BACKGROUND: Although general anesthesia is commonly utilized for endovascular thrombectomy for acute ischemic stroke, whether anesthetic agents affect clinical outcome is unknown. Retrospective studies comparing propofol...BACKGROUND: Although general anesthesia is commonly utilized for endovascular thrombectomy for acute ischemic stroke, whether anesthetic agents affect clinical outcome is unknown. Retrospective studies comparing propofol and volatile agents have shown mixed results. A randomized controlled trial is needed to determine whether anesthetic agent affects clinical outcomes. This pilot study aimed to evaluate the feasibility of conducting a definitive randomized controlled trial comparing propofol and sevoflurane-based anesthesia in patients undergoing endovascular thrombectomy. METHODS: Patients booked to undergo endovascular thrombectomy were randomized to receive either propofol or sevoflurane-based general anesthesia. Feasibility outcomes assessed were recruitment rate, protocol adherence, and data completeness. Secondary outcomes included functional recovery (90-d modified Rankin Scale 0 to 2), mortality, early neurological improvement, blood pressure control intraoperatively and postoperatively, and adverse events. We also assessed for independent risk factors for functional recovery and death. RESULTS: Of 201 eligible patients, 93 (46.3%) were enrolled and 73 (36.3%) included in the final analysis. The consent and randomization model was challenging. Adherence to drug protocols was 94.5%. Data completion rate was 99%. There were no differences in secondary outcomes between groups. Mortality was associated with higher admission National Institutes of Health Stroke Scale. Higher 90-day modified Rankin scores were associated with higher systolic blood pressures pre-reperfusion ( r =0.32, P <0.01) and post-reperfusion ( r =27, P =0.03). CONCLUSIONS: A definitive randomized controlled trial of propofol and sevoflurane-based anesthesia is feasible. Future studies would benefit from adapting the trial model to better integrate research into the clinical workflow. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12621000074897), January 29, 2021.
BACKGROUND: Opioid-free anesthesia (OFA) offers potential benefits of smoother recovery and reduced complications, compared with conventional opioid-based approach. We aimed to evaluate the use of OFA as an alternative a...BACKGROUND: Opioid-free anesthesia (OFA) offers potential benefits of smoother recovery and reduced complications, compared with conventional opioid-based approach. We aimed to evaluate the use of OFA as an alternative approach to conventional opioid-based anesthetic regimen in patients undergoing supratentorial brain tumor surgery. METHODS: Adult patients (>18 y) with supratentorial tumors undergoing elective craniotomy under general anesthesia (Aug 2022 to Dec 2023) were randomized into Dexmedetomidine (group D) or Fentanyl (group F) group. Primary outcome included emergence and extubation times and secondary outcomes were hemodynamic responses, pain scores, rescue analgesic use, and complications. RESULTS: A total of 44 patients were randomized (22 per group). Of these, 33 patients completed the study. Demographic variables were comparable, except for age and body mass index. Emergence (8.2±3.3 min vs. 6.8±2.6 min [ P =0.18]; Mean Difference [MD], 95% CI: 1.42, -0.69 to 3.55) and extubation times (12.7±4.2 min vs. 11.2±3.9 min [ P =0.27]; MD, 95% CI: 1.58, -1.31 to 4.46) were comparable between the groups, respectively. Group D demonstrated better hemodynamic stability during Mayfield pin application and tracheal extubation. Postoperative pain scores were similar, except at 12 hours, where group D reported lower Numerical Rating Scale. Postoperative Richmond Agitation-Sedation Scale at different time points was comparable between the groups. CONCLUSION: Our preliminary data suggest that OFA may provide better hemodynamic stability and improved pain control at 12 hours compared with opioid-based anesthesia, while maintaining similar emergence and extubation times.
