With so many outstanding articles published in the Journal of Neurosurgical Anesthesiology over the last year, it has once again proven an exceptional challenge to select only four articles for this summer edition of the Fellows’ Journal Club. Below is a collection of articles which highlight key curriculum themes for Fellows and will hopefully spark interesting and informative discussion and debate.

Clinical Investigations: Krismer L, Tröndle U, Schwer C, Trincado J, Pinar SM, Mercan Z, Wagner K, Mirlina E, Beck J, El Rahal A, Roelz R. Comparison of Subjective Patient Experiences Between Asleep-Awake-Asleep and Monitored Anesthesia Care Techniques During Awake Craniotomy. J Neurosurg Anesthesiol. 2026 Jul 1;38(3):211-217. doi: 10.1097/ANA.0000000000001068.

In this insightful study performed at the University Medical Centre, Freiburg Germany, patient satisfaction with differing anaesthesia techniques for awake craniotomy is explored. The advantages of awake craniotomy (AC) with direct electrical stimulation (DES) are discussed and the importance of this surgical technique to maximise tumour resection whilst conserving neurological function, particularly when operating near eloquent areas. With the Asleep-Awake-Asleep (SAS) technique, general anaesthesia is administered before and after the awake stages and invasive airway management is necessitated. Monitored Anaesthesia Care (MAC) negates the need for general anaesthesia and instead utilises conscious sedation throughout with spontaneous ventilation. The authors highlight that despite both techniques being widely used, there is limited research available studying patient satisfaction and experience. The primary objective of this study was a comparison of patient satisfaction with both techniques. All patients with brain tumours in eloquent areas undergoing awake craniotomy at the University Medical Center, Freiburg, Germany between October 2018 and April 2024 were retrospectively included in a database. At the study institution, SAS was the technique utilised until November 2023 and MAC thereafter. Telephone surveys focused on both intraoperative experience as well as postoperative quality of life. The anaesthetic techniques utilised in the study are described in detail in this article. Total intravenous anaesthesia (TIVA) was utilised for the SAS group with propofol and remifentanil with a laryngeal mask airway. In the MAC group, sedation with dexmedetomidine was first line with the addition of remifentanil (if the patient was in pain) and propofol infusions (if the patient requested further sedation). The authors found the operating room time was significantly reduced for the MAC (366 ± 107 min) than for SAS (453 ± 81 min) (P = 0.011). The mean duration of the surgical procedure was similar between the groups (MAC 208 ± 95 min vs. SAS 254 ± 71 min). Both techniques resulted in comparable intraoperative experience and postoperative quality of life. The authors acknowledge the limitations of the study which include a small sample size from a single centre.

Overall, this highly informative study aims to further enhance our understanding of patient satisfaction with differing anaesthetic techniques for awake craniotomy surgery. The authors highlight the need for larger scale, multi-centre studies in this area.

Week 2 online Neuroanesthesia Classroom:

• Craniotomy – Concerns and Complications

Advanced Neuroanesthesiology Rotation Goals and Objectives:

• Objective 1 Patient Care – perioperative management of the patient undergoing awake craniotomy
• Objective 2 Medical Knowledge – advanced understanding of neuromonitoring
• Objective 3 Systems-Based Practice – importance of working as part of an interprofessional team to enhance patient safety and advocate for and improve patient care quality
• Objective 6 Interpersonal and Communication Skills – emphasises that residents are expected to communicate effectively with the anaesthesia team, surgeon, neurophysiologist, ICU and PACU staff

Short Reports: Singh DJ, Prabhakar H, Kapoor I, Pandia MP, Pandey S. Opioid-free Anesthesia for Craniotomy in Supratentorial Tumors: An Open-labeled Single-blinded Randomized Controlled Study. J Neurosurg Anesthesiol. 2026 Apr 1;38(2):161-165. doi: 10.1097/ANA.0000000000001089.

This enlightening study from Singh et al. at the AIIMS, New Delhi India, addresses the important issue of pain optimisation and the potential benefits of opioid free anaesthesia following craniotomy surgery – specifically here for supratentorial tumours. The study compared the use of dexmedetomidine or fentanyl for postoperative pain control in this patient cohort. Primary outcomes of this study comprised emergence and extubation times after surgery with multiple secondary outcomes including haemodynamic responses and postoperative pain. The authors explore the proposed benefits of opioid free anaesthesia including mitigating the sedative effects of opioids, preventing postoperative respiratory depression and hypercapnia and rates of postoperative nausea and vomiting. 44 patients were randomised in this open-labelled single-blinded randomised controlled study, with 33 patients completing the study. Whilst the study authors found that the differing analgesia regimens resulted in comparable emergence and extubation times, they did conclude that opioid free analgesia may result in improved haemodynamic stability and pain control at 12 hours. Intraoperative haemodynamics, including heart rate and mean arterial pressure values did show a significant difference between the groups during certain activities including application of Mayfield pins and on tracheal extubation (P=<0.0001). Postoperative Numeric Rating Scale (NRS) score was significantly better in group D compared with group F at 12 hours post surgery (4 [1 to 6] vs. 5 [3 to 7], P=0.003). Whilst the study raises multiple key discussion points surrounding the use of opioid free anaesthesia in this patient group, the authors highlight certain limitations including the relatively small sample size and potential issues with blinding as well as inclusion of patients with a smaller tumour size of ≤ 40mm. The authors reflect that a larger scale and adequately powered trial would be useful to draw more robust conclusions in this area.

