BACKGROUND: This study aimed to compare analgesic practices for patients undergoing craniotomy in high-income countries (HICs) and low-income and middle-income countries (LMICs), focusing on variations in medication use...BACKGROUND: This study aimed to compare analgesic practices for patients undergoing craniotomy in high-income countries (HICs) and low-income and middle-income countries (LMICs), focusing on variations in medication use and techniques. METHODS: An English-language and Spanish-language electronic survey was sent to over 300 anesthesiologists in 35 countries from March 22 to May 19, 2024, to gather data on analgesia for craniotomy patients. Anonymous responses through REDCap were analyzed as a whole and by income category (HICs and LMICs). RESULTS: We received 328 responses (105 HICs, 221 LMICs, and 2 missing locations). Acetaminophen was used by 78% of respondents (HIC: 82%, LMIC: 76%), with low nonavailability in both groups (0.95% HICs, 4.98% LMICs). Fentanyl boluses were used in 57% of cases (HIC: 60%, LMIC: 55%). Incisional local anesthesia was administered in 51% (HIC: 52%, LMIC: 50%), with minimal nonavailability (1.9% HIC, 1.4% LMIC). The use of a remifentanil infusion was more common in HICs (64%) than LMICs (31%), where nonavailability was significantly higher (43.89% vs. 7.62% HICs). Scalp blocks were used by 15% of HICs and 43% of LMICs. Craniotomy indication influenced the choice of analgesia for 61% of respondents. CONCLUSIONS: Analgesic practices for craniotomy vary significantly between HICs and LMICs, primarily due to medication availability. Global guidelines should consider resource differences to improve postoperative pain management.
BACKGROUND: In endovascular treatment (EVT) for ischemic stroke, conversion from non-general anesthesia (non-GA) to general anesthesia (GA) may be necessary. This study aims to evaluate the effects of intra-EVT emergency...BACKGROUND: In endovascular treatment (EVT) for ischemic stroke, conversion from non-general anesthesia (non-GA) to general anesthesia (GA) may be necessary. This study aims to evaluate the effects of intra-EVT emergency GA conversion on patient outcomes and to identify potential risk factors for such conversions. METHODS: A retrospective cohort study was conducted on ischemic stroke patients who underwent EVT without GA at a tertiary hospital in China. The primary outcome was the modified Rankin scale (mRS) score at 90 days. Secondary outcomes included procedural duration, rates of successful reperfusion, discharge status, and mRS scores at 1 and 3 months. Multivariable logistic regression, propensity score matching (PSM), and coarsened exact matching (CEM) were utilized to control for confounding factors. RESULTS: Among 418 screened patients, 215 met eligibility criteria (non-GA=172, GA conversion=43). The 3-month mRS scores were similar between GA and non-GA groups across all analyses. However, GA conversion significantly reduced the likelihood of achieving mRS scores of 0 to 3 at discharge (unmatched: OR=0.37; PSM: OR=0.29; CEM: OR=0.33) and at 90 days (unmatched: OR=0.41; PSM: OR=0.38; CEM: OR=0.36). CEM analysis indicated that GA conversion significantly increased the 1-month mortality (OR=2.76). High National Institutes of Health Stroke Scale (NIHSS) scores and the absence of atrial fibrillation emerged as independent predictors of GA conversion. CONCLUSIONS: During EVT, the conversion from non-GA to GA is associated with significant hemodynamic fluctuations and may adversely affect both short-term and long-term neurological outcomes. The likelihood of GA conversion increases with higher NIHSS scores or in the absence of atrial fibrillation.
