Anesthetic management of neurosurgical emergencies

Neuroanesthesia presents unique challenges that require up-to-date knowledge in identification and management and multidisciplinary collaboration for optimal patient outcomes. This review paper aims to enhance the reader's understanding and preparedness for intraoperative emergencies based on current literature updates and consensus recommendations.

Recent findings in traumatic brain injury (TBI) emphasize the importance of controlling intracranial pressure (ICP) and maintaining cerebral perfusion. However, they also challenge the efficacy of sole ICP targeting interventions, suggesting potential benefits from multimodal monitoring approaches. In the context of acute stroke, recent randomized trials have demonstrated that general anesthesia (GA) compared with sedation techniques results in higher recanalization rates, with no significant difference in complications or long-term outcomes. Furthermore, multiple trials and a meta-analysis have shown that intensive blood pressure management following recanalization with endovascular therapy (EVT) offers no benefit and may impose harm when compared with conservative blood pressure targets.

Optimal management of neuroanesthetic emergencies requires up-to-date knowledge, training, and interdisciplinary coordination to ensure the best possible outcomes. Significant research effort has been devoted to advancing neuroanesthesia practice, so that in the last 2 years, several fundamental management questions have benefitted from randomized controlled trials (RCTs) from multiple groups, as well as meta-analyses of these RCTs. These address ICP and complementary physiologic monitoring for intracranial compartment syndrome after TBI, GA versus sedation for EVT, and postrecanalization blood pressure management. In this review, we have highlighted this important work as well as the next steps in further refining answers to these questions.