Author: Young May Cha, MD
The Daily Dose
Ischemic stroke, traumatic brain injury, and subarachnoid hemorrhage are neurologic emergencies in which anesthetic management can significantly influence long-term outcomes. At the 2026 IARS and SOCCA Annual Meeting, experts reviewed current approaches to maintaining cerebral perfusion, preventing secondary brain injury, and individualizing care for patients with severe neurologic disease.
Managing subarachnoid hemorrhage
Ines Koerner, MD, PhD, emphasized that the management of subarachnoid hemorrhage should focus on preserving cerebral perfusion and maintaining physiologic stability.
Early blood pressure control is essential to reduce the risk of aneurysm re-rupture. Sudden blood pressure elevations can increase transmural pressure across the aneurysm and should be avoided.
Hydrocephalus must be recognized promptly and treated with an external ventricular drain when necessary. Seizure prophylaxis may be appropriate for patients with high-grade hemorrhage, a middle cerebral artery aneurysm, or a cortical infarction.
Current evidence does not demonstrate a benefit from antifibrinolytic medications such as tranexamic acid.
General anesthesia is frequently appropriate for aneurysm coiling or embolization because it provides immobility, airway control, and stable operating conditions. Anesthesiologists should also be prepared to manage systemic complications such as neurogenic stunned myocardium and neurogenic pulmonary edema.
Intraoperative neuromonitoring may reduce postoperative neurologic deficits. When neuromonitoring is not required, the choice of anesthetic technique does not appear to significantly affect the risks of vasospasm, cerebral infarction, or brain swelling.
Postoperative fluid and cerebrospinal fluid management
The EARLYDRAIN trial demonstrated improved neurologic outcomes at six months when lumbar cerebrospinal fluid was continuously drained at approximately 5 mL per hour.
A retrospective analysis also found that a more positive fluid balance was associated with worse neurologic outcomes. This challenges the traditional practice of deliberately maintaining patients with subarachnoid hemorrhage in a positive fluid balance.
Potential treatments for vasospasm include intracranial nicardipine implants and single-injection stellate ganglion blocks. However, additional research is needed to determine whether these treatments improve long-term outcomes.
Anesthesia for endovascular thrombectomy
Tumul Chowdhury, MD, DM, FRCP(C), MSc, reviewed the continuing debate over general anesthesia versus monitored anesthesia care or local anesthesia for endovascular thrombectomy.
Earlier observational evidence suggested that general anesthesia might be associated with worse outcomes. More recent studies, however, indicate that carefully managed general anesthesia may provide equivalent or potentially better results.
Comparing studies remains difficult because the depth of sedation, anesthetic medications, blood pressure management, and stroke locations have varied considerably.
General anesthesia may be particularly appropriate for patients with a National Institutes of Health Stroke Scale score greater than 15, severe agitation, vomiting, inability to protect the airway, posterior circulation stroke, or dominant hemisphere involvement.
The most important goal is not simply choosing general anesthesia or sedation. Clinicians must avoid treatment delays, maintain appropriate blood pressure, preserve cerebral perfusion, and provide safe procedural conditions.
Preventing secondary injury after traumatic brain injury
Bhiken Naik, MBBCh, MSCR, emphasized that anesthesiologists play an important role in preventing secondary brain injury after traumatic brain injury.
Intracranial pressure treatment is generally recommended when pressure exceeds 22 mmHg. However, clinicians should examine both the absolute pressure and changes in the intracranial pressure waveform.
Lundberg A and B waves may indicate worsening intracranial compliance and an increased risk of cerebral herniation.
Guidelines generally recommend maintaining cerebral perfusion pressure between 60 and 70 mmHg. However, the ideal pressure may differ among patients depending on cerebral autoregulation.
Individualizing blood pressure targets
The pressure reactivity index evaluates the relationship between mean arterial pressure and intracranial pressure. It can help determine whether cerebral autoregulation is functioning normally.
The COGiTATE pilot study demonstrated that some patients required blood pressure targets outside the standard recommended range. This suggests that individualized cerebral perfusion targets may be more appropriate than applying the same target to every patient with traumatic brain injury.
Evidence regarding red blood cell transfusion after traumatic brain injury remains conflicting. Transfusion decisions should consider the patient’s oxygen-delivery requirements, bleeding, cardiovascular condition, and overall risk profile rather than relying exclusively on a universal hemoglobin threshold.
External ventricular drainage
Current guidelines no longer support routine hyperventilation as a general strategy for reducing intracranial pressure. Hyperventilation can decrease cerebral blood flow and potentially worsen cerebral ischemia.
Continuous cerebrospinal fluid drainage through an external ventricular drain has stronger evidence for reducing intracranial pressure burden.
Because surveys suggest that fewer than one-third of anesthesiologists have formal training or familiarity with external ventricular drain management, clinicians caring for neurologically injured patients should review the available SNACC guidance.
Clinical significance
The anesthesiologist’s actions can directly influence neurologic recovery in patients with subarachnoid hemorrhage, ischemic stroke, or traumatic brain injury.
Important priorities include preventing major blood pressure fluctuations, maintaining cerebral perfusion, recognizing hydrocephalus and elevated intracranial pressure, protecting the airway, avoiding secondary cerebral ischemia, and individualizing treatment according to the patient’s autoregulatory status.
Optimal neuroanesthetic care requires more than following a single blood pressure or intracranial pressure target. Clinicians must interpret physiologic trends, waveforms, cerebral perfusion, neurologic status, and the patient’s overall condition together.
Thank you to The Daily Dose, IARS, SOCCA, and SNACC for allowing us to summarize this important discussion of anesthetic management during neurologic emergencies.