Effect of dexmedetomidine on recovery profile of patients undergoing anterior cervical discectomy and fusion.

BACKGROUND AND AIM: Smooth and rapid emergence and extubation, with minimal coughing, is desirable after cervical spine surgery to facilitate early neurological examination. The present study investigated the effect of dexmedetomidine as an intraoperative anesthetic adjuvant on postoperative extubation and recovery profile in patients undergoing anterior cervical discectomy and fusion (ACDF) surgery. MATERIAL AND METHODS: Sixty-four, American Society of Anesthesiologist I or II adult patients (age 18-60 years) were randomized in this placebo-controlled, double-blind study. In group D, dexmedetomidine was started at 0.2 µg/kg/h after a loading dose of 1 µg/kg before induction and in group P, volume and infusion rate-matched normal saline was used. Perioperative hemodynamics, intraoperative anesthetic consumption, and postoperative recovery profile were observed. RESULTS: Thirty-one patients in each group successfully completed the study. Time to emergence (6.9 min vs 10 min, P < 0.001), time to extubation (8.5 min vs 12.2 min, P = 0.002), and time to achieve modified Aldrete score ≥9 (5 min vs 10 min, P < 0.001) were earlier in group D compared to group P, respectively. Pain score at extubation was lower (0 vs 20) and time for first analgesic was longer (50 min vs 15 min) in group D compared to group P. Coughing at extubation was comparable in both the groups. One patient in group D had severe postextubation bradycardia. CONCLUSIONS: Intraoperative use of dexmedetomidine at the lowest recommended dosage in adults undergoing ACDF surgery results in a favorable recovery profile with reduced emergence/extubation time and postoperative pain, but similar incidence of coughing.

Complications related to sitting position during Pediatric Neurosurgery: An institutional experience and review of literature.

BACKGROUND: Sitting position is preferred during posterior fossa surgeries as it provides better anatomical orientation and a clear surgical field. However, its use has been declining due to its propensity to cause life-threatening complications. This study was carried out to analyze the perioperative complications and postoperative course of children who underwent neurosurgery in sitting position. MATERIALS AND METHODS: Medical records of 97 children (<18 years) who underwent neurosurgery in sitting position over a period of 12 years, were retrospectively analyzed. Data pertaining to the perioperative course such as demographics, hemodynamic changes, various complications, duration of intensive care unit (ICU) and hospital stay, and neurological status at discharge were recorded. Statistical analysis was done by chi-square and Mann-Whitney test, and a P value <0.05 was considered as significant. RESULTS: The median age of these children was 12 (3-18) years. Hemodynamic instability was observed in 12 (12.3%) children. A total of 38 episodes of venous air embolism (VAE) were encountered in 21 (21.6%) children; nine experienced multiple episodes. VAE was associated with hypotension in five (23.8%) and desaturation in four (19.1%) children. Six children presented with postoperative tension pneumocephalus; three were managed with twist drill burr-hole evacuation. Brainstem handling was the most common indication (42.5%) for the requirement of elective postoperative ventilation. The duration of ICU and hospital stays were comparable among the children who experienced VAE and those who did not (P > 0.05). Neurological status at discharge was also comparable between these two groups (P = 0.83). CONCLUSIONS: This study observed a lesser incidence of VAE and associated complications. Tension pneumocephalus was managed successfully without any adverse outcome. Hence, it is believed that with meticulous anesthetic and surgical techniques, sitting position can safely be practiced in children undergoing neurosurgery.

The role of neuronavigation-guided functional MRI and diffusion tensor tractography along with cortical stimulation in patients with eloquent cortex lesions.

