Wongsripuemtet P, Ohnuma T, Temkin N
… +18 more, Barber J, Komisarow J, Manley GT, Hatfield J, Treggiari MM, Colton K, Sasannejad C, Chaikittisilpa N, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Miller JB, Vavilala MS, Krishnamoorthy V, TRACK-TBI investigators
J Neurosurg Anesthesiol
· 2026 Apr · PMID 41024341
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OBJECTIVE: Beta-blockers have been studied for their impact on traumatic brain injury (TBI). We aimed to examine the association of preinjury beta-blocker exposure with early brain injury biomarker levels and outcomes fo...OBJECTIVE: Beta-blockers have been studied for their impact on traumatic brain injury (TBI). We aimed to examine the association of preinjury beta-blocker exposure with early brain injury biomarker levels and outcomes following TBI. METHODS: We retrospectively studied adults (≥40 y) participating in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. The exposure was preinjury beta-blocker utilization. Primary outcome was blood-based brain injury biomarker levels on day 1 following injury. Secondary outcomes included biomarkers on days 3 and 5, hospital mortality, and the 6-month Glasgow Outcome Scale-Extended. Inverse probability-weighted models assessed the association between preinjury beta-blocker exposure, biomarker levels, and outcomes, stratified by TBI severity. RESULTS: A total of 1185 patients were included, with 101 on preinjury beta-blockers (BB+): 21 in the moderate/severe group and 80 in the mild TBI group. BB+patients were older than BB- in both mild (67 vs. 57 y, P <0.001) and moderate/severe TBI (64 vs. 56 y, P =0.003). Hypertension was more common in BB+patients (78% mild, 67% moderate/severe, P <0.001). Preinjury beta-blocker use was not associated with day 1 biomarker levels. The 6-month GOSE scores in the BB+ moderate/severe TBI were lower, but the effect was marginal (B= -1.20, 95% CI: -2.39 to -0.01, P =0.049). CONCLUSION: Our study did not find a clear association between preinjury beta-blocker exposure and day 1 blood-based brain injury biomarkers or clinical outcomes. These findings warrant confirmation in future studies with larger cohorts.
INTRODUCTION: Current commercial cerebral oximeters only monitor the frontal lobes, however, some cerebrovascular territories may experience ischemia while others remain well perfused. This pilot study used a novel, high...INTRODUCTION: Current commercial cerebral oximeters only monitor the frontal lobes, however, some cerebrovascular territories may experience ischemia while others remain well perfused. This pilot study used a novel, high-density, dual-wavelength, time-resolved functional cerebral oximeter (Kernel Flow) with 2000 channels to assess the regional differences of cerebral oxygenation (StO2) in response to hypotension across different vascular territories during shoulder surgery in the beach chair position. METHODS: Twenty-seven adult patients were monitored, recording blood pressure, heart rate, regional cerebral oxygen saturation, and other vital parameters. For each hypotensive event, regional cerebral oxygen saturations were compared against each other using a mixed-effect model. Data processing involved moment analysis and MATLAB-based detrending to correct for temperature-induced signal drifts. RESULTS: Twenty-one hypotensive events were excluded due to poor data quality. Results from 16 hypotensive events in 4 patients indicated no significant temporal or amplitude differences in StO2 across 8 cerebrovascular territories. The mean±SD decrease in systolic blood pressure was 30.2±18.3 mm Hg, resulting in a mean cerebral desaturation across all territories of 3.3%±1.8%. There were no statistically significant temporal or magnitude differences between different vascular territories, though large variabilities were observed. CONCLUSIONS: Despite limitations, such as small sample size and the exclusion of large number of events, this pilot study demonstrates that StO2 changes in response to hypotension in multiple brain regions can be measured and compared during surgery, providing insights and facilitating investigation of the selective vulnerability of brain regions. Future exploration will enhance our understanding of cerebral ischemia pathophysiology and perioperative stroke.
