Major spine surgery is associated with substantial blood loss and dynamic perioperative coagulation disturbances. Conventional coagulation tests may not adequately assess whole-blood clot formation, platelet contribution...Major spine surgery is associated with substantial blood loss and dynamic perioperative coagulation disturbances. Conventional coagulation tests may not adequately assess whole-blood clot formation, platelet contribution, or fibrinolysis. Viscoelastic hemostatic assays (VHAs), including thromboelastography and rotational thromboelastometry, have been explored for point-of-care coagulation assessment in spine surgery. This scoping review systematically mapped the literature evaluating VHA-guided transfusion practices and perioperative coagulation assessment in spine surgery, focusing on devices used, timing of testing, and reported clinical outcomes. The primary objective was evidence mapping rather than quantitative effect estimation or meta-analysis. The review followed a Population-Concept-Context framework and was reported in accordance with PRISMA-ScR guidelines. Electronic databases and gray literature were searched from inception to August 29, 2025. Eligible studies included patients undergoing spine surgery in whom VHAs were used perioperatively, evaluating system-level outcomes (devices, timing, algorithms, cost-effectiveness) and clinical outcomes (blood loss, transfusion composition and volume, pharmacotherapy, hypercoagulability, and hospital length of stay). Twenty-one studies met inclusion criteria, comprising 3 randomized controlled trials, 9 prospective observational studies, 8 retrospective cohort studies, and 1 case-control study. Most studies were observational with marked heterogeneity in design, patient populations, and surgical settings. Several studies reported targeted blood product administration with VHA-guided management. Evidence regarding reductions in blood loss and hospital stay was inconsistent, while data on hypercoagulability, thromboembolic events, and cost-effectiveness were limited. Though studies suggest that VHA may guide patient blood management in spine surgery, the evidence is predominantly observational, limiting causal inference and underscoring the need for well-designed, spine-specific studies.
BACKGROUND: The metabolic component of cerebral autoregulation is crucial in traumatic brain injury (TBI), yet continuously monitored indices are limited. This study introduces the ICP-EtCO2 Slope (IESlope), quantifying...BACKGROUND: The metabolic component of cerebral autoregulation is crucial in traumatic brain injury (TBI), yet continuously monitored indices are limited. This study introduces the ICP-EtCO2 Slope (IESlope), quantifying the dynamic relationship between end-tidal CO2 (EtCO2) and intracranial pressure (ICP), and evaluates its association with 12-month mortality and unfavorable outcome (Glasgow Outcome Scale-Extended, GOSE≤4). Second, IESlope visualization and its ability to predict short-term ICP changes during EtCO2 variations are assessed. METHODS: Intensive care unit records of 218 adult and pediatric TBI patients were retrospectively analyzed (median age 44, IQR: 24-66; 76% male). IESlope was calculated as the angle of the linear regression between EtCO2 and ICP over 60-minute moving windows and visualized using streamline mapping (ICP-EtCO2 space). IESlope values were averaged to obtain a single patient-level metric used in univariate and multivariable analyses (area under the curve, AUC). Predictive capability was assessed by comparing predicted versus observed ICP changes at 5, 10, and 20 minutes during significant EtCO2 variations. RESULTS: Lower IESlope values were associated with mortality and GOSE≤4 (median: 7.76 vs. 14.8 and 10.5 vs. 18.6, respectively, P<0.001), independent of age or decompressive craniectomy. Streamline maps showed expected CO2 reactivity patterns, with peak values at moderate ICP and EtCO2 levels and reductions at extremes and after decompressive craniectomy. IESlope maintained significant associations with outcomes (AUC ∼0.900) and accurately predicted short-term ICP responses to EtCO2 changes (mean absolute error, MAE=0.600-1.686 mm Hg). CONCLUSIONS: IESlope provides a continuous, quantitative measure of CO2-related ICP reactivity and may support individualized ventilatory management in TBI, pending prospective validation.
