Document Type : Systematic Review
Authors
1
MD, Brain and Spain Surgeon, Trauma and Injury Research center, Tehran, Iran
2
Department of Anesthesiology and Critical Care, School of Medicine, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran,
3
Department of Anesthesiology and Critical Care, School of Medicine, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
4
Emergency Medicine Specialist، Department of Emergency Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
10.5281/zenodo.22286891
Abstract
Background: Acute intracranial hypertension requiring emergency neurosurgical intervention is associated with substantial risks of neurological deterioration, cerebral hypo perfusion, and perioperative mortality. Anesthetic management in this setting is particularly challenging because induction, airway manipulation, ventilation, hemodynamic instability, and anesthetic drug selection may influence intracranial pressure (ICP), cerebral perfusion pressure (CPP), and neurological outcomes. However, evidence regarding the optimal perioperative anesthetic strategy remains heterogeneous.
Objective: This systematic review and meta-analysis aimed to evaluate perioperative anesthetic strategies and their associations with physiological and clinical outcomes in patients undergoing emergency neurosurgery for acute intracranial hypertension.
Methods: A systematic literature search designed to identify clinical studies evaluating anesthetic management during emergency or urgent craniotomy or craniectomy for intracranial hypertension or brain herniation. Relevant outcomes included ICP, CPP, arterial blood pressure, hemodynamic instability, brain swelling, extubation status, neurological outcomes, and mortality. Evidence concerning intravenous and volatile anesthetic techniques, induction strategies, and adjunctive perioperative interventions critically assessed. Risk of bias, clinical, and methodological heterogeneity considered before quantitative synthesis.
Results: Available evidence suggests that perioperative anesthetic management can influence cerebral and systemic physiology, although the certainty of evidence remains limited. Propofol-based anesthesia has been associated with lower ICP and reduced risk of brain swelling compared with volatile anesthetics in broader craniotomy populations, although this benefit not consistently demonstrated in emergency craniotomy subgroups. Contemporary evidence also challenges the historical concern that ketamine invariably increases ICP; systematic reviews have reported no consistent adverse effect on ICP, CPP, or mortality in patients with acute brain injury. Nevertheless, heterogeneity in patient populations, anesthetic regimens, concomitant therapies, and outcome definitions limits definitive comparisons.
Conclusions: Current evidence does not establish a single superior anesthetic regimen for emergency neurosurgery complicated by acute intracranial hypertension. Individualized, physiology-guided management emphasizing preservation of cerebral perfusion and avoidance of secondary physiological insults appears most appropriate.
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