BACKGROUND: Acute postoperative hypertension (APH) is encountered in patients following craniotomy and is associated with major complications. This retrospective cohort study evaluates 30-day survival for patients who re...BACKGROUND: Acute postoperative hypertension (APH) is encountered in patients following craniotomy and is associated with major complications. This retrospective cohort study evaluates 30-day survival for patients who received labetalol, nicardipine, or both drugs. METHODS: Patients 18 and older who underwent craniotomy between January 1, 2010 and January 1, 2023 were included in the study. Analyses were performed comparing (1) labetalol cohort versus nicardipine cohort, (2) labetalol cohort versus both cohort, and (3) nicardipine cohort versus both cohort. The primary outcome was survival at 30 days. Secondary outcomes included 30-day readmission, ST-elevation myocardial infarction (STEMI), congestive heart failure (CHF), non-ST elevation myocardial infarction (NSTEMI), arrhythmia, and intracranial hemorrhage. RESULTS: The labetalol cohort had improved 30-day survival compared with the nicardipine cohort (HR: 0.49, P<0.0001) or both (HR: 0.67, P<0.0001). The nicardipine cohort had worse survival compared with both cohorts (HR: 1.28, P<0.0001). The labetalol cohort had a lower risk of intracranial hemorrhage compared with nicardipine (RR: 0.89, P=0.001) and both cohorts (RR: 0.90, P<0.001). The labetalol cohort had less congestive heart failure than the nicardipine cohort (RR: 0.66, P<0.0001), and the nicardipine cohort had more CHF than the cohort that received both drugs (RR: 1.21, P=0.018). There was no difference in STEMI, NSTEMI, or readmissions across cohorts. CONCLUSIONS: Labetalol for APH after craniotomy is associated with improved survival compared with nicardipine or combination. A combination of these drugs is associated with improved survival compared with nicardipine alone.
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...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,...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 craniosynosto...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.
BACKGROUND: Propofol is widely used in neurosurgery, with its dosage typically based on patient weight and variability. While factors like age, sex, and cognitive function are known to influence propofol requirements, th...BACKGROUND: Propofol is widely used in neurosurgery, with its dosage typically based on patient weight and variability. While factors like age, sex, and cognitive function are known to influence propofol requirements, the impact of preoperative hearing function remains underexplored. This study investigates the relationship between hearing loss and propofol sensitivity in vestibular schwannoma surgery patients. METHODS: This retrospective study analyzed 475 patients who underwent vestibular schwannoma resection between May 12, 2020, and February 28, 2024. Total intravenous anesthesia (TIVA) with propofol and remifentanil was used, maintaining BIS values between 40 and 60. Hearing impairment was defined as a pure tone average (PTA) ≥20 dB. Multivariable linear regression was used to assess the relationship between preoperative hearing function and propofol requirements. RESULTS: The hearing-impaired group was older (51.7±10.5 vs. 42.9±10.5 y, P <0.001) and required lower median (IQR) propofol doses (96.7 [85.2 to 115.2] vs. 109.0 [91.4 to 126.9] μg·kg -1 ·min -1 , 95% CI: 5.511-15.016, P <0.001). In unadjusted analysis, hearing loss (PTA ≥20 dB) was associated with reduced propofol requirements (OR: -10.4, P <0.001). This association remained significant in multivariable analysis adjusting for age, sex, ASA, BMI, and anesthesia provider (ORadj: -5.0; 95% CI: -9.8 to -0.2; P =0.040). CONCLUSION: Hearing loss is associated with increased propofol sensitivity in vestibular schwannoma surgery, highlighting its potential relevance in anesthesia management.
BACKGROUND: Venous air embolism (VAE) occurs when air enters the venous circulation. During nonsitting craniotomies with elevated VAE risk due to proximity to a venous sinus, our institutional practice is to employ preco...BACKGROUND: Venous air embolism (VAE) occurs when air enters the venous circulation. During nonsitting craniotomies with elevated VAE risk due to proximity to a venous sinus, our institutional practice is to employ precordial Doppler ultrasound (PDU) and transesophageal echocardiography (TEE) for monitoring, as well as central venous catheterization (CVC) for aspiration. We utilized an electronic medical record (EMR) database to assess the frequency of VAE occurrence, its clinical detection, and the use of VAE-specific monitoring modalities. METHODS: EMR review identified all patients who underwent nonsitting craniotomies for an intracranial tumor. To identify episodes of VAE occurrence, the EMR was screened for intraoperative VAE events as determined by clinical diagnosis (cVAE) as well as an EtCO 2 drop >20% over a 2-minute interval, concerning for suspected VAE (sVAE). To identify patients who had VAE-specific monitoring, the EMR was scanned for placement of a CVC, TEE, or PDU. RESULTS: Three thousand nine hundred forty-five patients underwent a craniotomy for resection of tumor, and 3531 met study inclusion criteria. There were 14 episodes of intraoperative VAE diagnosed by a clinician (cVAE) and 86 episodes of suspected VAE (sVAE) based on review of anesthesia records for significant changes in EtCO 2 . There were 261 cases that used VAE-specific monitoring, with minimal overlap with sVAE cases. CONCLUSIONS: We identified 100 episodes of VAE, diagnosed either clinically (cVAE) or by abrupt EtCO 2 decrease (sVAE). Our data suggest that VAE in nonsitting craniotomy often occurs in instances where VAE-specific monitoring modalities are not used, and that our ability to preoperatively identify neurosurgical cases where VAE may occur is limited.
BACKGROUND: Intraoperative neuromonitoring (IONM) is used to detect neurological complications during carotid endarterectomy (CEA), and current data show mixed results in clinical outcomes. This study aimed to examine he...BACKGROUND: Intraoperative neuromonitoring (IONM) is used to detect neurological complications during carotid endarterectomy (CEA), and current data show mixed results in clinical outcomes. This study aimed to examine health care utilization metrics and outcomes relating to the use of IONM in CEA using a large national database in the USA. METHODS: Data were abstracted from the 2016 to 2021 Nationwide Readmissions Database. The primary aim was to evaluate whether adverse neurological events, hospital costs, length of stay (LOS), and routine discharge differed by the presence of IONM. We additionally evaluated whether all-cause 30-day and 90-day readmissions, and in-hospital mortality differed by IONM. We adjusted outcomes to control for age, comorbidity burden, left-sided surgery, and elective admission. RESULTS: There were an estimated 283,045 hospitalizations for CEA, of which 13,469 (4.79%) had IONM. IONM was associated with 12% longer adjusted stays, 16% higher adjusted costs and 35% lower odds of routine discharge ( P <0.001). In addition, IONM was associated with increased odds of an adverse neurological event, which included ischemic and hemorrhagic cerebrovascular complications (IONM: 19.40% vs. 12.65%, aOR: 1.31, 95% CI: 1.18-1.45, P <0.001). Lower income quartiles and rural/nonteaching facilities were associated with lower odds of IONM use. There were no differences in mortality or all-cause readmissions. CONCLUSIONS: Our findings showed worse outcomes associated with IONM use during CEA. IONM is typically utilized in high-surgical-risk patients, largely accounting for our findings. The higher costs, longer hospital stays, and lower odds of routine discharge associated with IONM use need to be balanced with potential benefits. We also found significant disparities based on facility type and income. Detailed procedural risk factors, which are lacking from this data, limit the results of this study.
Antiplatelet and anticoagulant medications are widely prescribed to the general population for therapeutic and prophylactic purposes in a wide range of diseases, mainly of cardiovascular interest, spanning from acute eve...Antiplatelet and anticoagulant medications are widely prescribed to the general population for therapeutic and prophylactic purposes in a wide range of diseases, mainly of cardiovascular interest, spanning from acute events such as acute coronary syndromes (ACS), strokes, and thromboembolic disorders to chronic conditions like atrial fibrillation (AF) and peripheral vascular diseases. The management of such therapies is expected to escalate over time due to the aging population, which has a growing need for these medications, and the rising demand for surgical procedures. The management of anticoagulants and antiplatelets still represents a tough challenge for clinicians in elective neurosurgical procedures, where the balance between preventing thromboembolic events and an increased bleeding risk plays a crucial role in all phases of the perioperative setting. Managing antiplatelet and anticoagulant drugs in elective neurosurgery is complex and requires a tailored and multidisciplinary approach. Careful assessment of patient factors, surgery type, and potential risks and benefits is essential. POC testing can be valuable in optimizing therapy management and bleeding risk assessment. This narrative review for clinicians aims to provide an updated overview of the management of these drugs in the perioperative setting of elective neurosurgical procedures. We explored coagulation abnormalities commonly found in neurosurgical patients, the pharmacological profile of each class of drugs, the appropriate management according to the type of procedure (brain or spinal), and the available diagnostic tests, focusing on the application of point-of-care (POC) coagulation testing.
Temporary blood flow reduction is essential in the management of complex neurovascular lesions in both open and endovascular settings. This focused review examines the four principal techniques commonly used to achieve f...Temporary blood flow reduction is essential in the management of complex neurovascular lesions in both open and endovascular settings. This focused review examines the four principal techniques commonly used to achieve flow reduction for neurovascular procedures. Deep hypothermic circulatory arrest (DHCA) has largely become obsolete in recent years due to significant perioperative morbidity and the emergence of less invasive flow reduction strategies. Intravenous adenosine remains a popular option since it is readily available in the perioperative setting, though the hemodynamic response may be unpredictable because of interindividual dose-response variability. Rapid ventricular pacing (RVP) provides controlled, predictable flow reduction but requires advanced procedural planning. Endovascular balloon-assisted occlusion provides localized control in anatomically challenging areas under a hybrid neurosurgical-endovascular approach. To date, no single technique has demonstrated superiority over another, and the optimal strategy should be individualized based on lesion characteristics, institutional expertise, and available resources. Future research should focus on potential neuroprotective strategies during flow reduction and further characterize the safety and efficacy profiles of various flow reduction techniques through prospective cohort studies.
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 effect...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.