BACKGROUND: Cricoid pressure is applied during intubation of full-stomach patients or in emergency situations, including trauma, oftentimes after excluding cervical spine injury. Cervical spine movements under cricoid pr...BACKGROUND: Cricoid pressure is applied during intubation of full-stomach patients or in emergency situations, including trauma, oftentimes after excluding cervical spine injury. Cervical spine movements under cricoid pressure are mainly studied in cadavers. METHODS: This prospective, randomized, assessor-blind trial (CTRI/2022/05/042505, dated May 12, 2022) enrolled adult ASA I and II patients with normal spines undergoing neurointerventional procedures with simulated cervical spine immobilization. Patients were randomized to single-handed or bimanual cricoid pressure (one hand anterior, the other providing posterior support below midcervical level). Cinefluoroscopic lateral images from occiput (C0) to C6 were obtained at baseline and during cricoid pressure. Angular displacement between adjacent cervical vertebrae was measured by a blinded radiologist. The primary outcome was maximal angular displacement at C4-C5. Secondary outcomes included segmental motion from C1 to C6, laryngoscopic view, intubation time and attempts, and hemodynamic responses. RESULTS: Fifty patients (25 per group) were analyzed. Bimanual cricoid pressure showed significantly reduced angular displacement at C4-C5 (4.34±3.98 vs. 0.71±1.92, P=0.001). Similar findings observed at C1-C2 (4.34±4.45 vs. 0.89±1.97, P=0.001), C2-C3 (5.46±4.14 vs. 1.27±2.66, P=0.001), C3-C4 (5.66±4.52 vs. 1.51±1.72, P=0.001), and C5-C6 (3.04±4.44 vs. 0.18±2.19, P=0.006). Other secondary outcomes were comparable. CONCLUSIONS: During simulated cervical spine immobilization, bimanual cricoid pressure significantly reduces cervical spine movements without impairing intubation conditions. Posterior support likely counteracts spine movements caused by cricoid pressure.
BACKGROUND: Intraoperative hypotension (IOH) can affect patient outcomes following craniotomy. The Hypotension Prediction Index (HPI) can predict IOH in advance, enabling early, proactive management. We evaluated whether...BACKGROUND: Intraoperative hypotension (IOH) can affect patient outcomes following craniotomy. The Hypotension Prediction Index (HPI) can predict IOH in advance, enabling early, proactive management. We evaluated whether an HPI-integrated hemodynamic management protocol reduces IOH during brain tumor surgery. METHODS: This single-center, parallel-group randomized controlled trial was registered prospectively with the Clinical Trial Registry-India (CTRI/2024/07/069939, dated 04/07/2024) and funded by the Indian Council of Medical Research. Consenting adult patients undergoing brain tumor decompression were randomized 1:1 to HPI-guided (n=90) or conventional care (control) (n=90) hemodynamic management. The primary outcome was duration of IOH (MAP<65 mm Hg). Secondary outcomes included time-weighted average (TWA) of IOH, episodes, severity, and timing of IOH, vasopressor use, myocardial ischemia, acute kidney injury, delirium, intensive care unit (ICU) stay, and hospital stay. RESULTS: Of 180 enrolled patients, 176 were analyzed (HPI n=86; control n=90). HPI guidance significantly reduced IOH duration (MAP<65 mm Hg: 600 [180 to 960] vs. 1820 [420 to 4620] s; P <0.001), TWA of MAP <65 mm Hg (0.10 [0.03 to 0.22] vs. 0.32 [0.07 to 1.01] mm Hg; P <0.001), and number of hypotensive episodes (4 [2 to 7] vs. 6 [2 to 13]; P =0.004). TWA of MAP<60 mm Hg and <55 mm Hg was also significantly lower in the HPI group ( P <0.001). The IOH duration was lesser in the HPI group than in the control group during both presurgical and surgical phases. Postoperative outcomes did not differ between groups. CONCLUSIONS: HPI-guided hemodynamic management significantly reduced the burden of IOH during brain tumor surgery.
Traumatic brain injury (TBI) triggers an acute neuroendocrine stress response characterized by a surge of catecholamines (epinephrine, norepinephrine, and dopamine) and activation of the hypothalamic-pituitary-adrenal ax...Traumatic brain injury (TBI) triggers an acute neuroendocrine stress response characterized by a surge of catecholamines (epinephrine, norepinephrine, and dopamine) and activation of the hypothalamic-pituitary-adrenal axis. This early hyperadrenergic "storm," termed early autonomic dysfunction, is initially an adaptive response, but, if prolonged, it can become maladaptive and contribute to secondary brain injury and systemic complications. Elevated circulating catecholamine levels after TBI correlate with worse outcomes and mortality. Dysregulated catecholaminergic signaling has widespread downstream effects following injury: it disrupts normal dopamine/noradrenergic pathways and alters sympathetic/parasympathetic balance, modulates immune responses toward immunosuppression, and impairs vascular and glymphatic homeostasis, leading to cerebral edema. If prolonged, patients can develop chronic paroxysmal sympathetic hyperactivity, which is associated with prolonged hospitalization and poor neurological recovery. Therapeutically, blockade or modulation of adrenergic and related neurotransmitter systems (β-blockers, α2-agonists, GABAergic modulators, dopaminergic drugs, neuromodulation) can mitigate these effects, though controlled data are limited. This narrative review summarizes current understanding of adrenergic dysregulation in TBI and its multisystem sequelae and discusses targeted interventions and future research directions.
