Update on anesthetic neuroprotection

Perioperative cerebral injury can result in a wide range of clinical consequences from subtle cognitive changes to devastating or fatal strokes. Although the overall incidence of perioperative stroke is low, the large and growing number of aging patients undergoing surgery and anesthesia is placing an increasing number of vulnerable patients at risk. The purpose of this review is to evaluate recent evidence concerning the use of pharmacological and nonpharmacological strategies to protect against perioperative cerebral injury.

Although a growing body of preclinical literature suggests that anesthetic agents such as barbiturates, volatile anesthetics, and propofol might have neuroprotective properties, clinical evidence of long-term benefit is lacking. Magnesium shows promise, although timing and dosing require clarification. Despite some early promise, there is no strong evidence that erythropoietin is neuroprotective. Remote ischemic preconditioning is the subject of intense study. It is noninvasive, cheap, and reasonably well tolerated and shows promise as a preconditioning neuroprotective intervention. A recent development has been a focus on the potential role of enhanced cardiorespiratory fitness in neuroprotection.

The evidence of benefit of current strategies remains sparse. Given the complex pathophysiology of cerebral ischemia and hypoxia, a multimodal approach to neuroprotective strategies seems sensible. The many variables and confounds associated with the clinical setting of patients, their comorbidities and concurrent medications, pose challenges to translate from experimental studies to clinical practice.