Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit.

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

The role of heart rate variability in predicting delirium: A systematic review and meta-analysis.

Brain and heart interact through multiple ways. Heart rate variability, a non-invasive measurement is studied extensively as a predicting model for various health conditions including subarachnoid hemorrhage, cancer, and diabetes. There is limited evidence to predict delirium, an acute fluctuating disorder of brain dysfunction, as it poses a significant challenge in the intensive care unit (ICU) and post-operative setting. In this systematic review of 9 articles, heart rate variability indices were used to investigate the occurrence of post-operative and ICU delirium. This systematic review and meta-analysis reveal evidence of a strong predilection between postoperative and intensive care unit delirium and alterations in the heart rate variability, measured by mean differences for standard deviation of NN-intervals. Other heart rate variability indices [root mean squares of successive differences, low-frequency (LF), high-frequency (HF), and LF:HF ratio] showed lack of or very weak association. A non-invasive tool of brain and heart interaction may refine diagnostic predictions for acute brain dysfunctions like delirium in such population and would be an important step in delirium research.

Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis.

Background and Aims: Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery. Methods: We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI). Results: Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4). Conclusion: Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

Predictor role of heart rate variability in subarachnoid hemorrhage: A systematic review.

Background- Subarachnoid hemorrhage (SAH) is one of the most devastating diseases with a high rate of morbidity and mortality. The heart rate variability (HRV) is a non-invasive method of monitoring various components of the autonomic nervous system activity that can be utilized to delineate autonomic dysfunctions associated with various physiological and pathological conditions. The reliability of HRV as a predictor of clinical outcome in aneurysmal subarachnoid hemorrhage (aSAH) is not yet well investigated in literature. Methods- A systematic review and in depth analysis of 10 articles on early HRV changes in SAH patients was performed. Results- This systematic review demonstrates a correlation between early changes in HRV indices (time and frequency domain) and the development of neuro-cardiogenic complications and poor neurologic outcome in patients with SAH. Conclusions- A correlation between absolute values or changes of the LF/HF ratio and neurologic and cardiovascular complications was found in multiple studies. Because of significant limitations of included studies, a large prospective study with proper handling of confounders is needed to generate high-quality recommendations regarding HRV as a predictor of post SAH complications and poor neurologic outcome.

Utilizing Artificial Intelligence and Chat Generative Pretrained Transformer to Answer Questions About Clinical Scenarios in Neuroanesthesiology.

OBJECTIVE: We tested the ability of chat generative pretrained transformer (ChatGPT), an artificial intelligence chatbot, to answer questions relevant to scenarios covered in 3 clinical guidelines, published by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), which has published management guidelines: endovascular treatment of stroke, perioperative stroke (Stroke), and care of patients undergoing complex spine surgery (Spine). METHODS: Four neuroanesthesiologists independently assessed whether ChatGPT could apply 52 high-quality recommendations (HQRs) included in the 3 SNACC guidelines. HQRs were deemed present in the ChatGPT responses if noted by at least 3 of the 4 reviewers. Reviewers also identified incorrect references, potentially harmful recommendations, and whether ChatGPT cited the SNACC guidelines. RESULTS: The overall reviewer agreement for the presence of HQRs in the ChatGPT answers ranged from 0% to 100%. Only 4 of 52 (8%) HQRs were deemed present by at least 3 of the 4 reviewers after 5 generic questions, and 23 (44%) HQRs were deemed present after at least 1 additional targeted question. Potentially harmful recommendations were identified for each of the 3 clinical scenarios and ChatGPT failed to cite the SNACC guidelines. CONCLUSIONS: The ChatGPT answers were open to human interpretation regarding whether the responses included the HQRs. Though targeted questions resulted in the inclusion of more HQRs than generic questions, fewer than 50% of HQRs were noted even after targeted questions. This suggests that ChatGPT should not currently be considered a reliable source of information for clinical decision-making. Future iterations of ChatGPT may refine algorithms to improve its reliability as a source of clinical information.

Emergence Patterns from General Anesthesia after Epilepsy Surgery: An Observational Pilot Study.

