Impact of a Perioperative Protocol on Length of ICU and Hospital Stay in Complex Spine Surgery Background: In an attempt to improve patient care, a perioperative complex spine surgery management protocol was developed through collaboration between spine surgeons and neuroanesthesiologists. The aim of this study was to investigate whether implementation of the protocol in 2015 decreased total hospital and intensive care unit (ICU) length of stay (LOS) and complication rates after elective complex spine surgery. Materials and Methods: A retrospective cohort study was conducted by review of the medical charts of patients who underwent elective complex spine surgery at an academic medical center between 2012 and 2017. Patients were divided into 2 groups based on the date of their spine surgery in relation to implementation of the spine surgery protocol; before-protocol (January 2012 to March 2015) and protocol (April 2015 to March 2017) groups. Outcomes in the 2 groups were compared, focusing on hospital and ICU LOS, and complication rates. Results: A total of 201 patients were included in the study; 107 and 94 in the before-protocol and protocol groups, respectively. Mean (SD) hospital LOS was 14.8±10.8 days in the before-protocol group compared with 10±10.7 days in the protocol group (P<0.001). The spine surgery protocol was the primary factor decreasing hospital LOS; incidence rate ratio 0.78 (P<0.001). Similarly, mean ICU LOS was lower in the protocol compared with before-protocol group (4.2±6.3 vs. 6.3±7.3 d, respectively; P=0.011). There were no significant differences in the rate of postoperative complications between the 2 groups (P=0.231). Conclusion: Implementation of a spine protocol reduced ICU and total hospital LOS stay in high-risk spine surgery patients. Study was presented under the name: “Protocolized Perioperative Care for Complex Spine Surgeries and the Resulting Reduction in ICU/Hospital Length of Stay” at: (1) American Society of Anesthesiologists (ASA) Annual Meeting in San Francisco, October 13, 2018 (Session EA-19-1). (2) SNACC Annual Meeting in San Francisco on October 12, 2018. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Eugenia Ayrian, MD. E-mails: eayrian@med.usc.edu; eugenia.ayrian@gmail.com. Received August 28, 2018 Accepted July 11, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Put the Kibosh On Bias No abstract available

Erector Spinae Plane Block For Postoperative Analgesia in Lumbar Spine Surgery: Is There a Better Option? No abstract available

General Anesthetic Agents Are Not Neuroprotective and May be Neurotoxic No abstract available

In Remembrance of Hiroshi Takeshita, MD, Pioneering Neuroanesthesiologist No abstract available

Correlation Between Electroencephalography and Automated Pupillometry in Critically Ill Patients: A Pilot Study Background: Electroencephalography (EEG) is widely used in the monitoring of critically ill comatose patients, but its interpretation is not straightforward. The aim of this study was to evaluate whether there is a correlation between EEG background pattern/reactivity to stimuli and automated pupillometry in critically ill patients. Methods: Prospective assessment of pupillary changes to light stimulation was obtained using an automated pupillometry (NeuroLight Algiscan, ID-MED, Marseille, France) in 60 adult patients monitored with continuous EEG. The degree of encephalopathy and EEG reactivity were scored by 3 independent neurophysiologists blinded to the patient’s history. The median values of baseline pupil size, pupillary constriction, constriction velocity, and latency were collected for both eyes. To assess sensitivity and specificity, we calculated areas under the receiver-operating characteristic curve. Results: The degree of encephalopathy assessed by EEG was categorized as mild (42%), moderate (37%), severe (10%) or suppression-burst/suppression (12%); a total of 47/60 EEG recordings were classified as “reactive.” There was a significant difference in pupillary size, constriction rate, and constriction velocity, but not latency, among the different EEG categories of encephalopathy. Similarly, reactive EEG tracings were associated with greater pupil size, pupillary constriction rate, and constriction velocity compared with nonreactive recordings; there were no significant differences in latency. Pupillary constriction rate values had an area under the curve of 0.83 to predict the presence of severe encephalopathy or suppression-burst/suppression, with a pupillary constriction rate of < 20% having a sensitivity of 85% and a specificity of 79%. Conclusions: Automated pupillometry can contribute to the assessment of cerebral dysfunction in critically ill patients. S.H., L.P., L.C., J.-L.V., and F.S.T.: conceived and designed the study. F.S.T., S.H., L.P., N.G., and L.C.: selected the population. S.H., L.P., L.C., and L.F.: screened and collected data from the population. L.F., B.L., and N.G.: analyzed the EEG recordings. F.S.T., J.C., and N.G.: conduced the statistical analysis. F.S.T., M.O., S.H., and L.P.: wrote the first draft of the manuscript. J.C., N.G., B.L., L.F. and J.-L.V.: revised the text for intellectual content. All the co-authors read and approved the final text. M.O. received lecture fees from Neuroptics. The remaining authors have no conflicts of interest to disclose. Address correspondence to: Fabio S. Taccone, MD, PhD. E-mail: ftaccone@ulb.ac.be. Received January 9, 2019 Accepted June 13, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