OBJECTIVE. To effectively combine functional MRI (fMRI), diffusion tensor tractography (both guided by neuronavigation) along with cortical stimulation (CS) for surgery of eloquent cortex (EC) lesions. MATERIALS AND METHOds. Fifteen patients with lesions adjacent to the eloquent motor and sensory cortex were included. Preoperative fMRI and diffusion tensor imaging were performed and then integrated into the neuronavigation system. Intraoperative CS of sensory/motor cortex was performed to localize the EC under awake condition and this was correlated with areas active on fMRI utilizing neuronavigation. For excision of the deeper structures, CS, and tractography guided by neuronavigation were utilized. RESULTS. A total of 127 cortical sites were evaluated with CS in 15 patients. The overall sensitivity, specificity, and accuracy of fMRI were 79%, 85%, and 82%, respectively, keeping the areas positive on CS as a referential parameter. Tractography helped in resecting the deeper areas of the tumor, but was not very accurate due to brain shift. However, it was useful in roughly assessing the deeper areas close to the long tracts. The risk of developing persistent neurological deficits was 6%. Pathologies included gliomas in ten patients, cavernous malformation in two patients, meningioma in one patient, and focal cortical dysplasia and Dysembryonic neuroepithelial tumor in one patient each. Near total excision was achieved in 7/10 (> 95% excision) gliomas and a total excision in all others lesions. CONCLUSIONS. Lesions directly over the EC present a special surgical challenge. The challenge lies in excising these lesions without producing any deficits. These goals may be achieved better by combined use of multimodal neuronavigation (fMRI and tractography) and intraoperative mapping with CS under awake conditions.

Predicting difficult laryngoscopy in acromegalic patients undergoing surgery for excision of pituitary tumors: A comparison of extended Mallampati score with modified Mallampati classification.

BACKGROUND: There are numerous reports of difficult laryngoscopy and intubation in patients with acromegaly. To date, no study has assessed the application of extended Mallampati score (EMS) for predicting difficult intubation in acromegalics. The primary aim of this study was to compare EMS with modified Mallampati classification (MMP) in predicting difficult laryngoscopy in acromegalic patients. We hypothesized that since EMS has been reported to be more specific and better predictor than MMP, it may be superior to the MMP to predict difficult laryngoscopy in acromegalic patients. MATERIALS AND METHODS: For this prospective cohort study with matched controls, acromegalic patients scheduled to undergo pituitary surgery over a period of 3 years (January 2008-December 2010) were enrolled. Preoperative airway assessment was performed by experienced anesthesiologists and involved a MMP and the EMS. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL) grading. MMP and CL grades of I and II were defined "easy" and III and IV as "difficult". EMS grade of I and II were defined "easy" and III as "difficult". Data were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MMP and EMS in predicting difficult laryngoscopy. RESULTS: Seventy eight patients participated in the study (39 patients in each group). Both MMP and EMS failed to detect difficult laryngoscopy in seven patients. Only one laryngoscopy was predicted to be difficult by both tests which was in fact, difficult. CONCLUSION: We found that addition of neck extension did not improve the predictive value of MMP.

Post-operative pulmonary complications in patients undergoing transoral odontoidectomy and posterior fixation for craniovertebral junction anomalies.

BACKGROUND: In patients with craniovertebral junction (CVJ) anomalies, the respiratory system is adversely affected in many ways. The sub-clinical manifestations may get aggravated in the postoperative period owing to anesthetic or surgical reasons. However, there is limited data on the incidence of postoperative pulmonary complications (PPCs) and associated risk factors in such patients, who undergo transoral odontoidectomy (TOO) and posterior fixation (PF) in the same sitting. MATERIALS AND METHODS: Five years data of 178 patients with CVJ anomaly who underwent TOO and PF in the same sitting were analyzed retrospectively. Preoperative status, intraoperative variables, and PPCs were recorded. Patients were divided into two groups depending on the presence or absence of PPCs. Bivariate analysis was done to find out association between various risk factors and PPCs. Multivariate analysis was done to detect relative contribution of the factors shown to be significant in bivariate analysis. P < 0.05 was considered as significant. RESULTS: The incidence of PPCs was found to be 15.7%. Factors significantly associated with PPCs were American Society of Anesthesiologists grade higher than II, preoperative lower cranial nerves palsy and respiratory involvement, duration of surgery, and intraoperative blood transfusion. In multivariate analysis, blood transfusion was found to be the sole contributing factor. The patients who developed PPCs had significantly prolonged stay in ICU and hospital. CONCLUSION: Patients with CVJ anomaly are at increased risk of developing PPCs. There is a strong association between intraoperative blood transfusion and PPCs. Patients with PPCs stay in the ICU and hospital for a longer period of time.

Thermal injury from forced-air warmer device precipitated by massive extravasation from peripheral venous cannula.