Objective Emergence from anesthesia starts from the limbic structures and then spreads outwards to brainstem, reticular activating systems, and then to the cortex. Epilepsy surgery often involves resection of limbic structures and hence may disrupt the pattern of emergence. The aim of this study was to explore the pattern of emergence from anesthesia following epilepsy surgery and to determine associated variables affecting the emergence pattern. Setting and Design Tertiary care center, prospective observational study. Materials and Methods We conducted a prospective observation pilot study on adult patients undergoing anterior temporal lobectomy and amygdalohippocampectomy for epilepsy. Anesthesia management was standardized in all patients, and they were allowed to wake up with "no touch" technique. Primary outcome of the study was the pattern of emergence (normal emergence, agitated emergence, or slow emergence) from anesthesia. Secondary outcomes were to explore the differences in preoperative neuropsychological profile and limbic structure volumes between the different patterns of emergence. Quantitative variables were analyzed using Student's t -test. Qualitative variables were analyzed using chi-square test. Results Twenty-nine patients completed the study: 9 patients (31%) had agitated emergence, and 20 patients had normal emergence. Among the agitated emergence, 2 patients had Riker scale of 7 indicating violent emergence. Patient demographics, anesthetic used, neuropsychological profile, and limbic structure volumes were similar between normal emergence and agitated emergence groups. However, two patients who had severe agitation (Riker scale of 7) had the lowest intelligence quotient. Conclusion Our pilot study showed that emergence agitation is not uncommon in patients undergoing epilepsy surgery. However, due to smaller sample size, the role of preoperative neuropsychologic profile and hippocampal volumes in predicting the pattern of emergence is inconclusive.

Postoperative cognitive recovery and prevention of postoperative cognitive complications in the elderly patient.

Elderly patients undergoing surgery are at higher risk of life-altering and costly complications. This challenge is increasingly recognized with the growing geriatric surgical population. Advanced age and comorbid conditions, such as disability and frailty that often develop with age, are all independent risk factors of postoperative morbidity and mortality. A common factor in this age group is cognitive impairment, which poses a challenge for the patient and clinician in the perioperative setting. It affects the capacity for informed consent and limits optimization before surgery; furthermore, an existing impairment may progress in severity during the perioperative period, and new onset of signs of delirium or postoperative cognitive dysfunction may arise during postoperative recovery. In this article, we aim to review the current literature examining the latest definitions, diagnostic criteria, and preventive strategies that may ameliorate postoperative cognitive complications.

The elderly in the post-anesthesia care unit.

It is increasingly conceivable that elderly patients will be treated in perioperative settings as the world's population shifts toward an older age distribution. They are more prone to a variety of unfavorable outcomes as a consequence of the physiological changes that accompany aging and the coexistence of multiple medical conditions. Postoperative complications in elderly patients are linked to a large increase in morbidity and mortality and the burden placed on the healthcare system. Our goal is to determine how elderly patients' recovery after anesthesia differs from that of younger patients. In addition, we will discuss the main postoperative complications experienced by elderly patients and the measures that are utilized to limit the risk of these complications developing.

Effects of Anesthetic Agents on Blood Brain Barrier Integrity: A Systematic Review.

BACKGROUND: The blood brain barrier (BBB) is a highly selective permeable barrier that separates the blood and the central nervous system. Anesthesia is an integral part of surgery, and there is little known about the impact of anesthetics on the BBB. Therefore, it is imperative to explore reversible or modifiable variables such as anesthetic agents that influence BBB integrity. We aimed to synthesize the literature pertaining to the various effects of anesthetics on the BBB. METHODS: MEDLINE, Embase, and Cochrane were searched from inception up to September 2022. RESULTS: A total of 14 articles met inclusion into the review. The articles included nine randomized control studies (64.3%) and five quasi-experimental studies (35.7%). Twelve studies used volatile anesthetics, one study used fentanyl intravenously, and one study used pentobarbital or ketamine intraperitoneally. BBB structural deficits following the administration of an anesthetic agent included ultrastructural deficits, decreases in tight junctions, and decreases in BBB components. BBB functional deficits included permeability increases following exposure to volatile anesthetics. However, two studies found decreased permeability after fentanyl, pentobarbital, or ketamine exposure. Moreover, the impact of anesthetics on the BBB seems to be related to the duration of exposure. Notably, study findings also suggest that changes following anesthetic exposure demonstrate some reversibility over the short-term. CONCLUSION: Overall, our systematic review highlights interesting findings pertaining to the impact of anesthetic agents on BBB integrity in previously healthy models. These findings and mechanisms should inspire future work to aid practitioners and healthcare teams potentially better care for patients.

Risk Factors and Characteristics of Intraoperative Seizures During Awake Craniotomy: A Retrospective Cohort Study of 562 Consecutive Patients With a Space-occupying Brain Lesion.