Alsolivany J, Mosch L, Wessels L
… +7 more, Hallek L, Sargut TA, Spies C, Vajkoczy P, Balzer F, Poncette A, Hecht N
J Neurosurg Anesthesiol
· 2026 Apr · PMID 41529102
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BACKGROUND: Continuous, wearable-based vital sign monitoring can enhance patient safety and reduce intensive care demands but is not routinely used on standard neurosurgical wards. This study assessed alarm events and te...BACKGROUND: Continuous, wearable-based vital sign monitoring can enhance patient safety and reduce intensive care demands but is not routinely used on standard neurosurgical wards. This study assessed alarm events and technology acceptance during the implementation of such a system for postoperative patients in a university hospital's neurosurgical ward. METHODS: In this pilot feasibility study, selected patients were continuously monitored for 12 to 24 hours after elective neurosurgery on a 44-bed ward. Phase 1 (June to December 2019) used 12 mobile units with manual alarm documentation; Phase 2 (August 2023 to January 2024) used 44 fixed bedside units with automatic documentation. Alarm patterns and nurse-rated technology acceptance (4-point Likert scale) were analyzed. RESULTS: Vital signs were monitored in 214 patients (median age: 58, IQR: 42 to 70) in Phase 1 and 290 patients (median age: 60, IQR: 43 to 77) in Phase 2. Procedures included cranial, spinal, and peripheral nerve surgeries. Phase 1 recorded 30 nonclinical alarms and no clinical alarms. In contrast, Phase 2 registered 14,500 clinical and 185,744 nonclinical alarms, mostly from detached sensors (177,989/185,744; 96%). Clinical alarms were mainly due to hypoxia (8305/14,500; 57%) and tachycardia (3487/14,500; 30%). Most alarms were acknowledged within 30 seconds (clinical: 12,969/14,500; 90% and nonclinical: 181,447/185,744; 98%), with delayed responses mostly for nonclinical events (3625/4189; 87%). Nurses reported improved convenience, usability, and system connection in Phase 2. CONCLUSIONS: Wearable-based vital sign monitoring is feasible on neurosurgical wards, but high nonclinical alarm rates highlight the need to refine alarm management strategies for effective clinical integration.
BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a common procedure in the United States. Unanticipated postoperative reintubation after ACDF is a rare but serious complication associated with increased morb...BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a common procedure in the United States. Unanticipated postoperative reintubation after ACDF is a rare but serious complication associated with increased morbidity, mortality, and health care costs. This study identifies risk factors for reintubation after ACDF using a large, contemporary cohort. METHODS: This retrospective cohort study examined demographic, clinical, and operative variables associated with unanticipated reintubation within 2 days of ACDF surgery using 2017 to 2022 data from the American College of Surgeons National Surgical Quality Improvement Program. Univariate analyses explored the relationship between variables and reintubation. Variables with P <0.15 were included in a multivariable model using logistic regression. RESULTS: Unanticipated reintubation occurred in 101 (0.2%) of 41,398 patients. Associated factors identified by univariate analysis included age, sex, race, operative time, corpectomy, number of vertebrae fused, posterior approach, ASA-PS, functional status, and select comorbidities. Using a multivariable model, independent risk factors for reintubation included older age (OR: 1.03, 95% CI: 1.01-1.06), male sex (OR: 1.59, 95% CI: 1.05-2.40), Black race (OR: 2.72, 95% CI: 1.73-4.30), longer operative time (OR per hour 1.20, 95% CI: 1.05-1.36), corpectomy (OR: 2.58, 95% CI: 1.67-3.98), procedures involving 3 or more levels (OR: 1.56, 95% CI: 1.00-2.44), and dependent functional status (OR: 2.99, 95% CI: 1.54-5.79). CONCLUSIONS: This study identified several surgical and nonmodifiable patient risk factors for reintubation after ACDF, which may aid in risk stratification to guide preoperative counseling, surgical planning, and patient disposition. Further research is needed to explore mitigation strategies and the association between race and reintubation.
INTRODUCTION: Takotsubo syndrome (TTS) is a transient left ventricular dysfunction triggered by stress, often associated with intracranial disorders. This review examines intracranial triggers of TTS, summarizing evidenc...INTRODUCTION: Takotsubo syndrome (TTS) is a transient left ventricular dysfunction triggered by stress, often associated with intracranial disorders. This review examines intracranial triggers of TTS, summarizing evidence and implications. METHODS: We searched PubMed and Web of Science following PRISMA guidelines. Eligible studies included case reports of TTS precipitated by intracranial events. Outcomes analyzed included TTS-associated complications, cardiomyopathy status at last follow-up, and recurrence rates. Subgroup analyses were performed based on trigger type and for the reverse TTS (rTTS). RESULTS: A total of 167 studies were included, comprising 156 patients with conventional TTS and 28 with rTTS. The mean age in the conventional cohort was 57.73 years, with 85.9% being female. Hypertension (16.5%) was the most common comorbidity. ST-segment elevation (45.1%) and T-wave inversion (38.2%) were predominant electrocardiographic findings, while left ventricular systolic dysfunction (65.2%) was the main echocardiographic abnormality. Complications occurred in 95 patients, most commonly arrhythmias (39.4%), pulmonary edema (15.1%), and new valve disorders (11.2%). At last follow-up, 134 cases resolved, 15 patients died, and recurrence was 10.9%. Triggers were: seizures (n=43), subarachnoid hemorrhage (SAH) (n=36), ischemic stroke (n=18), multiple sclerosis (n=6), traumatic brain injury (n=6), tumor removal (n=6), and others (n=30). CONCLUSION: Intracranial events are significant TTS triggers. While outcomes are favorable, mortality was more common in patients with SAH compared with other triggers. Standardized studies are needed to optimize treatment. Given that all included studies were case reports, findings should be interpreted cautiously, recognizing the exploratory nature of the data and the limitations in the level of evidence.
