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OBJECTIVE Stellate ganglion block (SGB) is a commonly used sympathetic nerve block technique that may have benefits for patients with aneurysmal subarachnoid hemorrhage (aSAH) in the early stage. Cerebral vasospasm (CVS), one of the most common complications of aSAH, is accompanied by an abnormal increase in cerebral blood flow velocity (CBFV) and neurological dysfunction. In this pilot study the authors sought to determine the feasibility of early SGB for CVS in aSAH patients by observing the incidence of symptomatic CVS. METHODS Prior to receiving surgical treatment, patients with aSAH were randomly assigned to the SGB group or the non-SGB group. The primary outcome was the incidence of symptomatic CVS within 14 ± 2 days after the onset of aSAH. As a higher CBFV is often associated with CVS and a poor prognosis, the mean CBFV of the middle cerebral artery was observed immediately after surgery and on postoperative days 1, 2, 3, 5, and 7. Other secondary outcomes included transcranial Doppler (TCD)/CTA-type CVS, delayed cerebral ischemia during hospitalization, new cerebral infarction within 3 months, adverse events (AEs), and clinical prognosis. RESULTS Symptomatic CVS occurred in 40% of patients in the non-SGB group and in 20% in the SGB group (RR 0.50, 95% CI 0.22–1.16). Continuous TCD sonography revealed that the postoperative mean CBFV was lower in the SGB group than in the non-SGB group (F = 3.608, p = 0.02). In addition, the percentages of patients with CVS evaluated by TCD (TCD-CVS) and total new infarctions within 3 months were also significantly lower than those in patients with CVS (TCD-CVS 36.7% vs 70%, RR 0.52, 95% CI 0.31–0.89, and total new infarctions 26.7% vs 53.3%, RR 0.50, 95% CI 0.25–0.99). In terms of AEs and mortality, there were no significant differences between the two groups. CONCLUSIONS This pilot study demonstrated for the first time, to the authors’ knowledge, that early SGB is feasible and has the potential to reduce the risk of CVS and improve the prognosis of aSAH. This method may be a new treatment for patients with aSAH that may have more advantages than traditional therapeutic drugs and is worth further study. Clinical trial registration no.: NCT04691271 (ClinicalTrials.gov)

No definitive conclusion can be made on the best choice of anesthesia for people with acute posterior circulation stroke during endovascular treatment. Only a few observational studies have focused on this topic in recent years, and they have differing conclusions.To examine whether conscious sedation (CS) is a feasible alternative to general anesthesia (GA) during endovascular treatment in patients with acute posterior circulation stroke.A randomized parallel-group exploratory trial with blinded end point evaluation (Choice of Anesthesia for Endovascular Treatment of Acute Ischemic Stroke [CANVAS II]) enrolled adult patients from March 2018 to June 2021 at 2 comprehensive care hospitals in China. Patients with acute posterior circulation stroke were enrolled, randomized, and monitored for 3 months. Of 210 patients admitted with acute ischemic posterior circulation stroke, 93 were recruited and 87 were included in the intention-to-treat (ITT) analysis after exclusions, 43 were assigned to GA and 44 to CS. All analyses were unadjusted or adjusted with the ITT principle.Participants were randomly assigned to CS or GA in a 1:1 ratio.The primary end point was functional independence at 90 days evaluated with the modified Rankin Scale (mRS).A total of 87 participants were included in the ITT study (mean [SD] age, 62 [12] years; 16 [18.4%] female and 71 [81.6%] male). Of these, 43 were in the GA group and 44 in the CS group. The overall baseline median (IQR) National Institute of Health Stroke Scale (NIHSS) score was 15 (12-17). In the CS group, 13 people (29.5%) were ultimately transferred to GA. The CS group had a higher incidence of functional independence; however, no significant difference was found between the 2 groups (48.8% vs 54.5%; risk ratio, 0.89; 95% CI, 0.58-1.38; adjusted odds ratio [OR], 0.91; 95% CI, 0.37-2.22). However, GA performed better in successful reperfusion (mTICI 2b-3) under ITT analysis (95.3% vs 77.3%; adjusted OR, 5.86; 95% CI, 1.16-29.53).The findings in this study suggest that CS was not better than GA for the primary outcome of functional recovery and was perhaps worse for the secondary outcome of successful reperfusion.ClinicalTrials.gov Identifier: NCT03317535.