INTRODUCTION: Intraoperative seizures (IOSs) during awake craniotomy (AC) are associated with significant morbidity. The reported incidence of IOS is between 3% and 30%. The aim of this study was to identify risk factors for IOS during AC for elective resection or biopsy of a space-occupying brain lesion. METHODS: In this retrospective study, we reviewed the records of all awake craniotomies performed by a single neurosurgeon at a single university hospital between July 2006 and December 2018. IOS was defined as a clinically apparent seizure that occurred in the operating room and was documented in the medical records. Explanatory variables were chosen based on previously published literature on risk factors for IOS. RESULTS: Five hundred and sixty-two patients had a total of 607 AC procedures during the study period; 581 cases with complete anesthesia records were included in analysis. Twenty-nine (5.0%) IOS events were reported during 29 (5%) awake craniotomies. Most seizures (27/29; 93%) were focal in nature and did not limit planned intraoperative stimulation mapping. Variables associated with IOS at a univariate P -value <0.1 (frontal location of tumor, preoperative radiotherapy, preoperative use of antiepileptic drugs, intraoperative use of dexmedetomidine, and intraoperative stimulation mapping) were included in a multivariable logistic regression. Frontal location of tumor (adjusted odds ratio: 5.68, 95% confidence interval: 2.11-15.30) and intraoperative dexmedetomidine use (adjusted odds ratio: 2.724, 95% confidence interval: 1.24-6.00) were independently associated with IOS in the multivariable analysis. CONCLUSIONS: This study identified a low incidence (5%) of IOS during AC. The association between dexmedetomidine and IOS should be further studied in randomized trials as this is a modifiable risk factor.

Feasibility of intraoperative MRI for endovascular coiling of intracranial aneurysms: A single centre experience.

BACKGROUND: Intraoperative magnetic resonance imaging system (iMRIS) surgical theatre is a highly integrated operating room with an intraoperative magnetic resonance imaging (iMRI) designed originally for brain tumour surgery. Its use in neurointerventional procedures, particularly in the setting of endovascular coiling of intracranial aneurysms, has not been discussed in the literature to date. We present our initial experience about the safety and feasibility of iMRI to assess post operative complications and provide baseline imaging post coiling of intracranial aneurysms. METHODS: Consecutive patients who underwent iMRI between 2015 and 2018 were included in the study. Demographic, clinical details, endovascular technique and surgical outcomes were collected. Details of anesthesia during the procedure were also collected. RESULTS: Fifteen patients underwent iMRI with MRA to assess post coiling status of their elective endovascular coiling of intracranial aneurysms. The mean age in this cohort was 61 years and 46.7% were male. No immediate complications were seen either from the endovascular procedures or from the iMRI. All iMRI scans were performed as planned with no aborted or truncated scans. The image quality of the iMRI/MRA was adequate to detect the residual aneurysm, if present. There was no residual aneurysm on the angiogram that were not detected on the iMRIs. Of the 15 patients, 10 were safely discharged the following day and other 5 were discharged 2 days after their surgery. CONCLUSIONS: The iMRI is an advantageous tool which can be integrated into neurointerventional workflow resulting in early post peri-procedural feedback and potentially reduced post-operative hospital stay.

Role of midazolam on cancer progression/survival - An updated systematic review.

Background and Aims: Cancer is a leading cause of mortality worldwide. Despite advancements in cancer management, cancer progression remains a challenge, requiring the development of novel therapies. Midazolam is a commonly used adjunct to anaesthesia care for various surgeries, including cancer. Recently, there has been a growing interest in exploring the potential role of midazolam as an anticancer agent; however, the exact mechanism of this linkage is yet to be investigated thoroughly. Methods: Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, this systematic review presented aggregated evidence (till November 2022) of the effects of midazolam on cancer progression and survival. All primary research article types where midazolam was administered in vivo or in vitro on subjects with cancers were included. No restrictions were applied on routes of administration or the type of cancer under investigation. Narrative synthesis depicted qualitative findings, whereas frequencies and percentages presented numerical data. Results: Of 1720 citations, 19 studies were included in this review. All articles were preclinical studies conducted either in vitro (58%, 11/19) or both in vivo and in vitro (42%, 8/19). The most studied cancer was lung carcinoma (21%, 4/19). There are two main findings in this review. First, midazolam delays cancer progression (89%, 17/19). Second, midazolam reduces cancer cell survival (63%, 12/19). The two major mechanisms of these properties can be explained via inducing apoptosis (63%, 12/19) and inhibiting cancer cell proliferation (53%, 10/19). In addition, midazolam demonstrated antimetastatic properties via inhibition of cancer invasion (21%, 4/19), migration (26%, 5/19), or epithelial-mesenchymal transition (5%, 1/19). These anticancer properties of midazolam were demonstrated through different pathways when midazolam was used alone or in combination with traditional cancer chemotherapeutic agents. Conclusion: This systematic review highlights that midazolam has the potential to impede cancer progression and decrease cancer cell survival. Extrapolation of these results into human cancer necessitates further investigation.

