Even in the absence of direct neurological injury, the brain remains acutely vulnerable during non-neurological surgeries, particularly in elderly patients, individuals with cerebrovascular disease, and those with pre-existing cognitive impairment. Anaesthetists play a vital role in protecting cerebral function through vigilant monitoring, personalised anaesthetic strategies, and the prevention of perioperative complications. As evidence continues to accumulate around postoperative neurocognitive disorders and silent brain injury, it becomes increasingly important to recognise the concept of the fragile brain and to adapt perioperative care accordingly.
In the Euroananaesthesia 2025 session “The Brain at Risk – Fragile Brain Undergoing Non-Neurological Surgeries,” clinical experts explored how to provide anaesthesia with increased neurological consideration, ensuring optimal brain protection across a range of patient populations.
While therapeutic hypothermia remains the standard of care for neonatal encephalopathy in term infants, outcomes are still suboptimal for many. Research into adjunct treatments such as erythropoietin, stem cell therapy, and melatonin is ongoing. At the same time, concerns persist regarding the neurodevelopmental impact of anaesthetic exposure in neonates, especially with prolonged or repeated procedures. Although the full clinical implications remain under investigation, the issue continues to draw scrutiny.
Professor Arash Afari, Senior Consultant at the University of Copenhagen’s Rigshospitalet, emphasised that general anaesthesia is often a medical necessity rather than a discretionary choice. The critical question, he asserts, is how to create the safest possible perioperative environment for the developing brain. While acknowledging the theoretical risks of anaesthetic neurotoxicity, he stresses that withholding anaesthesia in the context of required surgery or painful procedures is not a viable option—especially since untreated pain in neonates is itself associated with adverse long-term neurodevelopmental outcomes. Current clinical evidence does not conclusively demonstrate harm from anaesthesia at standard doses and durations.
Elderly patients face a significantly higher risk of postoperative cognitive complications. However, conventional screening tools like the Montreal Cognitive Assessment (MoCA) may fail to detect subtle but clinically important vulnerabilities.
Dr Dana Baron Shahaf, Head of Neuroanaesthesia at Rambam Health Care Campus, Israel, presented insights into the nuanced task of predicting cognitive risk in geriatric patients. In a recent study, Dr Shahaf and her team employed two EEG-derived markers during MoCA testing: The Cognitive Effort Index (CEI), measuring attentional engagement and the Tension Index (TensI)capturing stress-related arousal or alertness.
These markers were recorded before and after cardiac surgery in elderly patients. Results revealed that elevated CEI and TensI, especially among patients with intermediate MoCA scores, were associated with greater risk for postoperative cognitive decline. High preoperative TensI also predicted persistent cognitive deterioration beyond the immediate postoperative period, possibly reflecting anxiety in cognitively vulnerable individuals during testing.
These findings highlight an essential point: identical MoCA scores can conceal very different neurophysiological profiles. By incorporating these EEG-based indices into routine preoperative assessments, clinicians gain a deeper, individualised understanding of cognitive risk, enabling more accurate stratification and targeted interventions.
Patients with traumatic brain injury (TBI) present unique challenges when undergoing non-neurological surgery. The risk of secondary brain injury due to elevated intracranial pressure (ICP) or compromised cerebral perfusion pressure (CPP) is a central concern.
In his presentation “Fragile Brain Undergoing Non-Neurological Surgeries: The Patient with Traumatic Brain Injury,” Professor Özlem Korkmaz Dilmen of Istanbul University-Cerrahpasa’s Department of Anaesthesiology & Intensive Care outlined strategies to mitigate these risks.
The primary goal in TBI management is to prevent secondary brain injury by maintaining optimal ICP and CPP. Monitoring can be achieved through non-invasive methods (e.g. optic nerve sheath diameter, transcranial Doppler) or invasive techniques, with intraventricular catheters considered the gold standard. CPP targets typically range from 60–70 mmHg but should be individualised based on cerebral autoregulation (CA), assessed by observing ICP responses to vasopressors.
Key intraoperative goals include maintaining normoxia, normocapnia, normothermia, and careful titration of PEEP—especially in TBI patients with concurrent ARDS. Historically, ketamine was avoided due to concerns about raising ICP, but emerging evidence now supports its use in TBI, with potential benefits such as reducing cortical spreading depolarisations.
From neonates to the elderly, and from cognitively impaired patients to those with traumatic brain injury, the concept of the fragile brain challenges anaesthetists to think beyond standard protocols. By integrating emerging technologies, individualised monitoring strategies, and a nuanced understanding of neurophysiology, anaesthesia providers can significantly improve perioperative brain protection in high-risk populations.
Source: Euroanaesthesia 2025
Image Credit: iStock