Week 2 online Neuroanesthesia Classroom:

• Craniotomy – Concerns and Complications

Advanced Neuroanesthesiology Rotation Goals and Objectives:

• Objective 1 Patient Care – recognise where there are possibilities for enhancing patient care and quality
• Objective 2 Medical Knowledge – postoperative analgesia management
• Objective 4 Practice-Based Learning – apply scientific evidence to decision making

Review Articles: Blacker SN, Burbridge M, Chowdhury T, Gouker LN, Heller BJ, Kang M, Moreton E, Nadler JW, Sindelar LBD, Vincent AN, Williams JH, Lele AV. Intraoperative Anesthetic Care During Emergent/Urgent Craniotomy or Craniectomy for Intracranial Hypertension or Herniation: A Systematic Review. J Neurosurg Anesthesiol. 2026 Jan 1;38(1):23-31. doi: 10.1097/ANA.0000000000001014.

In this large-scale systematic review, the authors search PubMed, Scopus, EMBASE and Cochrane databases to ascertain best practice for the intraoperative anaesthetic management of patients undergoing emergency decompressive craniotomy or craniectomy. 1885 abstracts were initially reviewed with a further full text review of 276 articles. 9 studies were finally included which addressed the anaesthetic management of patients undergoing urgent/emergent craniotomy or decompressive craniectomy for all indications. Multiple areas of the intraoperative care of this patient cohort are addressed in this study. These areas include anaesthetic technique itself, use of hyperosmolar agents, intraoperative haemodynamic changes, time of extubation (specifically location of extubation post surgery) as well as intraoperative intracranial pressure monitoring and measurements of various quality metrics. The authors found that there is limited evidence surrounding the anaesthetic management of these patients and that further studies investigating optimum intraoperative anaesthetic care for this patient cohort are required. The studies included in this systematic review had multiple limitations. All studies were single centre with variable blinding, with inclusion of observational and retrospective studies. The authors of this study highlight that considering the large volume of traumatic brain injury cases and large numbers of urgent and emergent craniotomies undertaken, large data sets are available and could be utilised for baseline larger scale retrospective studies with a particular focus on anaesthetic techniques as well as aspects of enhanced recovery protocols.

Week 1 online Neuroanesthesia Classroom:

• Cerebral Physiology and Anesthetic Effects – Intracranial Pressure

Week 4 online Neuroanaesthesia Classroom:

• Overview of Neuroanesthetic Emergencies

Advanced Neuroanesthesiology Rotation Goals and Objectives:

• Objective 1 Patient Care – intraoperative care and perioperative management of patient with raised intracranial pressure
• Objective 2 Medical Knowledge – understanding of pathophysiology of raised intracranial pressure and its management
• Objective 6 Interpersonal and Communication Skills – communicating effectively in high pressure situations

Focused review: Budiansky, A. S., Ma, K., & Polis, T. (2025). Temporary Intraoperative Cerebral Blood Flow Reduction to Facilitate Neurovascular Procedures. Journal of Neurosurgical Anesthesiology, 37(4), 335–340. https://doi.org/10.1097/ANA.0000000000001046

This comprehensive focused review explores strategies to achieve cerebral blood flow reduction during neurovascular procedures. The differing strategies explored include deep hypothermic circulatory arrest (now superseded with newer techniques), the use of adenosine, rapid ventricular pacing and endovascular balloon-assisted techniques. The authors describe how blood flow reduction techniques are utilised for a multitude of neurovascular lesions, commonly arteriovenous malformations (AVMs) and aneurysms. The authors highlight how in open surgical cases, the decreased blood flow resulting from these techniques allows for microdissection and, in the case of aneurysm, clipping. When the critical situation of aneurysm rupture occurs, the ability to rapidly and effectively reduce blood flow across the aneurysm allows the surgeon to gain control and place an aneurysm clip. Adenosine remains a popular choice for flow-arrest in aneurysm clipping. It confers the benefits of a short-lived arrest state followed by a more prolonged period of nitric oxide-mediated hypotension which also results in improved surgical operating conditions. The authors describe how adenosine can also be used in cases of AVM embolisation to help with preventing the undesirable migration of embolisation products with a transarterial approach or to assist with overcoming antegrade pressure with a transvenous approach. The authors highlight the increasing use of right ventricular pacing in neurovascular surgery with its additional benefit of greater control over the duration of hypotension. They comment that this technique is particularly valuable in aneurysm clipping where placement of a temporary clip is not possible. Also emphasised is the utilisation of endovascular balloon-assisted flow reduction as an alternative to temporary clipping to acquire localised proximal control. This does however require a hybrid suite where both neurosurgeon and neuroradiologist can work simultaneously. Rapid balloon deployment has the added advantage of controlling acute bleeding in cases of intraoperative aneurysm rupture. This technique can also be used in cases of AVM embolisation. This highly informative review discusses the potential benefits and limitations of each technique in detail and is therefore of particular relevance to Fellows developing their knowledge base in this area.

Week 4 online Neuroanaesthesia Classroom:

• Overview of Neuroanesthetic Emergencies

Advanced Neuroanesthesiology Rotation Goals and Objectives:

• Objective 1 Patient Care – perioperative management of patients undergoing intracranial vascular surgery
• Objective 2 Medical Knowledge – advanced knowledge of anesthesia for cerebral aneurysms and arteriovenous malformations
• Objective 4 Practice-Based Learning – amalgamating and appraising knowledge from relevant textbooks and journals