When the Brain is on the Brink, the Anesthesiologist Can Help Optimize Brain Health

Young May Cha, MD

Ischemic stroke, traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) are neurologic emergencies with potentially devastating consequences. The anesthesiologist’s role in the care of these patients can have a significant impact on long-term neurologic outcomes. In this sweeping, comprehensive review, co-sponsored by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) on Friday, May 1 at the 2026 Annual Meeting presented by IARS and SOCCA, moderator Kan Ma, MD, FRCPC, assistant professor of anesthesiology & pain medicine at the University of Toronto and associate fellowship director of the Trauma-Neuroanesthesia and Critical Care Fellowship at St. Michael’s Hospital, joked that participants should pick up their certificates for a neuroanesthesia fellowship afterward.

Ines Koerner, MD, PhD, professor of anesthesiology and perioperative pain medicine and vice chair of critical care for the Department of Anesthesiology & Perioperative Medicine at Oregon Health & Science University, opened the session with an overview of management of SAH that centered around maintenance of homeostasis for cerebral perfusion. Early, effective management of blood pressure starting with the patient’s initial presentation in the emergency department is essential to reduce the risk of re-rupture and minimize blood pressure spikes that could raise aneurysm transmural pressures. Hydrocephalus must be recognized early and managed quickly with an external ventricular drain (EVD) if necessary. Seizure prophylaxis should be started if there is high grade hemorrhage, an aneurysm of the middle cerebral artery, or a cortical infarct. There is no benefit for antifibrinolytics, such as tranexamic acid.

For intraoperative management, Dr. Koerner recommends general anesthesia (GA) to facilitate procedures for coiling or embolization, and to be prepared for systemic complications, such as neurogenic stunned myocardium and neurogenic pulmonary edema. Intraoperative neuromonitoring (IONM) can reduce postoperative neurologic deficit. If IONM is not required, the choice of anesthetic does not change the risk of vasospasm, cerebral infarction, or brain swelling. For postoperative management, Dr. Koerner highlighted the EARLYDRAIN trial that showed improved neurologic outcomes at 6 months with continuous drainage of 5 ml/hour of lumbar cerebrospinal fluid. Retrospective analysis of the EARLYDRAIN trial showed an inverse relationship between fluid balance and 6-month neurologic outcomes, which is contrary to the classic teaching of maintaining a positive fluid balance. Dr. Koerner also introduced newer interventions that could mitigate vasospasm, such as intracranial implants of nicardipine and single shot stellate ganglion blocks, but more data on long-term outcomes is needed.

For management of endovascular thrombectomy, Tumul Chowdhury, MD, DM, FRCP(C), MSc (Epi), professor and vice chair of anesthesiology and perioperative medicine at the University of Alabama at Birmingham, discussed the changing evidence for GA vs monitored anesthesia care or local anesthesia. Originally, GA was thought to be inferior for endovascular procedures that did not strictly require GA. Then, due to the COVID-19 pandemic, nearly 50% of institutions changed their anesthesia practices. Now, growing evidence from the last several years may be tipping the scales in favor of GA. However, recent trials used varying levels of sedation (some with light sedation and others with deep sedation). These studies also do not necessarily specify which anesthetic agents were used. Questions also remain about potential differences that may arise from factors such as anterior vs posterior insults. Other factors that would favor use of GA include NIH Stroke Scale/Score >15, patient agitation, patient inability to protect their airway, active vomiting, and posterior circulation or dominant hemisphere strokes.

For management of TBI, Bhiken Naik, MBBCh, MSCR, professor of anesthesiology and neurological surgery at the University of Virginia, emphasized the importance of the anesthesiologist’s role in mitigating secondary injury from TBI, which is an enormous societal problem with significant cost and disability. Monitoring intracranial pressure (ICP) is recommended for ICP greater than 22 mmHg, but Dr. Naik encourages us to consider not only the value but also how the waveform changes over time. The presence of Lundberg A and B waves could signal an impending herniation. Guidelines also recommend maintaining cerebral perfusion pressures between 60 and 70 mmHg, but this range may need to be adjusted based on the patient’s autoregulatory status. The pressure reactivity index (PRx), which is defined as the Pearson correlation coefficient between thirty consecutive 10-second averages of mean arterial pressure (MAP) and ICP, measures the linear association between MAP and ICP and can reveal impaired autoregulation. COGiTATE, a small pilot feasibility study, showed some patients required blood pressure targets outside the recommended range based on PRx, likely due to their impaired autoregulatory status after TBI. Dr. Naik also highlighted conflicting evidence on transfusion strategies after TBI, suggesting that individual patient risk factors are likely to be an important factor. Hyperventilation is no longer supported by evidence in the current guideline as a temporizing measure to reduce ICP. Instead, level II evidence supports continuous drainage of an EVD to lower ICP burden. Since less than a third of anesthesiologists surveyed reported familiarity or formal training on EVD management, Dr. Naik encouraged the session to review the guideline published by SNACC.