergoing EVT, early postoperative arterial oxygenation was not associated with 90-day neurological recovery, whereas hypoxemia was associated with pulmonary infection.
BACKGROUND: The association between preoperative blood pressure and 30-day postoperative mortality in patients undergoing craniotomy for brain tumors remains unclear. This study aims to investigate this relationship and...BACKGROUND: The association between preoperative blood pressure and 30-day postoperative mortality in patients undergoing craniotomy for brain tumors remains unclear. This study aims to investigate this relationship and to identify specific blood pressure thresholds that may increase the risk of 30-day postoperative mortality. METHODS: This retrospective cohort study analyzed electronic health records of adults who underwent brain tumor craniotomy at West China Hospital, Sichuan University, between January 2011 and March 2021. Preoperative blood pressure parameters-systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and pulse pressure (PP)-were collected. Adjusted multivariable logistic regression models with restricted cubic splines were developed to assess 30-day mortality. RESULTS: A total of 12,643 patients were included, with a 30-day mortality of 1.8% (233/12,643). Both low and high preoperative blood pressure were linked to increased 30-day mortality, with U-shaped relationships observed for SBP, DBP, MAP, and PP. Compared with reference ranges (SBP: 120 to 140 mm Hg, DBP: 70 to 80 mm Hg, MAP: 90 to 110 mm Hg, and PP: 45 to 65 mm Hg), the strongest associations occurred at SBP ≥160 mm Hg (adjusted OR: 2.85, 95% CI: 1.44-5.67), DBP ≥100 mm Hg (OR 2.73, 95% CI: 1.52-4.93), MAP ≥130 mm Hg (OR 4.80, 95% CI: 1.66-13.94), and PP ≥85 mm Hg (OR 4.50, 95% CI: 1.52-13.29). CONCLUSIONS: Both low and high preoperative blood pressure were associated with increased 30-day mortality, demonstrating U-shaped relationships across all blood pressure parameters. Prospective studies are needed to test whether modification of preoperative blood pressure changes risk.
BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition characterized by high morbidity and mortality. Electroencephalography (EEG) is often used in the management of critically ill patients...BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition characterized by high morbidity and mortality. Electroencephalography (EEG) is often used in the management of critically ill patients in the intensive care unit (ICU). Its role in the management of aSAH is not well known. The objective of this study is to evaluate the role of EEG in the management of aSAH patients by determining the association between EEG and outcomes and resource utilization. METHODS: The National Inpatient Sample (NIS) 2012 to 2017 was queried for adult patients with aSAH. Patients were classified as having received EEG during the hospitalization or not. The NIS-SAH severity score (NIS-SSS) was used to account for illness severity. Weighted multivariable regression models were used to estimate the association between the use of EEG and outcome of interest (total cost of care, length of stay (LOS), in-hospital mortality, and home discharge) adjusting for demographic, comorbidities, and other clinical characteristics. RESULTS: Among 41,896 patients with SAH (mean age 61.3 years, 41.8% male), 3.8% received EEG monitoring and had higher NIS-SSS (11.2 vs. 7.3, P <0.001). In multivariable models, the use of EEG was associated with higher cost of care (β=$113,740, 95% CI: $101,109-126,371) and longer LOS (β=6.21, 95% CI: 5.57-6.85). Patients with EEG had significantly lower risk of death in hospital (ARR=0.86, 95% CI: 0.77-0.96) but lower likelihood of home/self-care discharge (ARR=0.79, 95% CI: 0.70-0.89). CONCLUSION: EEG monitoring was used in a minority of critically ill patients with aSAH. Although associated with increased cost of care and longer LOS, EEG likely averts adverse outcomes in patients with high severity and improves the chance of survival.