Extravasation injury (EVI) is an iatrogenic complication of venous cannulation. Usually innocuous but occasionally it engenders sequelae. Its severity is determined by various physicochemical properties of infusate. A 50-year-old patient developed leg EVI from crystalloids infused through a pressurized digital infuser (PDI), likely from cannula tip displacement during positioning for craniotomy. We ignored checking gravity-aided free-fluids flow before switching on PDI. Following surgery, the patient had an edematous leg with bullae and epidermal peelings from severe extravasation and burns, respectively. Doppler revealed patent leg arteries. Therefore, EVI was conservatively managed, with complete recovery. Apparently, increased local tissue pressure from extravasation produced conditions of peripheral circulation sufficiency predisposing the leg to thermal injury from the forced-air warmer. On inspecting PDI postoperatively, its upper-pressure alarm limit was 300 mmHg, which prevented it from sounding alarm during extravasation.

Effect of Goal-Directed Intraoperative Fluid Therapy on Duration of Hospital Stay and Postoperative Complications in Patients Undergoing Excision of Large Supratentorial Tumors.

Background: Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Materials and Methods: Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. Results: The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. Conclusions: This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. Clinical Trial Registry: CTRI/2016/10/007350.

A comparative evaluation of nitrous oxide-isoflurane vs isoflurane anesthesia in patients undergoing craniotomy for supratentorial tumors: A preliminary study.

BACKGROUND: Neuroanesthesiologists are a highly biased group; so far the use of nitrous oxide in their patient population is concerned. We hypothesized that any adverse consequence with use of nitrous oxide should affect the patient so as to prolong his/her stay in the hospital. The primary aim of this preliminary trial was to evaluate if avoidance of nitrous oxide could decrease the duration of Intensive Care Unit (ICU) and hospital stay after elective surgery for supratentorial tumors. PATIENTS AND METHODS: A total of 116 consecutive patients posted for elective craniotomy for various supratentorial tumors were enrolled between April 2008 and November 2009. Patients were randomly divided into Group I: Nitrous oxide - Isoflurane anesthesia (Nitrous oxide-based group) and Group II - Isoflurane anesthesia (Nitrous oxide-free group). Standard anesthesia protocol was followed for all the patients. Patients were assessed till discharge from hospital. RESULTS: The median duration of ICU stay in the nitrous group and the nitrous-free group was 1 (1 - 11 days) day and 1 (1 - 3 days) day respectively (P = 0.67), whereas the mean duration of hospital stay in the nitrous group was 4 (2 - 16) days and the nitrous free group was 3 (2 - 9) days (P = 0.06). The postoperative complications in the two groups were comparable. CONCLUSION: From this preliminary study with a low statistical power, it appears that avoidance of nitrous oxide in one's practice may not affect the outcome in the neurosurgical patients. Further large systemic trials are needed to address this issue.

A retrospective analysis of perioperative complications during intracranial neuroendoscopic procedures: our institutional experience.

BACKGROUND: Neuroendoscopic procedures are now being performed more frequently, and with advancement in technology, complications related to the procedure and equipments have also minimized or changed. We report our experience with 223 patients who underwent intracranial neuroendoscopic procedures. MATERIALS AND METHODS: The rates of various perioperative complications, both surgical and anesthesia related, during intracranial neuroendoscopic surgeries were studied. Data collected included demographics, patient's medical history and any associated comorbid conditions, diagnosis, procedure performed, anesthetic management, intraoperative and postoperative complications and outcomes. RESULTS: Of the 223 patients studied, 119 were pediatric (age <14 years) and 104 were adults. Hypothermia (25.1%) and cardiovascular complications (such as tachycardia 18.8%, bradycardia 11.3%, hypertension 16.1%, and hypotension 16.6%) were the commonly observed complications during intraoperative period both in pediatric and adult patients. At the end of the procedure, delayed arousal was observed in 17 patients and 19 patients required postoperative ventilatory support. Postoperative frequent complications included: fever (34.1%), tachycardia (32.7%), nausea and vomiting (18.8%). Potentially fatal complications such as intraoperative hemorrhage, air embolism, etc. were rare. Most of the complications were transient and self-limiting. CONCLUSION: Although endoscopic procedures are considered minimally invasive, at times may lead to life-threatening complications and one should be aware of them.

