Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection

Abstract

Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.

Keywords: agent selection; neuroanesthesia; neurological surgery; total intravenous anesthesia; volatile anesthesia.

Figure 1

The proposed mechanism of action for total intravenous anesthetic agent (TIVA), including receptor type affected and subsequent effects on cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), as well as intracranial pressure (ICP). Differing TIVA agents act on different receptors, for which varying effects on cerebral blood flow and oxygen consumption are a byproduct. Created with Biorender.com.

Figure 2

The proposed mechanism for inhalation anesthetics, including both nonvolatile (highlighted in green) and volatile anesthetics. Effects on CBF and CMRO2 are largely dependent on whether the agent is volatile or nonvolatile, but changes depicted to vasomotor reactivity and cerebral autoregulation have largely been studied in volatile anesthetics alone. Created with Biorender.com.