Perioperative Considerations in a Patient with Kleine-Levin Syndrome Undergoing a Neurosurgical Procedure under General Anesthesia.

Kleine-Levin syndrome (KLS) is a rare central disorder of daytime hypersomnolence and is often characterized by a relapsing and remitting course, recurrent episodes of excessive sleep lasting from 12 to 20 hours a day, and symptoms including hyperphagia, hallucinations, derealization, disorientation, and hypersexuality. There are numerous perioperative considerations in dealing with KLS that include challenges during induction of anesthesia, delayed emergence, postoperative sleep disorders, and delirium. However, due to its rare occurrence, the anesthetic considerations of KLS remain poorly described. This case report outlines the anesthetic considerations and management of a young female patient with KLS who underwent transnasal excision of a trigeminal schwannoma under general anesthesia.

Tolerability of Repeat Awake Craniotomy: A Propensity-Score-Matched Analysis on 607 Consecutive Cases.

BACKGROUND: Awake craniotomy is used for addressing lesions adjacent to eloquent brain regions to minimize damage to neurological functions, and to expedite postoperative recovery. Redo (i.e., repeat) awake surgery is not common, but always an option, especially for recurrent tumors. This study investigated the tolerability of redo awake surgery in terms of surgical characteristics and postoperative clinical course. METHODS: Single-institution cohort study of 607 awake craniotomies by 1 surgeon at Toronto Western Hospital, 2006-2018. RESULTS: Out of 607 surgeries, 501 surgeries were first-time, and 106 surgeries were redo. Between the 2 groups, surgery time was longer in redo cases than first-time cases and the rate of reoperation was higher in the former. Matched propensity cohort analysis included 104 cases each, based on adjustments for age, sex, tumor location, malignancy, and preoperative performance status. This revealed differences again in surgery time (128.0 vs. 111.9 minutes, P = 0.0004) and the reoperation rate (7.4 vs. 1.0%, P = 0.03). The causes of reoperation were infection (3 wound infection and 3 brain abscess) and wound dehiscence (n = 1). There was no significant difference in the length of hospital stay, the rates of postoperative hemorrhage, new postoperative neurological deficits, home discharge, or readmission. CONCLUSIONS: Although redo surgery might increase the surgery time and the risk of reoperation due to postoperative infection, it was found to be well tolerated in other aspects overall. With extra care to infection and wound healing, redo awake surgery is a viable option to patients with the same surgical indication as for first-time surgery.

Benzodiazepine Sedation and Postoperative Neurological Deficits after Awake Craniotomy for Brain Tumor - An Exploratory Retrospective Cohort Study.

An awake craniotomy is a common neurosurgical procedure for excising brain tumor(s) located near or in eloquent areas. The use of benzodiazepine (BZD) for sedation in some patients with neuropathological conditions (e.g., stroke, brain tumors) has been previously linked with re-appearance of neurological deficits including limb incoordination, ataxia, and motor weakness, resulting in complications for the patient along with procedural challenges. Whether or not these findings can be extrapolated to patients undergoing brain tumor resection is largely unknown. The current work primarily sought to compare neurological outcome(s) in the immediate postoperative period between BZD-free and BZD-based sedation techniques in patients undergoing awake craniotomy. Using a database composed of awake craniotomies conducted within a single center and by a single surgeon, patients were retrospectively classified based on midazolam administration into BZD-free sedation (n=125) and BZD-based sedation (n=416) groups. Patients from each group were matched based on age, sex, tumor location, tumor grade, preoperative neurological deficits, non-operative BZD use, and Karnofsky Performance Scale scores, resulting in 108 patients within each group. Postoperative neurological deficits were recorded. Logistic regression analyses were conducted comparing postoperative neurological deficits between the matched groups. Postoperative neurological deficits were more prevalent within the BZD-based sedation group compared to the BZD-free sedation group (adjusted odds ratio (aOR)=1.903, 95% CI=1.018-3.560, p=0.044). In addition, subgroup analysis of the matched cohort showed a relationship between preoperative neurological symptoms and postoperative neurological deficits in the BZD-based sedation group (aOR=3.756, 95% CI=1.390-10.147, p=0.009). Our findings support the notion that the increased incidence of postoperative neurological deficits with BZD sedation may in part be related to the unmasking of preoperative neurological deficits. Further studies are required to confirm this phenomenon.

