Author: Young May Cha, MD
IARS and SOCCA 2026 Annual Meeting coverage
Patients with subarachnoid hemorrhage, ischemic stroke, or traumatic brain injury are vulnerable to secondary neurologic injury. At the 2026 IARS and SOCCA Annual Meeting, neuroanesthesia experts reviewed how blood pressure control, cerebral perfusion, anesthetic selection, cerebrospinal fluid drainage, and individualized monitoring may improve long-term brain health.
Ines Koerner, MD, PhD, discussed the management of subarachnoid hemorrhage. Early blood pressure control is essential to reduce the risk of aneurysm re-rupture and prevent sudden increases in transmural pressure.
Hydrocephalus should be identified quickly and treated with an external ventricular drain when indicated. Seizure prophylaxis may be appropriate in patients with high-grade hemorrhage, middle cerebral artery aneurysms, or cortical infarction. Antifibrinolytic therapy such as tranexamic acid has not demonstrated benefit.
General anesthesia is commonly used for aneurysm coiling or embolization. Anesthesiologists should also anticipate systemic complications, including 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.
The EARLYDRAIN trial found that continuous lumbar cerebrospinal fluid drainage at 5 mL per hour improved neurologic outcomes at six months. A later analysis found that a more positive fluid balance was associated with worse outcomes, challenging the traditional practice of maintaining deliberate hypervolemia after subarachnoid hemorrhage.
Emerging treatments for vasospasm include intracranial nicardipine implants and single-injection stellate ganglion blocks, but additional evidence regarding long-term outcomes is needed.
Tumul Chowdhury, MD, DM, FRCP(C), MSc, reviewed anesthesia for endovascular thrombectomy. General anesthesia was once considered inferior to monitored anesthesia care or local anesthesia because of concerns about treatment delays and hemodynamic instability. More recent evidence suggests that carefully managed general anesthesia may provide equal or potentially better outcomes in selected patients.
Interpretation remains difficult because studies have used different levels of sedation and have not consistently reported which anesthetic medications were administered.
Factors favoring general anesthesia include:
- National Institutes of Health Stroke Scale score greater than 15
- Significant agitation
- Inability to protect the airway
- Active vomiting
- Posterior circulation stroke
- Dominant-hemisphere stroke
The anesthetic technique should be individualized according to the patient’s neurologic condition, airway risk, ability to cooperate, and the location of the stroke.
Bhiken Naik, MBBCh, MSCR, discussed strategies for reducing secondary injury after traumatic brain injury. Intracranial pressure treatment is generally recommended when ICP exceeds 22 mmHg, but clinicians should also evaluate trends and waveform morphology rather than relying only on a single number.
Lundberg A and B waves may indicate worsening intracranial compliance and possible impending herniation.
Current guidelines recommend maintaining cerebral perfusion pressure between 60 and 70 mmHg. However, the ideal target may vary according to the patient’s cerebral autoregulation.
The pressure reactivity index measures the relationship between mean arterial pressure and intracranial pressure. A positive correlation may indicate impaired autoregulation. The COGiTATE pilot study demonstrated that some patients required blood pressure targets outside the conventional range to achieve more favorable autoregulatory conditions.
Evidence regarding transfusion thresholds after traumatic brain injury remains conflicting. Decisions should consider the individual patient’s oxygen-delivery requirements, bleeding risk, comorbidities, and neurologic condition.
Routine hyperventilation is no longer recommended as a standard method of reducing intracranial pressure. Continuous cerebrospinal fluid drainage through an external ventricular drain has stronger supporting evidence for lowering the burden of elevated ICP.
Key Takeaways
Anesthesiologists play a central role in preventing secondary brain injury by maintaining stable blood pressure, oxygenation, ventilation, cerebral perfusion, and intracranial pressure.
After subarachnoid hemorrhage, early blood pressure management, rapid treatment of hydrocephalus, and appropriate cerebrospinal fluid drainage may improve outcomes.
General anesthesia is increasingly supported for selected patients undergoing endovascular thrombectomy, particularly when airway protection, immobility, or procedural control is essential.
Traumatic brain injury management should move beyond fixed pressure thresholds toward individualized targets based on cerebral autoregulation and evolving intracranial pressure waveforms.
External ventricular drain management is an important neurocritical care skill. Anesthesiologists involved in these cases should review current SNACC guidance and receive formal education on EVD monitoring and drainage.
Thank you to IARS and SOCCA for allowing us to summarize this important coverage from the 2026 Annual Meeting.