INTRODUCTION: Hyperglycemia is a prevalent condition among pediatric neurosurgical patients. However, the impact of postoperative hyperglycemia after pediatric craniotomy remains unexplored. This study aimed to determine...INTRODUCTION: Hyperglycemia is a prevalent condition among pediatric neurosurgical patients. However, the impact of postoperative hyperglycemia after pediatric craniotomy remains unexplored. This study aimed to determine the association between postoperative hyperglycemia and mortality in children undergoing elective craniotomy. METHODS: This was a retrospective, single-center study involving pediatric patients who underwent elective craniotomy. We used multivariable regression to adjust for potential confounders and identify associations between postoperative hyperglycemia and mortality. We defined mild hyperglycemia as 8.3 to 11.1 mmol/L (150 to 200 mg/dL) and severe hyperglycemia as 11.1 mmol/L (200 mg/dL) or higher. The primary outcome was postoperative 90-day mortality. Secondary outcomes included 30-day mortality, composite morbidity, and prolonged hospital stay. RESULTS: This study involved 1309 children undergoing elective craniotomy. Overall, 198 (15.1%) patients experienced mild hyperglycemia, whereas 125 (6.0%) patients experienced severe hyperglycemia. The overall 90-day mortality rate was 6.8% (n=89). Mortality was 5.0% in the normoglycemia group, 9.1% in the mild hyperglycemia group, and 24.1% in the severe hyperglycemia group. Severe hyperglycemia (aOR 3.65, 95% CI: 1.82-7.35) was associated with increased 90-day mortality, while mild hyperglycemia showed no association (aOR 1.84, 95% CI: 1.00-3.40). Similarly, severe hyperglycemia was associated with greater morbidity and prolonged hospital stays. In subgroup analysis, no association was observed in children younger than 5 years (aOR 1.19, 95% CI: 0.49-2.89). CONCLUSION: Among children undergoing elective craniotomy, severe hyperglycemia was associated with increased mortality.
BACKGROUND: Patients undergoing resection of spinal cord tumours require intraoperative neuromonitoring. Transcranial electrical stimulation is used to record myogenic responses during surgery. This study aimed to compar...BACKGROUND: Patients undergoing resection of spinal cord tumours require intraoperative neuromonitoring. Transcranial electrical stimulation is used to record myogenic responses during surgery. This study aimed to compare the effect of 2 anaesthetic regimens, propofol/fentanyl versus desflurane/dexmedetomidine, on the ability to record MEPs with an amplitude of 50 µV or greater. Our secondary outcome compared intraoperative haemodynamics, recovery profile, and postoperative analgesia between the groups. METHODS: We conducted a prospective, double-blinded, open-label, single-centre, randomized controlled trial of 50 adult patients undergoing spinal cord tumour resection with TcmMEP monitoring. Patients were randomized to 2 groups: Group P (n=25) received intravenous anaesthesia with propofol and fentanyl; group D (n=25) received desflurane and dexmedetomidine. RESULTS: We recorded TcmMEP's in 80% of group P and 76% group D (95% CI: -23% to 31%, P=1.00). The time in minutes for spontaneous breathing (21.04±11.31 vs. 8.00±3.42 [8.29-,17.79, P=0.01]), extubation (31.56±17.56 vs. 10.84±3.99 [13.48-27.96; P=0.01]), emergence (33.68±18.11 vs. 10.92±4.01 [15.30-30.22, P=0.001]), discharge readiness (45.00±25.24 vs. 15.56±6.08 [19.00-39.88; P=0.001]) and requirement of first analgesia (136.6±108.04 vs. 230.8±81.33) (-148.58 to -39.82; P=0.01) was lower in group D compared with group P. Postoperative analgesia assessed using the Visual Analogue Score was lower in group D compared with group P at 12 and 24 hours. (1.68±1.18 vs. 0.64±1.31 [0.33-1.74 P=0.001]) :1.4±0.95 vs. 0.36± 0.70 (0.56-1.51; P=0.001). CONCLUSIONS: We found similar rates of successful TcMEP monitoring using desflurane-dexmedetomidine and propofol-fentanyl. Patients who received desflurane-dexmedetomidine had reduced emergence time, discharge readiness, and lower pain scores in the postoperative period.
BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications, leading to prolonged hospital stays and reduced patient satisfaction. Acoustic neuroma (AN) resections are associated with a higher risk of P...BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications, leading to prolonged hospital stays and reduced patient satisfaction. Acoustic neuroma (AN) resections are associated with a higher risk of PONV than other craniotomies. We aimed to detect if preoperative aprepitant is associated with less PONV following AN surgery. METHODS: Perioperative data were collected from the electronic medical record for patients undergoing AN resection between December 19, 2017 and April 26, 2022. Variables were compared between a cohort that received aprepitant and a matched cohort. Univariable and multivariable regression analyses were performed. Our primary outcome was PONV on the day of surgery. RESULTS: A total of 579 patients were included, of which 49% (n=283) developed PONV. A cohort of 108 patients who received aprepitant was matched in a 1:2 manner. Aprepitant was not associated with reduced PONV ( P =0.239, odds ratio=0.756 [95% CI: 0.475-1.204]). On the basis of our univariable logistic regression model, tumor size, a translabyrinthine approach, total dose of propofol, total volume of crystalloids, highest nitrous oxide concentration, and anesthetic duration were associated with decreased odds of PONV. In multivariable regression modeling, none of these characteristics were associated with decreased odds of PONV. CONCLUSION: Our results confirm that PONV is a common complication following AN resection. Preoperative aprepitant administration was not associated with reduced PONV. Intraoperative variables such as the surgical approach and duration of anesthesia might play a role in mitigating the risk of PONV. Future studies should identify other perioperative interventions to allow for the development of protocols addressing PONV.
BACKGROUND: The association between intraoperative hypotension and delirium in patients with brain tumors remains unclear. We thus evaluated the association between intraoperative hypotension and postoperative delirium i...BACKGROUND: The association between intraoperative hypotension and delirium in patients with brain tumors remains unclear. We thus evaluated the association between intraoperative hypotension and postoperative delirium in patients recovering from neurological surgery. METHODS: This was a secondary analysis of 3 prospective studies. Patients aged greater than 18 years who were scheduled for elective craniotomy for resection of glioma or frontotemporal lobe tumor were enrolled. Intraoperative hypotension was quantified through 3 metrics: mean arterial pressure area under the curve, time-weighted mean arterial pressure, and cumulative duration of hypotension. Our primary outcome was the association between hypotension and postoperative delirium. RESULTS: The study comprised 738 patients (median age 56 y; 50% male) undergoing craniotomy for brain tumor resection. Postoperative delirium occurred in 29.0% (95% CI: 25.7%-32.3%) of patients. No statistically significant associations between intraoperative hypotension (absolute mean arterial pressure 60 to 75 mm Hg, relative reductions 10% to 40% from baseline) and postoperative delirium. However, the presence of preoperative tumor midline shift was an independent risk factor for postoperative delirium (adjusted odds ratio: 1.56, 95% CI: 1.09-2.22, P=0.014), and interacted with time-weighted average mean arterial pressure at relative reductions 10% based on the subgroup analysis. CONCLUSIONS: In adult patients undergoing elective craniotomy for tumor resection, no significant association is found between intraoperative hypotension and postoperative delirium.
BACKGROUND: Venous air embolism (VAE) is a potentially catastrophic complication during neurosurgical procedures, particularly in the sitting position. As practices vary widely, we conducted a survey to describe the glob...BACKGROUND: Venous air embolism (VAE) is a potentially catastrophic complication during neurosurgical procedures, particularly in the sitting position. As practices vary widely, we conducted a survey to describe the global practice patterns for intraoperative detection and management of VAE. METHODS: Following institutional review board (IRB) approval, we conducted a cross-sectional study using a 48-question online survey that was distributed via a snowball sampling approach, initially to the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) community and subsequently to international collaborators. Descriptive statistics summarized responses, and proportional comparisons between high-income and low- and middle-income country respondents were assessed using a χ2 or the Fisher exact tests, as appropriate. RESULTS: Of 307 responses, 297 were analyzed, representing 40 countries. Survey response rate was 25% among SNACC members. End-tidal carbon dioxide (EtCO2) monitoring was the most frequently reported VAE monitoring modality, particularly for sitting craniotomies. Common barriers to implementing advanced monitoring included limited equipment availability and a lack of a transesophageal echocardiography (TEE) specialist. Decision-making for cases at VAE risk relied on team consensus (62%), review articles and primary literature (48%), and institutional protocols (42%). Among respondents, 89% expressed interest in consensus guidelines for VAE management. CONCLUSIONS: There is substantial global variability in both the preparation for and management of VAE during neurosurgical procedures. EtCO2 is the preferred monitoring approach in routine practice, as resource limitations prevent the broader adoption of more sensitive techniques, such as TEE. The high interest in consensus guidelines underscores an opportunity for professional societies to standardize approaches and improve patient safety.