Selecting only four articles to highlight for the Fellows Journal Club has again proven a challenge with the vast array of high-quality articles published in the JNA over the last year. However here is a short selection of those which illuminate both key aspects of the Neuroanesthesiology curriculum and also hopefully will result in engaging and informative discussions.

Robinson, L., Forget, P., & Nesvadba, D. (2024). Systemic Hypertension and Postoperative Symptomatic Spinal Epidural Hematoma: A Scoping Review. Journal of neurosurgical anesthesiology, 36(4), 303–308. https://doi.org/10.1097/ANA.0000000000000947

This scoping review carried out by the Department of Anaesthesia, NHS Grampian and Epidemiology Group at the University of Aberdeen School of Medicine investigates the role of hypertension in the development of postoperative symptomatic spinal epidural haematoma (PSSEH). In their comprehensive review of 18 studies, the authors consider the effects of preoperative hypertension, a hypertensive episode on extubation and postoperative hypertension on the development of PSSEH. The findings include increased risk of developing PSSEH with a preoperative systolic blood pressure of greater than 140mmHg. This could have important implications in determining preoperative BP targets for these patients, balancing the risk of bleeding with desired intraoperative BP targets to ensure spinal cord perfusion in those with cord compression. The authors also highlight a possible correlation between postoperative PSSEH and postoperative hypertension. Despite raising several interesting discussion points, the authors acknowledge that the quality of evidence in the study is low, largely due to the retrospective nature of the included studies and the studies being based on limited observational data. The authors suggest further research to investigate the risk factors for mild PSSEH not requiring surgical intervention and also studies into asymptomatic epidural haematoma as these cases were not included here. Whilst this literature search does raise the important question of a link between hypertension in the perioperative period and PSSEH, it highlights the need for further prospective studies into the effects of blood pressure and hypertension on PSSEH. The perioperative management of patients undergoing spinal surgery is a key curriculum requirement for Neuroanesthesiology Fellows and is reviewed in detail in Week 3 of the SNACC Neuroanesthesia Classroom. An advanced understanding of anesthesia for complex spine surgery is also a key Learning Objective under Objective 2 – Medical Knowledge in the Advanced Neuroanesthesiology Rotation objectives.

Kim, S. H., Choi, S. H., Moon, J., Kim, H. D., & Choi, Y. S. (2025). Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis. Journal of neurosurgical anesthesiology, 37(1), 11–19. https://doi.org/10.1097/ANA.0000000000000967

This systematic review and meta-analysis from the Department of Anesthesiology and Pain Medicine and Yonsei University College of Medicine in Seoul, Korea provides an informative review of the use of Enhanced Recovery After Surgery (ERAS) protocols for craniotomy surgery. The review includes five prospective randomised controlled trials and focuses on effects of ERAS protocols on the care of patients undergoing elective craniotomy, with a total of 871 patients included in these trials. Whilst the authors note that ERAS protocols will differ from centre to centre, similarities between protocols are present in most. The focus here is on postoperative length of hospital stay (LOS), with secondary outcomes including postoperative pain, rates of postoperative nausea and vomiting (PONV), complications, reoperation, readmission, and mortality. The review found that ERAS protocols do have the potential to improve postoperative outcomes for this cohort of craniotomy patients. Patients had a reduced LOS, improved rates of PONV and reduced pain scores. Complication and readmission rates were similar when comparing ERAS groups with conventional perioperative care pathways. This indicates a potential important role for ERAS programmes for this patient cohort. The authors detail key aspects of ERAS protocols, from preoperative optimisation and carbohydrate loading to minimally invasive surgery and scalp blocks and subsequently minimising PONV, pain and encouraging early mobilisation. Limitations of the review include the RCTs having a moderate to high risk of bias and differences in surgery type and location between the studies. 3 of the total 5 RCTs included were also from the same institution – a point highlighted in the correspondence letter from Kapoor I. et al in the July 2025 edition of the JNA. Multicentre trials with higher quality evidence are encouraged by the authors going forward. Further research into this area is ongoing however as also demonstrated in the July JNA issue where Di Donato A, Velásquez C, Larkin C, et al. review Enhanced Recovery After Craniotomy: Global Practices, Challenges, and Perspectives. A complete understanding of the perioperative management of patients undergoing craniotomy is essential as a Neuroanesthesiology Fellow. Craniotomy: Concerns and Complications and Basic OR Management of Craniotomy are explored in Week 2 of the SNACC Neuroanesthesia Classroom. Improving patient care including patient safety and efficiency are discussed in more depth in the Advanced Neuroanesthesiology Rotation Learning Objectives, Objective 1 – Patient Care: Intraoperative care. Advanced understanding of post-operative management of the neurosurgical patient is also included in Objective 2 – Medical Knowledge and in Objective 3 – Systems-based practice, providing comprehensive care for the neurosurgical patient is explored.

