Authors: Bright M et al.
Journal of Neurosurgical Anesthesiology. 38(1):3–9, January 2026.
Summary
This focused narrative review examined the relationship between perioperative blood pressure management and postoperative neurocognitive disorders (pNCD) and stroke following noncardiac surgery. Although intraoperative hypotension has long been viewed as a modifiable risk factor through its potential effects on cerebral perfusion, accumulating evidence challenges the assumption that simply targeting higher blood pressures improves neurological outcomes.
The authors synthesize data from observational studies and large randomized controlled trials, including POISE-3 and the CogPOISE substudy, which consistently demonstrate that strategies aimed at maintaining higher perioperative mean arterial pressure do not reduce postoperative delirium, long-term cognitive decline, or perioperative stroke in unselected surgical populations. These findings undermine the traditional “one size fits all” approach to blood pressure targets during anesthesia.
The review emphasizes that perioperative brain injury is multifactorial. While cerebral hypoperfusion may contribute in select cases, neuroinflammation, mitochondrial dysfunction, autonomic dysregulation, anesthetic depth, vascular pathology, and patient vulnerability (such as frailty and preexisting cerebrovascular disease) likely play larger roles in the development of pNCD. The wide interindividual variability in cerebral autoregulation further weakens the rationale for universal blood pressure thresholds.
Importantly, the authors argue that neutral trial results should not be interpreted as evidence that blood pressure is irrelevant, but rather that systemic arterial pressure is an imprecise surrogate for cerebral perfusion and metabolism. Future progress will depend on shifting toward personalized, physiology-guided perioperative care. Proposed strategies include individualized autoregulation monitoring, multimodal neurophysiologic assessment, and targeted interventions for high-risk patients rather than population-wide blood pressure elevation.
Key Points
Large randomized trials show no reduction in delirium, cognitive decline, or stroke from targeting higher perioperative blood pressure in noncardiac surgery.
Perioperative neurocognitive disorders arise from multifactorial mechanisms, with cerebral hypoperfusion likely a minor contributor in many patients.
Wide interindividual variability in cerebral autoregulation makes universal MAP targets physiologically unsound.
Blood pressure should be viewed as a safety parameter, not a standalone neuroprotective strategy.
Future research should focus on personalized, multimodal, physiology-guided approaches to perioperative brain protection.
Thank you for allowing us to review and summarize this important perspective from the Journal of Neurosurgical Anesthesiology.