Introduction Neuromuscular blockade suppresses transcranial electrical motor evoked potential (TceMEP) amplitude and is usually avoided during TceMEP monitoring. In this randomized controlled trial, we investigated whether rocuronium-induced suppression of TceMEP amplitude could be reversed by sugammadex in patients undergoing spine surgery. Methods Seventy-six patients undergoing spinal surgery were randomly allocated into sugammadex and control groups. In the sugammadex group, a rocuronium infusion was titrated to maintain moderate neuromuscular blockade (2 twitches on train-of-four) until dural opening when the rocuronium infusion was discontinued and 2 mg/kg sugammadex administered. In the control group, no neuromuscular blockade was administered after induction of anesthesia. The primary outcome was a comparison between sugammadex and control groups of mean TceMEP amplitudes in the abductor pollicis brevis muscles of both upper extremities 5 minutes after dural. Secondary outcomes included TceMEP amplitudes at 10, 20, 30, and 60 minutes after dural opening. Results Sixty-six patients were included in the analysis. TceMEP amplitudes were significantly greater in the sugammadex group (629 μV, interquartile range: 987 μV) than in the control group (502 μV, interquartile range: 577 μV; P=0.033) at 5 minutes after dural opening. TceMEP amplitudes were also greater in the sugammadex group at 10 minutes (P=0.0010), 20 minutes (P=0.003), 30 minutes (P=0.001), and 60 minutes (P=0.003) after dural opening. Conclusions Moderate neuromuscular blockade induced by continuous infusion of rocuronium was effectively reversed by sugammadex. This suggests that sugammadex could be used to enhance TceMEP waveform monitoring during spine surgery requiring muscle relaxation.

There is continued controversy regarding the optimal anesthetic technique for endovascular therapy in patients with acute posterior circulation ischemic stroke. To compare the clinical outcomes general anesthesia (GA) and non-GA, we performed a systematic review and meta-analysis of randomized controlled trials and observational studies focused on the anesthetic management for endovascular therapy in patients with acute posterior circulation stroke, without language restriction. In addition, we compared clinical outcomes among the studies with different non-GA types (conscious sedation or local anesthesia). Outcome variables were functional independence, excellent outcomes, favorable outcomes, mortality, successful recanalization, hemodynamic instability, intracerebral hemorrhage, and respiratory or vascular complications. Eight studies including 1777 patients were identified. Although GA was associated with a lower odds of functional independence at 90 days (odds ratio [OR]: 0.55; 95% confidence interval [CI] 0.38 to 0.81; P=0.009), substantial heterogeneity was noted (I2=65%). Subgroup analysis showed that GA was associated with higher odds of mortality than conscious sedation (OR: 1.83; 95% CI, 1.30 to 2.57; I2=0%), but there was no difference between GA and local anesthesia (I2=0%). Interestingly, subgroup analysis did not identify a relationship between functional independence and GA compared with local anesthesia (OR: 0.90; 95% CI, 0.64 to 1.25; P=0.919; I2=0%). This meta-analysis demonstrates that GA is associated with worse outcomes in patients with acute posterior circulation stroke undergoing endovascular therapy based on current studies.

Background Perioperative stroke is a rare but devastating complication. The risk factors for massive cerebral stroke in surgical patients include older age, male sex, prior cerebrovascular disease, hypertension, renal failure, smoking, diabetes mellitus, and atrial fibrillation. Case summary We describe two cases of perioperative massive cerebral stroke following thoracic surgery and one case following bronchoscopy. Neurologic symptoms, including changes in mental status and hemiplegia, occurred within 10 h after surgery in the three patients. All three patients died after the surgery. Conclusion Perioperative massive cerebral stroke may be more likely to occur in thoracic surgical patients if there are pre-existing factors including previous stroke, hypotension, and hypoxemia. Sufficient pain control after surgery and timely neurology consultation and management are helpful for the diagnosis and control of stroke in high-risk patients.