Sharma, S., Dube, S. K., Esmail, T., Hoefnagel, A. L., Jangra, K., Mejia-Mantilla, J., Shiferaw, A. A., De Sloovere, V., Wright, D., Lele, A. V., & Blacker, S. N. (2025). Assessing Practice Variation of Anesthetic Management for Endovascular Thrombectomy in Acute Ischemic Stroke: A Comprehensive Multicenter Survey. Journal of neurosurgical anesthesiology, 37(2), 196–205. https://doi.org/10.1097/ANA.0000000000000976

This worldwide survey performed by the Department of Anesthesiology and Perioperative Medicine, Penn State Health, investigates the care of patients undergoing Endovascular Thrombectomy (EVT) for acute ischaemic stroke (AIS). The study has a particular focus on the involvement of anesthesiologists in the care of these patients and investigates variability in practices when assessing low/middle-income (LMICs) countries and high-income (HICs) countries. The study involved the completion of a 54-question electronic survey, with 38 surveys completed by hospitals in HICs and 49 from LMICs. It is interesting to note that EVTs were undertaken more in HICs than LMICs. Particular areas of focus of the survey included involvement of anaesthesia teams in pre-EVT care, anesthesia team composition and mode of anesthesia, as well as pre- and post-EVT handoffs. It was found that anesthetists were not involved in pre-EVT care in the majority of survey responses although inter-team communication about a pending EVT was commonplace. The authors report on details in the survey surrounding the intrahospital transfer of these patients including involvement of the anesthetist and monitoring used. Surprisingly, they found that only 50% of respondents from HICs confirmed monitoring EtCO2 during the transfer of intubated patients. The authors reviewed the use of guidelines and cognitive aids, with HICs observing published guidelines more often but cognitive aid use being universally low. A thorough understanding of the care of the patient for EVT is a key requirement for the Neuroanesthesiology Fellow and various aspects of this study link to topics within the Neuroanesthesia Classroom. Specifically, Week 1 – Cerebral Physiology and Anesthetic Effects: Cerebral Ischemia and Cerebral Protection. The Advanced Neuroanesthesiology Learning Objectives also expect Fellows to understand the application of anesthesia in the management of AIS under Objective 2 – Medical Knowledge. Involvement in Quality Improvement is emphasised in Objective 3 – Systems-based practice and the importance of handover is reflected in Objective 6 – Interpersonal and communications skills.

Ragulojan, M., Krolczyk, G., Al Aufi, S., Wang, A. P., McIsaac, D. I., Hicks, S., Sinclair, J., & Budiansky, A. S. (2025). Rapid Ventricular Pacing for Clipping of Intracranial Aneurysms: A Single-centre Retrospective Case Series. Journal of neurosurgical anesthesiology, 37(3), 288–295. https://doi.org/10.1097/ANA.0000000000000988

In this study the authors from the Division of Neurosurgery and Department of Anesthesiology and Pain Medicine in Ottawa, Canada present novel data surrounding the use of Rapid Ventricular Pacing (RVP) to assist in the surgical management of ruptured and unruptured intracranial aneurysms. In this retrospective single-institution case series of 40 patients, the authors concentrate on multiple aspects of this technique. Firstly, describing practices in their Canadian institution, secondly the aneurysm procedures this technique is used for and finally the intraoperative management of RVP with any intraoperative and postoperative complications of this technique. The authors describe how, when used, RVP causes a reduction in MAP during aneurysm clipping which in turn results in a reduction in aneurysm wall tension, permitting greater surgical manipulation of the aneurysm which may ordinarily result in rupture. In this study, RVP involved insertion of a pacing wire via the subclavian or internal jugular vein with a maximum pacing rate of 200 beats per minute and a target MAP of 30 to 35mmHg, with the use of IV agents if the desired MAP was not achieved. RVP was used for both ruptured and unruptured aneurysms and in particular for those thought to be more complex or in a challenging operative location. Adenosine is commonly administered in this setting where a reduction in BP is required, however the authors propose that RVP offers a more controlled and short-lived period of hypotension. They considered the effects of RVP on cardiac function and monitored for troponin rise and cardiac complications postoperatively (there was one recorded case of arrhythmia intraoperatively but no postoperative cardiac complications following RVP). Whilst the authors attest this study is a retrospective, single-institution, single-surgeon design and has a lack of control group, this novel data is compelling and highlights the need for further prospective studies in this area. It links with several aspects of the Neuroanesthesia curriculum, including Week 2 of the SNACC Neuroanesthesia Classroom – Craniotomy: Concerns and Complications and Basic OR Management of Craniotomy. Fellows can also be signposted to Objective 1 – Patient Care in the Advanced Neuroanesthesiology Rotation Learning Objectives where the perioperative management of patients undergoing intracranial vascular surgery is highlighted.