Journal of neurosurgical anesthesiology
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J Neurosurg Anesthesiol · Jan 2025
Meta Analysis Comparative StudyIntensive Versus Standard Blood Pressure Management after Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-analysis.
Prospective clinical studies on blood pressure (BP) management targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) have recently been published. Our objective was to assess the impact on clinical outcomes of BP management guided by established systolic BP (SBP) targets within the first 24 hours after successful EVT. Four randomized controlled trials (RCTs) including 1556 participants across 5 SBP target settings identified from 5 databases up to September 6, 2023 were included in this systematic review and meta-analysis. ⋯ Patients receiving intensive SBP management had lower risk of 90-day functional independence as assessed by the modified Rankin scale score (relative risk [RR], 0.81; 95% confidence interval [CI], 0.72 to 0.91; I2 , 12%), excellent outcomes (RR,0.86; 95% CI, 0.75 to 0.99; I2 , 7%), favorable outcomes (RR, 0.85; 95% CI, 0.78 to 0.92; I2 , 0%), and quality of life (standardized mean difference, -0.22; 95% CI, -0.35 to -0.10; I 2 ,0%). There were no differences in the probability of any intracerebral hemorrhage (RR, 1.04; 95% CI, 0.92 to 1.19; I2 ,0%), symptomatic intracerebral hemorrhage (RR, 1.10; 95% CI, 0.76 to 1.60; I2 , 0%), stroke-related death (RR, 1.16; 95% CI, 0.80 to 1.68; I2 , 0%), or parenchymal hematoma (RR, 1.71; 95% CI, 0.74 to 3.98; I2 , 47%) between SBP targets. This meta-analysis provides evidence from RCTs suggesting that intensive SBP control (target<160 mm Hg) may be detrimental to clinical outcomes in AIS patients with successful reperfusion after EVT.
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J Neurosurg Anesthesiol · Jan 2025
ReviewPerioperative Methadone for Spine Surgery: A Scoping Review.
Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. ⋯ On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.
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J Neurosurg Anesthesiol · Jan 2025
Meta AnalysisEnhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis.
The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. ⋯ Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.
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J Neurosurg Anesthesiol · Jan 2025
ReviewAntiplatelet Agents in Endovascular Neurointerventional Procedures.
Minimally invasive, image-guided endovascular procedures are becoming increasingly prevalent as techniques and technologies have advanced, particularly within the realm of neurovascular interventions. Endovascular approaches ubiquitously result in endothelial injury with subsequent risk of thromboembolic complications. Periprocedural antiplatelet agent use is an integral component of the management of patients undergoing endovascular neurointerventional procedures. ⋯ This focused review will discuss the major mechanisms of action of antiplatelet agents, and their clinical indications and management in the periprocedural neurointerventional setting. Despite the importance of antiplatelet agents in the management of neurointerventional patients, many questions remain. Further research and clinical expertise are needed to establish standardized, procedure-specific, antiplatelet regimens as well as standardized monitoring of antiplatelet agent regimen efficacy and safety.
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J Neurosurg Anesthesiol · Jul 2024
ReviewA Reappraisal of the Pathophysiology of Cushing Ulcer: A Narrative Review.
In 1932, Harvey Cushing described peptic ulceration secondary to raised intracranial pressure and attributed this to vagal overactivity, causing excess gastric acid secretion. Cushing ulcer remains a cause of morbidity in patients, albeit one that is preventable. This narrative review evaluates the evidence pertaining to the pathophysiology of neurogenic peptic ulceration. ⋯ Alternations in the gut microbiome in patients with severe traumatic brain injury include colonization with commensal flora associated with peptic ulceration. The brain-gut-microbiome axis integrates the central nervous system, the enteric nervous system, and the immune system. Following the review of the literature, we propose a novel hypothesis that neurogenic peptic ulcer may be associated with alterations in the gut microbiome, resulting in gastrointestinal inflammation leading to ulceration.