Introduction Stellate ganglion block has been reported to expand cerebral vessels and alleviate vasospasm after aneurysmal subarachnoid hemorrhage. However, the causal relationship between early stellate ganglion block and cerebral vasospasm prevention has not yet been established. Methods/design This is a single-center, prospective, randomized, controlled, blinded-endpoint assessment trial to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment for cerebral vasospasm and delayed cerebral ischemia. A total of 228 patients will be randomized within 48 h of aneurysmal subarachnoid hemorrhage onset in a 1:1 ratio to two groups with an additional e-SGB or only a camouflaging action before craniotomy aneurysm clipping. The primary efficacy outcome is the incidence of symptomatic vasospasm within 14 days after aSAH. Further safety and efficacy parameters include the incidence of radiographic vasospasm, new cerebral infarction, postoperative delirium, and complications up to 90 days, postoperative cerebral hemodynamics, mini-mental state examination, the modified Rankin scale and all-cause mortality up to 90 days.Discussion This is the first randomized controlled trial to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment to reduce cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. If the result is positive, it may provide a new direction for the prevention and treatment of cerebral vasospasm and delayed cerebral ischemia.Trial registration ClinicalTrials.gov NCT04691271

IntroductionTranscranial motor-evoked potentials (TceMEPs) is conventionally performed without neuromuscular blockade (NMB) because of its potential interference with neuromuscular junction and signal interpretation. Sugammadex is the first highly selective antagonist that binds to rocuronium and can rapidly and effectively reverse NMB. This study aims to evaluate the success rate of intraoperative muscle relax reversal by sugammadex on intraoperative TceMEP recording.Methods and analysisWe will conduct a single-centre randomised controlled study. In total, 162 patients undergoing thoracic or lumbar spinal surgery will be randomly divided into the sugammadex group or control group at a ratio of 1:1. Total intravenous anaesthesia by propofol and remifentanil will be performed in both groups. In the sugammadex group, patients will receive continuous infusion of rocuronium to produce a blockade maintained for at least two twitches in train-of-four, rocuronium infusion will be discontinued and 2 mg/kg sugammadex will be given while performing TceMEPs monitoring. In the control group, rocuronium infusion will be discontinued and the same volume of saline will be infused while performing TceMEPs monitoring. The primary aim of this study is to evaluate the success rate of TceMEPs recording between two groups.Ethics and disseminationThe approval for the study was certificated by the Ethical Committee of Beijing Tiantan Hospital, Capital Medical University on, 16 July 2021 (KY2021-082-02). The study was registered on clincaltrials.gov on 25 October 2020. Our study might guide neuromuscular blockade plans in TceMEPs monitoring undergoing spinal surgery. The findings of the study will be published in peer-reviewed journals and will be presented at national or international conference.Trial registration numberNCT04608682.

Background Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus, is highly contagious. Global medical systems have been heavily impacted by the COVID-19 pandemic. Although the majority of patients with intracranial disease require time-sensitive surgery, how to conduct neurosurgery and prevent and control nosocomial infection during a pandemic is challenging. Materials and methods We retrospectively reviewed the clinical data of patients undergoing neurosurgical and neurointerventional procedures at Beijing Tiantan Hospital, China during the early stages of the COVID-19 pandemic between January 21 and July 31, 2020. A 3-level system of COVID-19 risk was established based on medical conditions, epidemiologic, and symptom inquiry and the results of triage. A transitional unit was established for patients in whom COVID-19 had not been ruled out on admission to hospital. Results A total of 4025 patients underwent neurosurgery during the study period, including 768 emergent and 3257 nonemergent procedures. Of these patients, 3722 were low-risk for COVID-19, 303 were moderate-risk, and none were high-risk. In addition, 1419 patients underwent neurointerventional procedures, including 114 emergent and 1305 nonemergent interventions, of which 1339 were low-risk patients, 80 were moderate-risk and none were high-risk. A total of 895 patients (neurosurgical and neurointerventional) were admitted to the transitional unit. Forty-five patients were diagnosed with COVID-19 and transferred to the COVID-19 designated hospital. There were no cases of COVID-19 nosocomial infections among surgical patients or health care workers. Conclusion On the basis of our single-center experience, developing a full screening protocol for COVID-19, establishing a risk level, and using a transitional unit for those with unknown COVID-19 status are effective measures to provide a safe environment for patients and health care workers.