Anesthetic consideations for endovascular treatment of acute ischemic stroke.

PURPOSE: The purpose of this Continuing Professional Development module is to provide information pertaining to anesthetic considerations and management of endovascular thrombectomy (EVT) for patients with acute ischemic stroke. PRINCIPAL FINDINGS: Acute ischemic stroke is a devastating neurologic disorder and timely intervention is key to a good neurologic outcome. This article provides an overview of three important concepts: pathophysiology and disease characteristics of acute ischemic stroke, and the procedural and anesthetic aspects of EVT. Key considerations include recognition of stroke symptoms, timing and urgency of intervention, procedural considerations for anesthesiologists, risks and benefits of different anesthetic techniques, and a summary of recent guidelines. In particular, current recommendations for blood pressure management in this setting are reviewed. CONCLUSIONS: Timely intervention for patients with acute ischemic stroke is of utmost importance. Endovascular thrombectomy is a minimally invasive procedure that has evolved over recent decades and improves outcomes for selected patients with ischemic stroke. Anesthesiologists should have a good understanding of potential complications and anesthetic options. Recent randomized trials have shown that both general anesthesia and sedation are associated with good outcomes; the anesthetic approach should be individualized and may vary by institution. Careful monitoring and maintenance of hemodynamic goals are critical, as is effective communication with the multidisciplinary team.

RéSUMé: OBJECTIF: L'objectif de ce module de développement professionnel continu est de fournir des informations sur les considérations anesthésiques et la prise en charge de la thrombectomie endovasculaire (TEV) chez les patients atteints d'AVC ischémique aigu. CONSTATATIONS PRINCIPALES: L'AVC ischémique aigu est un trouble neurologique dévastateur; une intervention rapide est la clé d'un bon devenir neurologique. Cet article donne un aperçu de plusieurs concepts importants : la physiopathologie et les caractéristiques pathologiques de l'AVC ischémique aigu, ainsi que les aspects procéduraux et anesthésiques de la TEV. Les principales considérations comprennent la reconnaissance des symptômes de l'AVC, le moment et l'urgence de l'intervention, les considérations procédurales pour les anesthésiologistes, les risques et les avantages des différentes techniques d'anesthésie, et un résumé des lignes directrices récentes. Plus spécifiquement, nous passerons en revue les recommandations actuelles pour la prise en charge de la pression artérielle dans un tel contexte. CONCLUSIONS: Une intervention rapide est essentielle pour les patients atteints d'AVC ischémique aigu. La thrombectomie endovasculaire est une procédure minimalement invasive qui a évolué au cours des dernières décennies et qui améliore les devenirs de certains patients atteints d'AVC ischémique. Les anesthésiologistes doivent avoir une bonne compréhension des complications potentielles et des options anesthésiques. Des études randomisées récentes ont montré que l'anesthésie générale et la sédation sont associées à de bons pronostics; l'approche anesthésique devrait être personnalisée et peut varier d'un établissement à l'autre. Un monitorage attentif et le maintien des cibles hémodynamiques sont essentiels, tout comme une communication efficace avec l'équipe multidisciplinaire.

Perioperative Complications and Anesthesia Practices in Managing Patients With Quadriplegia Undergoing Surgery: A Systematic Review.

Quadriplegia is associated with a multitude of health complications affecting numerous organ systems. Complications during the perioperative periods are not uncommon in this patient population due to abnormal responses to surgical stressors. Such complications include autonomic dysreflexia, cardiac ischemia, and respiratory compromise. Currently, there is no clear consensus on the ideal technique for perioperative anesthesia management in this population. In addition, the relationship between the perioperative complications and anesthesia practices have not been explored in-depth. Therefore, we aimed to investigate perioperative complications in the context of anesthesia that are associated with patients with quadriplegia undergoing various surgical procedures. Our PRISMA compliant systematic review included 12 articles covering the literature from inception to January 12, 2021. The review showed complications being pulmonary, cerebral, but most importantly and commonly cardiac in nature, with many patients suffering hypertension, and many others hypotension. In addition, our review showed that autonomic dysreflexia is common and in majority of patients, it was managed successfully with good recovery. Based on our findings, the use of anesthesia, either general or spinal, can be considered. Future studies are needed to elucidate the exact mechanisms involved in perioperative complications and anesthetic management that are associated with patients with quadriplegia. This review will aid in developing general recommendations based on the information available in the literature to guide perioperative management of this vulnerable patient population.