BACKGROUND: Scalp nerve block (SNB) enhances neurosurgical recovery, but local anesthetics alone provide short-term analgesia. This study aimed to ascertain if a betamethasone and ropivacaine combination (betamethasone p...BACKGROUND: Scalp nerve block (SNB) enhances neurosurgical recovery, but local anesthetics alone provide short-term analgesia. This study aimed to ascertain if a betamethasone and ropivacaine combination (betamethasone plus ropivacaine) prolongs analgesia relative to ropivacaine alone. METHOD: This prospective, single-center, randomized controlled clinical trial was conducted from August 16, 2022, to December 19, 2024. Eligible patients for elective craniotomy were randomly allocated in a 1:1 ratio to the betamethasone group (n=45), which received SNB with 0.5% ropivacaine combined with betamethasone, or the control group (n=45), which received SNB with 0.5% ropivacaine alone. The primary outcome was the Numerical Rating Scale (NRS) pain score at 48 hours postoperatively. The secondary outcomes were NRS pain score within 48 hours postoperatively and plasma concentrations of interleukin-6, interleukin-10, and interferon-γ. RESULTS: The baseline data of the groups showed no significant differences. The betamethasone group had significantly lower NRS scores at 48 hours postoperatively (1 [0 to 2] vs 2 [2 to 3], P<0.001). Betamethasone plus 0.5% ropivacaine improved the NRS scores within 24 hours postoperatively. The betamethasone group had significantly lower interleukin-6 (3.3 [2.5 to 5.6] vs 11.6 [4.5 to 21.5] pg/ml, P=0.001) and interferon-gamma (3.4 [2.4 to 8.3] vs 5.3 [3.6 to 9.1] pg/ml, P=0.042) concentrations than the control group. Their interleukin-10 concentrations were not different (P=0.582). CONCLUSION: Betamethasone plus 0.5% ropivacaine SNB significantly decreased postoperative pain intensity within and at 48 hours postoperatively, likely due to prolonged analgesia and reduced inflammatory responses. CLINICAL TRIAL REGISTRATION: No. ChiCTR2200062670.
Perioperative neurocognitive disorder (pNCD) and stroke are frequent and serious complications following noncardiac surgery, leading to increased mortality and healthcare expenditure. While intraoperative hypotension has...Perioperative neurocognitive disorder (pNCD) and stroke are frequent and serious complications following noncardiac surgery, leading to increased mortality and healthcare expenditure. While intraoperative hypotension has long been considered a potentially modifiable risk factor through its impact on cerebral perfusion, a direct role in causing pNCD is now challenged. Large randomized controlled trials, including the recent CogPOISE trial, have demonstrated that strategies targeting higher perioperative mean arterial pressure do not reduce the incidence of delirium, long-term cognitive decline, or major vascular events in the surgical population. These findings suggest that the "one size fits all" approach to blood pressure management is insufficient. The pathophysiology of perioperative brain injury is multifactorial, and the role of cerebral hypoperfusion remains uncertain. Future research must shift from population-based blood pressure thresholds towards investigating the impact of personalized, multimodal, neurophysiology-guided care for vulnerable patients, including cerebral autoregulation and metabolic markers to protect against pNCD and stroke.