Intraoperative central diabetes insipidus in a postpartum patient during decompression of base of brain lesion: Missing out the diagnosis of Sheehan's syndrome?

A 35-year-old female presented with headache in the third week postpartum period following uneventful cesarean delivery. She had left sided ptosis, pain, and numbness over left face since third trimester. Post-delivery magnetic resonance imaging revealed invading left sphenoid sinus meningioma. She was planned for combined endonasal and pterional craniotomy. Her preoperative investigations including sodium, glucose, and liver functions were normal. Intraoperatively during endonasal phase a high urine output (UO) with rising sodium were noticed which continued with worsening sodium (156 mEq/L after 3 h). Desmopressin 1 mcg IV administered which normalized UO for the rest of surgical duration with trends of declining sodium (149 mEq/L at the end of procedure). Her postoperative MRI was normal however desmopressin could not be discontinued because of increasing sodium and UO without it. She was discharged on oral desmopressin, hydrocortisone and levothyroxine. On her follow-up 3.5 months later she had normal sodium and normal UO.

Effect of dexmedetomidine on dynamic cerebral autoregulation and carbon dioxide reactivity during sevoflurane anesthesia in healthy patients.

BACKGROUND: There are conflicting opinions on the effect of dexmedetomidine on cerebral autoregulation. This study assessed its effect on dynamic cerebral autoregulation (dCA) using a transcranial Doppler (TCD). METHODS: Thirty American Society of Anesthesiologists physical status I and II patients between 18 and 60 years, who underwent lumbar spine surgery, received infusions of dexmedetomidine (Group D) or normal saline (Group C), followed by anesthesia with propofol and fentanyl, and maintenance with oxygen, nitrous oxide and sevoflurane. After five minutes of normocapnic ventilation and stable bispectral index value (BIS) of 40-50, the right middle cerebral artery flow velocity (MCAFV) was recorded with TCD. The transient hyperemic response (THR) test was performed by compressing the right common carotid artery for 5-7 seconds. The lungs were hyperventilated to test carbon dioxide (CO2) reactivity. Hemodynamic parameters, arterial CO2 tension, pulse oximetry (SpO2), MCAFV and BIS were measured before and after hyperventilation. Dexmedetomidine infusion was discontinued ten minutes before skin-closure. Time to recovery and extubation, modified Aldrete score, and emergence agitation were recorded. RESULTS: Demographic parameters, durations of surgery and anesthesia, THR ratio (Group D: 1.26 ± 0.11 vs. Group C: 1.23 ± 0.04; P = 0.357), relative CO2 reactivity (Group D: 1.19 ± 0.34 %/mmHg vs. Group C: 1.23 ± 0.25 %/mmHg; P = 0.547), blood pressure, SpO2, BIS, MCAFV, time to recovery, time to extubation and modified Aldrete scores were comparable. CONCLUSIONS: Dexmedetomidine administration does not impair dCA and CO2 reactivity in patients undergoing spine surgery under sevoflurane anesthesia.

An assessment of the predictors of difficult intubation in patients with acromegaly.

Various clinical signs have been used for assessing difficult intubation in patients with acromegaly. These signs include the modified Mallampati classification, measurement of thyromental distance and head and neck movements. Some authors have also tried to establish a relationship between growth hormone levels and difficult intubation. We hypothesized that duration of symptoms in patients with acromegaly may have an association with difficult airway and difficult laryngoscopy. In this prospective study we evaluated tests of airway assessment such as: (i) the Mallampati grade; (ii) the thyromental distance; and (iii) the laryngoscopic grade (Cormack-Lehane). The growth hormone levels and the duration of disease symptoms were also examined. Significant correlation was observed between the Cormack-Lehane and Mallampati gradings (p = 0.05; rho = 19.3%), and between the thyromental distance and the duration of the symptoms (p = 0.03; rho = 26.9%). The incidence of Mallampati III and IV grades was higher in patients with acromegaly. Increased thyromental distance was noted in patients with a long duration of disease. However, increased thyromental distance was not associated with difficult laryngoscopy.

A review of perioperative complications during frameless stereotactic surgery: our institutional experience.