Hemodynamic stability and timely neurological assessment are critical components of anesthetic management in intracranial neurosurgery. This systematic review and meta-analysis were prospectively registered in PROSPERO (...Hemodynamic stability and timely neurological assessment are critical components of anesthetic management in intracranial neurosurgery. This systematic review and meta-analysis were prospectively registered in PROSPERO (CRD420251274560, registered December 28, 2025) and evaluated the efficacy and hemodynamic stability of remimazolam versus propofol as hypnotic agents in patients undergoing these procedures. PubMed, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) comparing remimazolam with propofol in patients undergoing intracranial neurosurgical procedures. The outcomes evaluated were heart rate (HR), mean arterial pressure (MAP), hypotension incidence, recovery characteristics, and adverse events. We computed mean difference (MD) or standardized mean difference (SMD) for continuous outcomes and risk ratio (RR) for binary outcomes, with 95% confidence intervals (CIs). Heterogeneity was assessed using I2 statistics. We included 7 RCTs, comprising 770 patients. Remimazolam was associated with a significantly shorter recovery time compared with propofol (MD: -1.74 min; 95% CI: -3.40 to -0.08; P =0.040; I2 =48.7%). There were no significant differences between groups in anesthesia duration (MD: -3.31 min; 95% CI: -9.40 to 2.78; P =0.286; I2 =0%), HR (MD: -1.79 bpm; 95% CI: -8.97 to 5.39; P =0.625; I2 =97.5%), MAP (MD: -2.54 mm Hg; 95% CI: -6.09 to 1.00; P =0.160; I ²=29.5%), and incidence of hypotension (RR: 0.56; 95% CI: 0.26-1.22; P =0.143; I2 =72.4%). In conclusion, in patients undergoing intracranial neurosurgery, remimazolam use was associated with shorter recovery time and a hemodynamic profile similar to that of propofol.
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
Our objective was to perform a systematic review and meta-analysis of published literature on ventriculostomy-related infection (VRI) and evaluate temporal and global trends. We conducted a systematic review and Bayesian...Our objective was to perform a systematic review and meta-analysis of published literature on ventriculostomy-related infection (VRI) and evaluate temporal and global trends. We conducted a systematic review and Bayesian hierarchical random-effects meta-analysis of VRI rates in adults, stratified by country-income level (high-income countries [HIC]; low- or middle-income countries [LMIC]), study design, sample size, enrollment period, VRI intervention, and VRI definition. We identified 159 articles published between 1989 and 2025 that included 523,704 patients with 7293 VRIs. The pooled VRI rate was 8.64% [95% CI: 7.44-9.97], with moderate heterogeneity and good model fit. The leave-one-out sensitivity analysis showed a mean absolute change of 0.06% and a maximum change of 0.2%, indicating robust analysis. Five of the 33 represented countries had VRI rates below the global pooled rate of 8.64%. Four were HICs: Singapore (VRI rate 3.3% [0.8-7]), the United States (VRI rate 4.6% [3.4-5.9]), Germany (VRI rate 6.1% [1.1-18.9]), Norway (8.3% [0.3-68.4]), with 1 LMIC: China (8.5% [5.4-12.4]). VRI was significantly higher in studies using definitions beyond CSF culture alone for VRI (+3.16% [0.11- 6.52]) and in those from Europe (+7.29% [4.62-10.10]) and the Western Pacific (+4.09% [1.55-6.98]). No other subgroup demonstrated significant differences. This Bayesian meta-analysis provides global estimates and factors associated with VRI. Standardization of VRI definitions is critical for future benchmarking of VRI rates.
Grondin-Hoareau JC, Vinclair M, Schilte C
… +11 more, Hautefeuille S, Henry P, Godon A, Francony G, Legris L, Lazard A, Detante O, Krainik A, Bouzat P, Gauss T, Champigneulle B
BACKGROUND: Traumatic cerebral venous sinus thrombosis (tCVST) may complicate traumatic brain injury (TBI), for which anticoagulation practices remain poorly defined. We aimed to investigate anticoagulant practices, earl...BACKGROUND: Traumatic cerebral venous sinus thrombosis (tCVST) may complicate traumatic brain injury (TBI), for which anticoagulation practices remain poorly defined. We aimed to investigate anticoagulant practices, early complications, and factors associated with venous recanalization in patients with tCVST. METHODS: We conducted a retrospective cohort study between 2012 and 2023 in 2 level 1 trauma centers, including TBI patients admitted to intensive care units (ICU). Data on trauma, tCVST features, anticoagulation practices, bleeding complications, venous infarction, and recanalization were extracted from medical records. Predictors of recanalization were identified using multivariable logistic regression. RESULTS: Among the 91 TBI patients identified with concomitant tCVST (1.7% of ICU TBI admissions), anticoagulation practices were heterogeneous. Fourteen patients (15.4%) were managed conservatively (none or prophylactic anticoagulation), while the remaining patients (77/91, 84.6%) received intermediate-dose or therapeutic anticoagulation, within the first 7 days post-TBI (53/91, 58.2%) or later (24/91, 26.4%). New or worsening intracranial hemorrhage (ICH) under anticoagulation occurred in 9/91 (9.9%) patients, regardless of timing, and tCVST-related venous infarction was documented in 1/91 (1.1%) patient. Among the 79/91 (86.8%) survivors at hospital discharge, 59/79 (74.7%) patients had full or partial recanalization. In multivariable analysis, early anticoagulation was not associated with recanalization (OR=0.64, 95% CI: 0.12-3.07, P =0.6); only tCVST features, including initial partial sinus obstruction (OR=7.12, 95% CI: 1.41-49.25, P =0.03) and presence of depressed skull fracture (OR=0.07, 95% CI: 0.01-0.53, P =0.02) were associated with recanalization. CONCLUSIONS: Early anticoagulation was not associated with secondary ICH or tCVST recanalization, although limited power and residual confounding may affect these findings. Larger prospective studies are warranted.