INTRODUCTION: The Wada test involves the intracarotid injection of anesthetics-commonly etomidate-to transiently anesthetize one hemisphere for assessing language and memory dominance during presurgical evaluation. Howev...INTRODUCTION: The Wada test involves the intracarotid injection of anesthetics-commonly etomidate-to transiently anesthetize one hemisphere for assessing language and memory dominance during presurgical evaluation. However, evidence on guiding intracarotid etomidate remains limited. This retrospective study aimed to investigate cannabis use and other factors such as body weight that may influence the intracarotid etomidate dosing regimen. METHODS: We included all adults who underwent the Wada test at our institution between February 2012 and January 2024. The primary exposure was cannabis use. The primary outcome was the total etomidate dose, defined as the cumulative amount (mg) required to achieve and maintain hemispheric anesthesia during each injection. Multivariable linear regression analysis was performed to assess the association between active cannabis use and total etomidate dose. We also compared the pharmacodynamic characteristics between cannabis users and nonusers. RESULTS: A total of 47 patients with 98 intracarotid etomidate injections were included. Active cannabis use was significantly associated with an increased total etomidate dose per injection (adjusted β=0.99, 95% CI: 0.03-1.9, P =0.04). Factors such as age, sex, body weight, and a history of alcoholism or other drug abuse were not significantly associated with the dose. Cannabis users experienced faster recovery, with a shorter time from the initial bolus to motor strength recovery (624 s [441 to 808] vs. 750 s [564 to 908], P =0.01). DISCUSSION: Our findings suggest that cannabis use is associated with a higher dose requirement of intracarotid etomidate and faster recovery times following cessation of the etomidate infusion.
BACKGROUND: Cervical plexus block (CPB) provides postoperative analgesia and reduces postoperative nausea and vomiting (PONV), which are important for improving the quality of recovery after head and neck surgical proced...BACKGROUND: Cervical plexus block (CPB) provides postoperative analgesia and reduces postoperative nausea and vomiting (PONV), which are important for improving the quality of recovery after head and neck surgical procedures. This randomized controlled trial investigated the effect of superficial CPB on early postoperative quality of recovery in patients undergoing microvascular decompression (MVD). METHODS: Patients undergoing MVD for trigeminal neuralgia and hemifacial spasm were randomly assigned to receive superficial CPB or not (n = 30 per group). Ultrasound-guided superficial CPB was performed with 10 cc of 0.5% ropivacaine before surgery. The primary outcome measure was the Korean version of the 15-item Quality of Recovery (QoR-15K) score on postoperative day 1. The secondary outcome measures included postoperative pain scores, the incidence of PONV, and perioperative inflammatory cytokine levels. RESULTS: The QoR-15K score on postoperative day 1 did not show a significant difference (94.5 [68.0-116.0] vs. 80.5 [51.5-100.8], P = 0.077) between the 2 groups. Perioperative QoR-15K scores also showed no significant time × group effect ( P = 0.324). Postoperative pain scores did not differ between the 2 groups. The incidence of PONV was significantly reduced in the superficial CPB group at 6 ( P = 0.001) and 12 ( P < 0.001) hours postoperatively. Perioperative inflammatory cytokine levels showed no differences between the 2 groups. CONCLUSIONS: Superficial CPB did not improve early postoperative QoR in patients undergoing MVD. However, it reduced the incidence of PONV during the early postoperative period, which could potentially enhance patient comfort and satisfaction.
BACKGROUND: Recent studies have shown a potential neuroprotective role of dexmedetomidine in subarachnoid hemorrhage. However, its effect on neurological outcomes and optimal dosing regimen remains unclear. METHODS: We r...BACKGROUND: Recent studies have shown a potential neuroprotective role of dexmedetomidine in subarachnoid hemorrhage. However, its effect on neurological outcomes and optimal dosing regimen remains unclear. METHODS: We randomized 75 adults with good grade aneurysmal subarachnoid hemorrhage undergoing clipping to receive dexmedetomidine, low-dose (Group D1,0.2 μg kg -1 h -1 , n = 25), standard dose (Group D2, 0.5 μg kg -1 h -1 , n = 25), or normal saline (Group C, n = 25) commenced postinduction of anesthesia and continued for 24 hours. Our primary objective was to assess rates of good functional outcome, defined as a modified Rankin Scale (mRS) Score of 0 to 2, at hospital discharge. Secondary outcomes included rates of good functional outcome at 3 months, levels of blood lactate, S100β, and Neuron Specific Enolase (NSE), incidence of vasospasm, delayed cerebral ischemia (DCI), and cerebral dysautoregulation. RESULTS: Neurological outcome at discharge was better in Group D1 as compared to Group C (mRS 0 to 2, Group D1 vs. C; 19 (76%) vs. 9 (36%), P = 0.02), while it was similar in Group D2 as compared to D1 and C. Neurological outcome at 3 months was comparable among the 3 groups. The lactate levels were significantly lower in Group D1 as compared to Groups D2 and C at 12 and 24 hours. The levels of NSE and S100β were significantly lower in D1 and D2 as compared to Group C. Other measured parameters were comparable. CONCLUSION: Low-dose dexmedetomidine was associated with a favourable neurological outcome at discharge compared to the control group. Larger trials are necessary to conclusively establish the neuroprotective effect of dexmedetomidine.