PURPOSE: Frameless stereotactic neurosurgery is increasingly being used for the biopsy of intracranial tumors and the resection of deep-seated lesions where reliance on surface anatomic landmarks can be misleading, as well as in movement disorders, psychiatric disorders, seizure disorders, and chronic refractory pain. Nascent biological approaches, including gene therapy and stem-cell and tissue transplants for movement disorders, also utilize neuronavigational techniques. These procedures are complex and involve understanding of the basic principles and factors affecting neuronavigation. The procedure may appear to be simple, but serious complications may occur. METHODS: The purpose of this study was to review the intraoperative and postoperative complications occurring during frameless stereotaxy at our institution from January 2003 to July 2007. RESULTS: Seventy-eight patients underwent various neurosurgical procedures under general anesthesia. Intraoperative complications seen were intraoperative brain bulge (n = 3), seizures (n = 3), failure to extubate (n = 4), and fresh neurodeficits (n = 6). No hemodynamic disturbances such as hypertension or hypotension or bradycardia or tachycardia requiring active intervention were observed. CONCLUSION: Awareness and vigilance can help in the early identification and better management of the above intraoperative complications.

Isoflurane and sevoflurane decrease entropy indices more than halothane at equal MAC values.

Recently, bispectral index (BIS) values were demonstrated to be different for various anesthetics as a result of differential effects on electroencephalographic (EEG) signals. Entropy is similar to the BIS monitor, as both process raw EEG to derive a number. We hypothesized that entropy may also be anesthetic agent-specific. Thirty adult patients undergoing spinal surgery were randomized to receive halothane, isoflurane, or sevoflurane. Entropy indices were recorded at various minimum alveolar concentration (MAC) values-0.5, 0.75, 1.0 and 1.5-both during wash-in and wash-out of the agent. Heart rate (HR), mean arterial blood pressure (MAP), response entropy (RE), and state entropy (SE) were noted. Statistical analysis was done using a one-way analysis-ofvariance test. P values less than 0.05 were considered significant. Ten patients in each group completed the study. The demographics and baseline values of HR, MAP, RE, and SE were comparable in all three groups. During the study period, for a given MAC value, both RE and SE remained low in the isoflurane and sevoflurane groups compared to the halothane group. For a given MAC, the RE and SE were comparable during wash-in and wash-out phases. Halothane produced higher entropy values as compared to isoflurane and sevoflurane at equivalent MAC levels.

Intracranial hemorrhage after percutaneous radiofrequency trigeminal rhizotomy.

Radiofrequency thermocoagulation (RFT) of trigeminal ganglion is a commonly performed percutaneous procedure for the management of trigeminal neuralgia. However, it is not free from potentially life-threatening complications. A case of intracranial hemorrhage following RFT, which was managed conservatively, is reported. The authors suggest that coagulation parameters be normalized and intra-procedural blood pressure controlled while performing this technique. As RFT is carried out as an ambulatory procedure, absence of any intracranial complication must be ascertained clinically before the patient is discharged.

Intraoperative Dexmedetomidine Maintains Hemodynamic Stability and Hastens Postoperative Recovery in Patients Undergoing Transsphenoidal Pituitary Surgery.

Background Transsphenoidal resection of pituitary tumors is the neurosurgical procedure of choice to excise most of the tumors of the sellar/suprasellar region. The main goals of anesthesia are maintenance of hemodynamic stability, provision of conditions that facilitate good surgical exposure, and a prompt and smooth emergence to allow neurological and visual assessment. Dexmedetomidine (Dex), a selective α-2 agonist, is known to maintain cardiovascular stability and anxiolysis and provide pain relief. Therefore, we hypothesized that intraoperative Dex will attenuate hemodynamic response to nasal speculum (NS) insertion, decrease analgesic requirement, and hasten postoperative recovery. Materials and Methods This prospective, randomized, double-blind, placebo-controlled study was conducted in 60 adult patients of either sex, American Society of Anesthesiologists status I or II undergoing elective pituitary surgery for excision of pituitary adenoma. Randomization was done into two groups; Group D ( n = 30) received Dex bolus 1 µg/kg over 10 minutes, followed by 0.5 µg/kg/h, and group control Group C ( n = 30) received normal saline (0.9%) in a similar manner. A standard anesthesia technique comprising fentanyl, propofol, rocuronium, sevoflurane, nitrous oxide, and oxygen was used. Intraoperative monitoring was uniform and standardized in all the patients; cardiovascular perturbations, if any, were noted and managed appropriately. After completion of surgery, tracheal extubation was performed, and emergence time, extubation time, modified Aldrete score, sedation, pain, time for first analgesic, nausea, vomiting, and shivering were recorded. Results In both the groups, an increase in heart rate and blood pressure occurred at the time of laryngoscopy and intubation, NS insertion, and extubation, but it was more in Group C ( p < 0.05). In Group D, intraoperative requirement of analgesic, neuromuscular relaxant, and inhalational anesthetic was lesser compared with Group C. Emergence time as well as visual analog scale at emergence was less in Group D. Conclusions Intraoperative Dex infusion is a reasonable choice in patients undergoing transsphenoidal pituitary surgery.