BACKGROUND: Effective treatments for prolonged disorders of consciousness (pDoC) remain limited. Grounded in the entropic brain hypothesis-that psychedelic agents facilitate consciousness recovery by increasing brain com...BACKGROUND: Effective treatments for prolonged disorders of consciousness (pDoC) remain limited. Grounded in the entropic brain hypothesis-that psychedelic agents facilitate consciousness recovery by increasing brain complexity-this study investigated esketamine, a nonclassical psychedelic drug, and its effects on electroencephalographic (EEG) neurophysiological metrics in pDoC patients. METHODS: In this prospective exploratory cohort study, 27 patients with pDoC were enrolled, and 22 with sufficient EEG signal quality were included in the final analysis. Patients were diagnosed with vegetative state/unresponsive wakefulness syndrome (VS/UWS) or a minimally conscious state (MCS). Patients received a 1-hour intravenous infusion of esketamine (0.3 mg/kg/h). EEG data were collected at baseline, 1 hour after infusion, and 30 minutes post-discontinuation. The power spectral density and Lempel-Ziv complexity (LZC) were analyzed. The study was registered at ClinicalTrials.gov (NCT06473285) on June 23, 2024. RESULTS: Esketamine reshaped the EEG power spectrum, suppressing global delta relative power (p_FDR=0.040) while increasing beta (p_FDR=0.040) and gamma (p_FDR=0.009) relative power. The alpha relative power increased selectively in the VS/UWS (p_FDR=0.012). The LZC increased in the parietal (P=0.030) and occipital (P=0.007) regions. In MCS patients, the increase in LZC persisted for 30 minutes post-discontinuation, most prominently in the occipital region, whereas changes in VS/UWS were transient. No behavioral improvements were observed on the Coma Recovery Scale-Revised assessments. CONCLUSIONS: Esketamine-induced neurophysiological alterations in patients with pDoC are characterized by reorganization of the EEG power spectral density and region-specific increases in signal complexity. However, these changes were not accompanied by improvements in behavioral responsiveness.
Acute brain injury (ABI) is a major cause of mortality and disability. Although intracranial pressure (ICP) monitoring traditionally relies on static thresholds, ICP variability (ICPV) may provide additional prognostic i...Acute brain injury (ABI) is a major cause of mortality and disability. Although intracranial pressure (ICP) monitoring traditionally relies on static thresholds, ICP variability (ICPV) may provide additional prognostic insight. This study aims to evaluate the association between short- and long-term ICPV and clinical outcomes in patients with ABI. Embase, Web of Science, Medline, Scopus, CENTRAL, and PubMed were searched from inception to August 29, 2025; the protocol was registered in PROSPERO (CRD420251116221) on July 30, 2025. Prospective and retrospective studies assessing ICPV and clinical outcomes in adult (18 y or older) patients with ABI were included. Two reviewers independently performed screening and data extraction. Random-effects meta-analyses were conducted separately for short-term and long-term ICPV effect estimates, risk of bias was assessed using ROBINS-E. Ten studies comprising 3243 patients with ABI were included. Higher short-term ICPV was associated with significantly reduced odds of poor clinical outcome in adjusted (aOR=0.58, 95% CI: 0.41-0.81; P<0.005) and crude analyses (OR=0.65, 95% CI: 0.55-0.78; P<0.005). Long-term ICPV showed no statistically significant association with poor outcome in adjusted (aOR=1.29, 95% CI: 0.84-1.96; P=0.24) or crude analyses (OR=1.47, 95% CI: 0.68-3.19; P=0.33). Overall, short-term ICPV was associated with favorable clinical outcomes, whereas long-term ICPV demonstrated no significant association. Further research using standardized ICPV metrics is needed to clarify its prognostic role in neurocritical care.