Blacker SN, Prabhakar H, Moreton EO
… +15 more, Burbridge M, Dunn L, Gouker LN, Heller BJ, Jangra K, Kang M, Nadler JW, De Sloovere V, Raquer A, Shrestha GS, Sindelar B, Williams J, Winecoff D, Yajnik V, Lele AV
External ventricular drains (EVDs) are critical for managing acute intracranial conditions but are associated with infections. We conducted a systematic review and meta-analysis to evaluate whether the implementation of...External ventricular drains (EVDs) are critical for managing acute intracranial conditions but are associated with infections. We conducted a systematic review and meta-analysis to evaluate whether the implementation of infection prevention bundles reduces the risk of EVD-associated infections, which was registered with PROSPERO on July 25, 2024 (https://www.crd.york.ac.uk/prospero/): CRD42024573168. PubMed, EMBASE, and Scopus databases were systematically searched for studies reporting EVD infection rates with and without bundle implementation. Two reviewers independently assessed bundle element presence and extracted infection outcomes. The meta-analysis was performed using a random-effects model with Hartung-Knapp adjustment, and heterogeneity was assessed using the I² statistic. An exploratory subgroup analysis compared bundle element implementation between studies achieving <5% infection rates and those with ≥5%. Twenty-two studies were analyzed, including 6330 patients (3895 in the bundle group and 2435 in the nonbundle group). Hand hygiene (100%) and administration of preinsertion antibiotics (91%) were the most frequently implemented bundle elements, whereas structured weaning protocols were infrequently reported (9%). Bundle implementation was associated with a significant reduction in EVD infection risk (pooled Risk Ratio [RR]: 0.46, 95% CI: 0.33-0.65, P<0.001). Moderate heterogeneity was observed across studies (I²=50.9%). The use of antimicrobial-impregnated catheters, tunneled catheter placement, and structured education programs were more frequently present among studies achieving infection rates <5%. Implementing an infection prevention bundle is associated with a significant reduction in EVD infections. Adoption of core practices, supplemented by technology enhancements and education programs, may further optimize infection prevention strategies.
BACKGROUND: Awake craniotomy (AC) with functional brain mapping is the standard approach for the resection of brain tumors in eloquent areas. Two main anesthetic techniques are commonly used: "Asleep-Awake-Asleep" (SAS)...BACKGROUND: Awake craniotomy (AC) with functional brain mapping is the standard approach for the resection of brain tumors in eloquent areas. Two main anesthetic techniques are commonly used: "Asleep-Awake-Asleep" (SAS) and "Monitored Anesthesia Care" (MAC). SAS involves general anesthesia during nonawake phases, while MAC utilizes conscious sedation, allowing for spontaneous ventilation without invasive airway devices. Both are effective and safe, but information on patient-reported intraoperative experiences is lacking. Here, we compare the subjective experience, postoperative quality of life, and operating room time of patients managed by SAS versus MAC. METHODS: We performed a postoperative telephone survey of all consecutive patients who underwent AC for eloquent brain tumors at the University Medical Center Freiburg, Germany, between October 2018 and April 2024. SAS was used until November 2023, while MAC was used thereafter. The third part of the Beez interview protocol and the EuroQol EQ-5D-5L (including the EQ Visual Analog Scale) were delivered to assess patient-reported intraoperative experience and current health-related quality of life. Patient-reported outcomes and operating room time were compared between the 2 groups. RESULTS: Thirty-four of 40 patients (17 in each group) were available for telephone interview with more female patients in the SAS group compared with the MAC group (82% vs. 12%, P <0.001). Other baseline parameters were balanced. Patient-reported intraoperative experience and quality of life were similar between the SAS and MAC groups. Operating room times were significantly shorter for MAC (366±107 min) than for SAS (453±81 min) ( P =0.011). CONCLUSIONS: Our institutional protocols for SAS and MAC resulted in similar intraoperative experience and postoperative QoL, while MAC procedures had shorter operating room times. Larger studies are required to confirm these findings.