Interventions that preserve motor neurons or restore functional motor neuroplasticity may extend longevity in amyotrophic lateral sclerosis (ALS). Delivery of neurotrophins may potentially revive degenerating motor neurons, yet this approach is dependent on the proper subcellular localization of neurotrophin receptor (NTR) to plasmalemmal signaling microdomains, termed membrane/lipid rafts (MLRs). We previously showed that overexpression of synapsin-driven caveolin-1 (Cav-1) (SynCav1) increases MLR localization of NTR [e.g., receptor tyrosine kinase B (TrkB)], promotes hippocampal synaptic and neuroplasticity, and significantly improves learning and memory in aged mice. The present study crossed a SynCav1 transgene-positive (SynCav1+) mouse with the mutant human superoxide dismutase glycine to alanine point mutation at amino acid 93 (hSOD1G93A) mouse model of ALS. When compared with hSOD1G93A, hSOD1G93A/SynCav1+ mice exhibited greater body weight and longer survival as well as better motor function. Microscopic analyses of hSOD1G93A/SynCav1+ spinal cords revealed preserved spinal cord α-motor neurons and preserved mitochondrial morphology. Moreover, hSOD1G93A/SynCav1+ spinal cords contained more MLRs (cholera toxin subunit B positive) and MLR-associated TrkB and Cav-1 protein expression. These findings demonstrate that SynCav1 delays disease progression in a mouse model of ALS, potentially by preserving or restoring NTR expression and localization to MLRs.-Sawada, A., Wang, S., Jian, M., Leem, J., Wackerbarth, J., Egawa, J., Schilling, J. M., Platoshyn, O., Zemljic-Harpf, A., Roth, D. M., Patel, H. H., Patel, P. M., Marsala, M., Head, B. P. Neuron-targeted caveolin-1 improves neuromuscular function and extends survival in SOD1G93A mice.

Interventions that preserve motor neurons or restore functional motor neuroplasticity may extend longevity in amyotrophic lateral sclerosis (ALS). Delivery of neurotrophins may potentially revive degenerating motor neurons, yet this approach is dependent on the proper subcellular localization of neurotrophin receptor (NTR) to plasmalemmal signaling microdomains, termed membrane/lipid rafts (MLRs). We previously showed that overexpression of synapsin-driven caveolin-1 (Cav-1) (SynCav1) increases MLR localization of NTR [e.g., receptor tyrosine kinase B (TrkB)], promotes hippocampal synaptic and neuroplasticity, and significantly improves learning and memory in aged mice. The present study crossed a SynCav1 transgene–positive (SynCav1(+)) mouse with the mutant human superoxide dismutase glycine to alanine point mutation at amino acid 93 (hSOD1(G93A)) mouse model of ALS. When compared with hSOD1(G93A), hSOD1(G93A)/SynCav1(+) mice exhibited greater body weight and longer survival as well as better motor function. Microscopic analyses of hSOD1(G93A)/SynCav1(+) spinal cords revealed preserved spinal cord α-motor neurons and preserved mitochondrial morphology. Moreover, hSOD1(G93A)/SynCav1(+) spinal cords contained more MLRs (cholera toxin subunit B positive) and MLR-associated TrkB and Cav-1 protein expression. These findings demonstrate that SynCav1 delays disease progression in a mouse model of ALS, potentially by preserving or restoring NTR expression and localization to MLRs.—Sawada, A., Wang, S., Jian, M., Leem, J., Wackerbarth, J., Egawa, J., Schilling, J. M., Platoshyn, O., Zemljic-Harpf, A., Roth, D. M., Patel, H. H., Patel, P. M., Marsala, M., Head, B. P. Neuron-targeted caveolin-1 improves neuromuscular function and extends survival in SOD1(G93A) mice.