Intracranial Pressure Monitoring in Children with Severe Traumatic Brain Injury: A Retrospective Study.

INTRODUCTION: There is a paucity of literature on intracranial pressure (ICP) monitoring in children. The aim of this study was to ascertain whether ICP monitoring is useful in children with severe traumatic brain injury (TBI). MATERIALS AND METHODS: Medical records of children between 1 and 12 years, admitted to neurocritical care unit with severe TBI in 2 years, were reviewed. The children were divided into two groups: study group (ICP monitored) and control group (ICP not monitored). Admission demographics, vital parameters, and computed tomographic scan findings were recorded. In the study group, date of ICP catheter insertion/removal with ICP values and treatment carried out for increased ICP were noted. Data on tracheostomy, duration of mechanical ventilation, hospital stay, and outcome at discharge were noted. RESULTS: Demographic variables were comparable between the two groups. When adjusted for death, no significant difference was observed between the study and the control groups in median duration of mechanical ventilation: 35 days (95% confidence interval [CI]: 12-73) versus 55 days (95% CI: 29-55) (P = 0.96), hospital stay: 36 days (95% CI: 12-73) versus 58 days (95% CI: 29-58) (P = 0.96), and time to tracheostomy: 6 days (95% CI: 5-8) versus 5 days (95% CI: 4-7) (P = 0.49). Mortality rates, incidence of cranial surgeries, and outcome at discharge were also comparable. CONCLUSION: ICP monitoring did not reduce the incidence of death, cranial surgeries, duration of mechanical ventilation, hospital stay, or improve the outcome at discharge in children with severe TBI.

Planning for early emergence in neurosurgical patients: a randomized prospective trial of low-dose anesthetics.

BACKGROUND: For early detection of a cerebral complication, rapid awakening from anesthesia is essential after craniotomy. Systemic hypertension is a major drawback associated with fast tracking, which may predispose to formation of intracranial hematoma. Although various drugs have been widely evaluated, there are limited data with regards to use of anesthetics to blunt emergence hypertension. We hypothesized that use of low-dose anesthetics during craniotomy closure facilitates early emergence with a decrease in hemodynamic consequences. METHODS: Three emergent techniques were evaluated in 150 normotensive adult patients operated for supratentorial tumors under standard isoflurane anesthesia. At the time of dural closure, the patients were randomized to receive low-dose propofol (3 mg.kg(-1).h(-1)), fentanyl (1.5 microg.kg(-1).h(-1)) or isoflurane (end-tidal concentration of 0.2%) until the beginning of skin closure. Nitrous oxide was discontinued after head dressing. RESULTS: Median time to emergence was 6 min with propofol, 4 min with fentanyl, and 5 min with isoflurane (P=0.008). More patients had hypertension in the pre-extubation compared with extubation or postextubation phase (P=0.009). Comparing the three groups, fewer patients required esmolol with fentanyl use overall, and in the pre-extubation phase (P=0.01). Significant midline shift in the preoperative cerebral imaging scans was found to be an independent risk factor for emergence hypertension. CONCLUSIONS: Pain during surgical closure may be an important cause of sympathetic stimulation leading to emergence hypertension. The use of low-doses of fentanyl during craniotomy closure is more advantageous than propofol or isoflurane for early emergence in neurosurgical patients and is the most effective technique for preventing early postoperative hypertension.