Critical care challenges after brain surgery and interventional neuroradiology

To revise key components of early postoperative management in acute brain injury (ABI) patients, including transfusion strategies, oxygenation and fluid targets, hemodynamic support, noninvasive intracranial pressure (ICP) assessment, and anticoagulation management.

Recent large randomized trials suggested that liberal transfusion strategies (i.e. aiming at hemoglobin ≥9 g/dl) showed potential benefits in functional outcomes and reduced ischemic complications. While hypoxemia is clearly harmful in ABI, observational and meta-analytic data link hyperoxia to worse neurological and survival outcomes, supporting to maintain normoxia (i.e. PaO2 80-120 mmHg) and avoid unnecessary supplemental oxygen. Euvolemia is the goal in ABI patients; current evidence supports saline as first-line maintenance fluid, with balanced crystalloids reserved for correcting electrolyte abnormalities, given signals of increased mortality with their use in TBI. When invasive ICP monitoring is unavailable or contraindicated, multimodal noninvasive strategies may guide timely interventions and reduce the risk of unrecognized intracranial hypertension. Thrombo-prophylaxis timing and type in ABI must balance bleeding and thrombotic risks, resumption of oral anticoagulants after ischemic or hemorrhagic stroke should be individualized, and reversal of anticoagulation before urgent neurosurgery mainly relies on prothrombin complex concentrate, with the role of specific antidotes to be further demonstrated.

This review offers evidence-based guidance on key aspects of managing acute brain injury patients undergoing neurosurgical or interventional neuroradiological procedures. Current literature highlights the complexity of care in this population, emphasizing the need for ongoing clinician education and high-quality research to refine and optimize management strategies.