BackgroundObservational studies indicate that the type of anesthesia, local or general, may be associated with the post-procedural neurological function in patients with acute ischemic stroke undergoing endovascular treatment. However, these results need further confirmation, and the causal relationship has not yet been established.MethodsThis is a randomized controlled equivalence trial. Permuted block randomization stratified by culprit vessels will be used. Six hundred and forty patients with acute ischemic stroke undergoing endovascular recanalization will be randomized one to one to receive either general anesthesia or local anesthesia. The primary endpoint is the modified Rankin scale at 90 days after endovascular treatment. The secondary endpoints are the peri-procedural mortality and morbidity.DiscussionThe study aims to determine the effects of anesthetic choice on neurological outcomes in patients with acute ischemic stroke undergoing intra-arterial recanalization. If the results are positive, the study will indicate that the type of anesthesia does not affect neurological outcome after endovascular treatment. Trial registration: ClinicalTrial.gov identifier: NCT02677415

Functional connectivity patterns of the human brain show unique inherent or intrinsic characteristics at rest and when performing a task, similar to a fingerprint. However, whether this unique functional organization is preserved during sedation currently remains unknown. Here, we collected resting-state functional magnetic resonance imaging data from 20 subjects in each of three resting states: wakefulness, sedation, and recovery. We found that functional connectivity patterns could successfully identify individual subjects in any pair of the three resting states. In particular, identification analysis using functional connectivity patterns based on the frontoparietal network showed the highest success rates. Moreover, the overall individual difference in the frontoparietal-based functional connectivity patterns was much larger than that derived from other networks in each resting state. Collectively, our findings indicate that functional connectivity patterns within individual subjects are unique and relatively robust to brain state changes, regardless of dexmedetomidine-induced sedation.

To explore the propofol regulation of Bcl-2 protein expression through miR-181a in glucose deprivation (GD) cultured astrocytes.Primary cultured murine astrocytes were treated with 0, 1, 5, 10, 15, 20 µmol/L propofol for 12 h and then cultured with GD medium for 24 h. The cell survival rate was recorded with microscope. Reactive oxygen species (ROS) formation and mitochondrial membrane stabilization were observed. And the expression levels of miR-181a and Bcl-2 protein were recorded to analyze the protection effects of propofol on astrocytes.After the treatments of propofol and GD, the survival rates of 0, 1, 5, 10, 15, 20 µmol/L propofol groups were (0.51 ± 0.03)%, (0.52 ± 0.02) %, (0.52 ± 0.02) %, (0.73 ± 0.04) %, (0.31 ± 0.02) % and (0.21 ± 0.02)%. And there were statistical significance (F = 118.62, P0.001). Compared with 0 µmol/L propofol group, the survival rate was much higher in 10 µmol/L propofol group while much lower in 15 µmol/L and 20 µmol/L propofol groups. 10 µmol/L propofol could decrease ROS formation and stabilize mitochondrial membrane. And Bcl-2 protein expression was up-regulated while miR-181a expression inhibited by 10 µmol/L propofol.The protection of 10 µmol/L propofol against GD stress in astrocytes is correlated with inhibiting miR-181a and up-regulating Bcl-2 protein expression.

Background Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated syndrome caused by the production of anti-NMDAR receptor antibodies. The syndrome characterised by psychosis, seizures, sleep disorders, hallucinations and short-term memory loss. Ovarian teratoma is the confirmed tumour associated with anti-NMDAR antibodies. The patients with anti-NMDAR encephalitis complicated by ovarian teratoma require surgical treatment under general anesthesia. NMDARs are important targets of many anesthetic drugs. The perioperative management and complications of anti-NMDAR encephalitis, including hypoventilation, paroxysmal sympathetic hyperactivity (PSH) and epilepsy, are challenging for ansthesiologists. Case presentation This report described two female patients who presented for resection of the ovarian teratoma, they had confirmed anti-NMDAR encephalitis accompanied by ovarian teratoma. Two patients received gamma globulin treatments and the resection of the ovarian teratoma under total intravenous anesthesia. They were recovered and discharged on the 20th and 46th postoperative day respectively. Conclusions There is insufficient evidence about the perioperative management, monitoring and anesthesia management of anti-NMDAR encephalitis. This report was based on the consideration that controversial anesthetics that likely act on NMDARs should be avoided. Additionally, BIS monitoring should to be prudently applied in anti-NMDAR encephalitis because of abnormal electric encephalography (EEG). Anesthesiologists must be careful with regard to central ventilation dysfunctions and PSH due to anti-NMDAR encephalitis.