General Anesthetics Are Neuroprotective No abstract available

Perioperative Management of Direct Oral Anticoagulants in Intracranial Surgery The use of direct oral anticoagulants is increasing rapidly, because of perceived benefits over older agents, such as predictable pharmacokinetics and a reduced risk of bleeding. Elderly patients, who are more likely to be prescribed these drugs, are also presenting for neurosurgical procedures more often. The combination of these factors will result in neurosurgeons and neuroanesthesiologists encountering patients prescribed direct oral anticoagulants on an increasingly frequent basis. This review provides a summary of the current evidence pertaining to the perioperative management of these drugs, in the context of elective and emergency intracranial surgery. It highlights emerging therapies, including specific antidotes, as well as areas where the evidence base is likely to improve in the future. The authors have no funding or conflicts of interest to disclose. Address correspondence to: John Porter, MD, FRCA, FFICM, E-mail: johnporter@nhs.net. Received March 30, 2019 Accepted June 12, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Propofol But Not Desflurane Maintains Rat Cerebral Arteriolar Responses to Acetylcholine During Acute Hyperglycemia Background: Acute hyperglycemia causes vascular endothelial dysfunction in various organs including the cerebral vessels. It is associated with increased mortality and morbidity in the perioperative period. The impact of anesthetic agents on cerebral vasodilatory responses during hyperglycemia remains unclear. We investigated endothelial function in rat cerebral arterioles during acute hyperglycemia, under propofol or desflurane anesthesia. Materials and Methods: A closed cranial window preparation was used to measure changes in pial arteriole diameter induced by topical application of acetylcholine (ACh), an endothelium-dependent vasodilator, in rats anesthetized with propofol or desflurane. Pial arteriole responses to ACh were measured during normoglycemia and hyperglycemia. We then investigated whether the response of cerebral arterioles to acute hyperglycemia under propofol anesthesia were related to propofol or its vehicle, intralipid. Results: ACh resulted in a dose-dependent dilation of cerebral arterioles during propofol and desflurane anesthesia under normoglycemic conditions. The vasodilatory effects of ACh were also maintained under hyperglycemic conditions during propofol anesthesia, but the vasodilator response to ACh was significantly impaired during hyperglycemia compared with normoglycemia with desflurane anesthesia. The vasodilatory effects of ACh were maintained during normoglycemia and hyperglycemia in rats receiving propofol or intralipid. Conclusions: Rat pial arteriole responses to ACh are maintained during conditions of acute hyperglycemia with propofol anesthesia but suppressed compared with normoglycemia with desflurane anesthesia. Supported in part by a Grant-in-Aid for Scientific Research from Ministry of Education, Science and Culture of Japan (grant nos. 15K10509 and 17K11046). Part of this report was previously presented at the Annual Meeting of American Society of Anesthesiologists held in Boston on October 21, 2017. The authors have no conflicts of interest to disclose. Address correspondence to: Hiroki Iida, MD, PhD. E-mail: iida@gifu-u.ac.jp. Received March 19, 2019 Accepted June 19, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Noninvasive Intracranial Pressure Estimation With Transcranial Doppler: A Prospective Observational Study Background: Transcranial Doppler (TCD) ultrasonography has been described for the noninvasive assessment of intracranial pressure (ICP). This study investigates the relationship between standard, invasive intracranial pressure monitoring (ICPi) and noninvasive ICP assessment using a simple formula based on TCD-derived flow velocity (FV) and mean arterial blood pressure values (ICPTCD). Material and Methods: We performed a prospective observational study on 100 consecutive traumatic brain injury patients requiring invasive ICP monitoring, admitted to the Neurosciences and Trauma Critical Care Unit of Addenbrooke’s Hospital, Cambridge, UK. ICPi was compared with ICPTCD using a method based on the “diastolic velocity-derived estimator” (FVd), which was initially described for the noninvasive estimation of cerebral perfusion pressure but subsequently utilized for ICP assessment. Results: Median ICPi was 13 mm Hg (interquartile range: 10, 17.25 mm Hg). There was no correlation between ICPi and ICPTCD (R=−0.17; 95% confidence interval [CI]: −0.35, 0.03; P=0.097). Bland-Altman analysis demonstrated wide 95% limits of agreement between ICPi and ICPTCD (−27.58, 30.10; SD, 14.42). ICPTCD was not able to detect intracranial hypertension (ICPi >20 mm Hg); the area under the receiver operating characteristic curve for prediction was 34.5% (95% CI, 23.1%-45.9%) with 0% sensitivity and 74.4% specificity for ICPTCD to detect ICPi>20 mm Hg. Conclusions: Using a formula based on diastolic FV, TCD is an insufficiently accurate method for the noninvasive assessment of ICP. Further studies are warranted to confirm these results in a broader patient cohort. D.C. and C.R. have contributed equally. D.C. and M.C. are partially supported by NIHR Brain Injury Healthcare Technology Co-operative, Cambridge, UK. P.R. and E.B. are partially supported by the grant SIR RBSI14LOVD of the Italian Ministry of Education, University and Research. G.C. is a member of the speakers’ bureau of Integra-Codman, and he received funding for educational activities. The remaining authors have no conflicts of interest to disclose. Address correspondence to: Chiara Robba, MD, PhD, E-mail: kiarobba@gmail.com. Received February 15, 2019 Accepted May 28, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved