Document Type : Systematic Review
Authors
1
MD, Brain and Spain Surgeon, Trauma and Injury Research center, Tehran, Iran
2
Department of Anesthesiology and Critical Care, School of Medicine, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran, Assistant professor of Anesthesiology, Tehran University of Medical
3
Department of Anesthesiology and Critical Care, School of Medicine, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
4
Emergency Medicine Specialist، Department of Emergency Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
5
PhD of Anatomy, Trauma and Injury Research center, Iran University of medical sciences, Tehran, Iran
10.5281/zenodo.22286357
Abstract
Background: Emergency craniotomy is a life-saving intervention for patients with acute brain injury (ABI), yet it carries a significant risk of postoperative neurological deterioration and mortality. Identifying modifiable anesthetic and perioperative predictors is crucial for improving outcomes. This systematic review and meta-analysis aims to quantify the association between specific perioperative factors and adverse outcomes following emergency craniotomy for ABI.
Methods: A systematic search of PubMed, Embase, and the Cochrane Library conducted from inception to January 2026. We included observational studies and randomized controlled trials reporting on adult patients undergoing emergency craniotomy for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). Studies were required to report data on anesthetic or perioperative predictors and their association with neurological deterioration or mortality. Pooled odds ratios (ORs) were calculated using random-effects models.
Results: Twenty-five studies comprising 4,872 patients were included. The overall 30-day mortality rate was 28.5%. Significant perioperative predictors of mortality included intraoperative hypotension (systolic blood pressure <90 mmHg; OR=2.45, 95% CI: 1.78-3.36, p<0.001), prolonged operative time (>4 hours; OR=1.89, 95% CI: 1.45-2.47, p<0.001), and high intraoperative blood transfusion volume (>4 units; OR=2.11, 95% CI: 1.55-2.87, p<0.001). Predictors of neurological deterioration included postoperative hyperglycemia (>180 mg/dL; OR=2.98, 95% CI: 2.01-4.42, p<0.001) and early postoperative seizures (OR=3.45, 95% CI: 2.12-5.61, p<0.001). The use of total intravenous anesthesia (TIVA) was associated with a non-significant trend towards reduced neurological deterioration (OR=0.78, 95% CI: 0.59-1.03, p=0.08).
Conclusion: This meta-analysis identifies key modifiable perioperative factors—hypotension, prolonged surgery, and blood transfusion—as significant predictors of mortality. Strict glycemic control and seizure prophylaxis are critical to preventing neurological decline. These findings underscore the need for targeted perioperative protocols to mitigate these risks and improve outcomes in this high-risk patient population.
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