5-aminolevulinic acid (ALA) is used during resection of malignant gliomas due to its fluorescence properties and has been shown to render resection more effective than resection without ALA guidance. The aim of this narr...5-aminolevulinic acid (ALA) is used during resection of malignant gliomas due to its fluorescence properties and has been shown to render resection more effective than resection without ALA guidance. The aim of this narrative review is to categorize the adverse effects of ALA relevant to anesthesia providers. Intraoperative hypotension, porphyria-related side effects, alterations in blood chemistry and coagulation, photosensitivity, and increased levels of liver enzymes have all been reported. We also sought to examine the impact of dosage and timing of oral administration on efficacy of ALA and on these side effects. Twenty-seven studies met our inclusion criteria of patients undergoing craniotomy for glioma resection using ALA and occurrence of at least one adverse effect. The results of these studies showed that there was heterogeneity in levels of intraoperative hypotension, with some reporting an incidence as high as 32%, and that hypotension was associated with antihypertensive medication use. Clinical symptoms of porphyria, such as gastrointestinal disturbance, were less commonly reported. Photosensitivity of the skin after 5-ALA administration was well documented particularly in patients exposed to light; however, adverse effects on the eye were not adequately studied. Elevation in liver enzymes was a common finding postoperatively but was often clinically insignificant. The timing of oral administration presents practical issues for the preoperative management of patients undergoing resection with ALA. We provide guidance for perioperative management of patients who receive ALA for brain tumor resection. Controlled studies with adequate statistical power are required to further understand and prevent the adverse effects of ALA.
Transfusion strategies in neurocritical care require a delicate and nuanced balance between optimizing oxygen delivery to the injured brain and minimizing transfusion-associated risks. Although restrictive transfusion pr...Transfusion strategies in neurocritical care require a delicate and nuanced balance between optimizing oxygen delivery to the injured brain and minimizing transfusion-associated risks. Although restrictive transfusion protocols are widely adopted in critical care, their applicability to patients with neurological injury remains the subject of debate. Anemia may exacerbate cerebral hypoxia, potentially worsening neurological outcomes, yet transfusion carries risks such as thrombosis, immune modulation, and increased intracranial pressure. Studies comparing liberal and restrictive transfusion strategies in neurocritical care have yielded mixed results, with most settling on the noninferiority of a restrictive approach while still considering a higher threshold for particular subgroups. This focused review will examine the current evidence on transfusion strategies in neurocritically ill patients and highlight key areas for future research.
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 red...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: S evere cerebral venous thrombosis (CVT) patients often require neurointensive care with multimodal monitoring. However, optimal treatment targets for intracranial pressure (ICP), cerebral perfusion pressure...BACKGROUND: S evere cerebral venous thrombosis (CVT) patients often require neurointensive care with multimodal monitoring. However, optimal treatment targets for intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral autoregulation remain unclear. This study investigated the relationships between ICP, CPP, and autoregulation indices (PRx, optimal CPP [CPPopt]) with clinical outcomes in severe CVT. METHODS: This observational study included 15 patients with severe CVT with ICP-monitoring, treated in the neurointensive care (NIC) unit, Uppsala. The percentage of eligible monitoring time (EMT) outside certain thresholds was calculated for ICP, PRx, CPP, and ΔCPPopt (CPP-CPPopt) and analysed in relation to outcome (Glasgow Outcome at Discharge Scale [GODS]). Outcome heatmaps were generated to visualize transitions from better to worse outcomes for single variables and 2 variables (ICP, CPP, or ΔCPPopt in combination with PRx). RESULTS: Median %EMT for ICP>20 mm Hg and CPP<60 mm Hg was <5%. Higher %EMT for ICP>20 mm Hg ( r =-0.60, P =0.02) correlated with worse outcome (lower GODS). The median %EMT of impaired cerebral pressure autoregulation was 34%. Outcome heatmaps indicated transitions toward worse outcome when PRx exceeded zero and ΔCPPopt became negative, but these correlations were not significant. Higher PRx reduced the safe ICP and CPP range, in 2-variable heatmaps. CONCLUSIONS: A higher %EMT of ICP>20 mm Hg was unfavorable in severe CVT. Impaired cerebral autoregulation with high PRx was frequent and may reduce the safe ICP/CPP range. Larger, multi-centre studies are needed to validate these findings in this rare condition.
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 eff...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.
Xu J, Boppana SH, Scott L
… +14 more, Trauner E, Chavarria C, Penberthy K, Nicholson R, Gribensk A, Sklar M, Sun B, Khouzani PJ, Mehrzadeh A, Li N, Raj R, Waldron N, Lee S, Mintz CD