Correction of intraoperative arterial hypotension in the post-induction period during elective craniotomy for brain tumors

Introduction. Intraoperative arterial hypotension (IAH) is a common side effect of general anesthesia, often occurring after induction of anesthesia – post-induction arterial hypotension (PIH). IAH is associated with an increased risk of perioperative complications, including perioperative myocardial injury. The effectiveness and safety of targeted protocols for IAH prevention and management using vasopressors remain understudied in neurosurgery, particularly in patients with elevated cardiac risk.
The objective was to evaluate the effectiveness and safety of a novel protocol for the prevention and treatment of post-induction IAH in high cardiac risk patients undergoing brain tumor surgery.
Materials and methods. This prospective study included 123 elevated cardiac risk patients (age ≥ 65 years or ≥ 45 years with RCRI ≥ 1) scheduled for elective brain tumor resection. Patients were assigned to a control group (Group 1; n = 92) receiving conventional hemodynamic management (non-aggressive correction of IAH primarily by means of infusion therapy), or a protocol group (Group 2; n = 31) receiving the measures for the prevention and correction of IAH: withholding antihypertensive drugs (except β-blockers), crystalloid infusion if SBP < 90 mmHg, and norepinephrine if MAP < 65 mmHg. Primary estimated outcomes were the incidence and duration of IAH and PIH (MAP < 65 mmHg), incidence of perioperative myocardial injury and arterial hypertension (SBP > 140 mmHg).
Results. The incidence of IAH did not differ between groups (57% in Group 1 vs. 55% in the Group 2, p = 0.87). The duration of IAH was significantly higher in Group 1 (30 min [15-60]) compared with Group 2 (12 min [9-21], p = 0.002). PIH accounted for a substantial proportion of IAH: 21 min [12–30] in Group 1 (70% of IAH duration) vs. 9 min [6–15] in Group 2 (75% of IAH duration). The incidence of perioperative myocardial injury, diagnosed by an isolated asymptomatic change in hs-cTnI levels, was higher in Group 1 compared with Group 2 (17% vs. 6.5%, p = 0.099). The frequency of episodes of hypertension was comparable.
Conclusion. Тhe proposed protocol effectively reduces the duration of IAH, particularly during the post-induction period, in high cardiac risk neurosurgical patients without raising the risk of hypertension. These findings support a combined, etiology‑driven approach to early IAH management to improve perioperative outcomes.

1. Cnirik G. S., Kazancev F. N. Controlled hypotension in neurosurgery. Kazan medical journal, 1967, vol. 48, no. 1, pp. 32–35. (In Russ.). http://doi.org/10.17816/kazmj58532.

2. Usachev D. Yu., Dombaanay B. S., Lishchuk A. N. et al. Analysis of postoperative complications in a cardio- and neuroangiosurgery clinic: what remains outside the field of view. Effective Pharmacotherapy, 2024, vol. 20, no. 31, pp. 42–50. (In Russ.). http://doi.org/10.33978/2307-3586-2024-20-31-42-50.

3. Tsilina S. V., Shesterikov Y. A., Dashyan V. G. et al. Locoregional anesthesia in endoscopic surgery of intracerebral hypertensive hemangiomas. Burdenko’s Journal of Neurosurgery = Zhurnal voprosy neirokhirurgii im. N. N. Burdenko, 2020, vol. 84, no. 2, pp. 65–71. (In Russ.). https://doi.org/10.17116/neiro20208402165.

4. Abbott T. E. F., Pearse R. M., Archbold R. A. et al. A prospective international multicentre cohort study of intraoperative heart rate and systolic blood pressure and myocardial injury after noncardiac surgery: results of the VISION Study. Anesth Analg, 2018, vol. 126, no. 6, pp. 1936–1945. http://doi.org/10.1213/ANE.0000000000002560.

5. Ali A., Altiparmak O., Tetik A. et al. Pulse pressure variation and weight-loss percentage predict hypotension after anesthesia induction in neurosurgery patients: a prospective, observational, blinded study. J Neurosurg Anesthesiol, 2017, vol. 29, no. 3, pp. 304–311. http://doi.org/10.1097/ANA.0000000000000326.

6. Bette S., Wiestler B., Wiedenmann F. et al. Safe brain tumor resection does not depend on surgery alone – role of hemodynamics. Sci Rep, 2017, vol. 7, no. 1, pp. 5585. http://doi.org/10.1038/s41598-017-05767-2.

7. Bijker J. B., van Klei W. A., Kappen T. H. et al. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology, 2007, vol. 107, no. 2, pp. 213–220. http://doi.org/10.1097/01.anes.0000270724.40897.8e.

8. Brierley J. B., Cooper J. E. Cerebral complications of hypotensive anaesthesia in a healthy adult. J Neurol Neurosurg Psychiatry, 1962, vol. 25, no. 1, pp. 24–30. http://doi.org/10.1136/jnnp.25.1.24.

9. Chen B., Pang Q. Y., An R. et al. A systematic review of risk factors for postinduction hypotension in surgical patients undergoing general anesthesia. Eur Rev Med Pharmacol Sci, 2021, vol. 25, no. 22, pp. 7044–7050. http://doi.org/10.26355/eurrev_202111_27255.

10. Lee T. H., Marcantonio E. R., Mangione C. M. et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 1999, vol. 100, no. 10, pp. 1043–1049. http://doi.org/10.1161/01.cir.100.10.1043.

11. De Hert S., Staender S., Fritsch G. et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol, 2018, vol. 35, no. 6, pp. 407–465. http://doi.org/10.1097/EJA.0000000000000817.

12. Devereaux P. J., Goldman L., Cook D. J. et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ, 2005, vol. 173, no. 6, pp. 627–634. http://doi.org/10.1503/cmaj.050011.

13. Duceppe E., Parlow J., MacDonald P. et al. Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol, 2017, vol. 33, no. 1, pp. 17–32. http://doi.org/10.1016/j.cjca.2016.09.008.

14. Gregory A., Stapelfeldt W. H., Khanna A. K. et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg, 2021, vol. 132, no. 6, pp. 1654–1665. http://doi.org/10.1213/ANE.0000000000005250.

15. Jessen M. K., Vallentin M. F., Holmberg M. J. et al. Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis. Br J Anaesth, 2022, vol. 128, no. 3, pp. 416–433. http://doi.org/10.1016/j.bja.2021.10.046.

16. Kouz K., Hoppe P., Briesenick L. et al. Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches. Indian J Anaesth, 2020, vol. 64, no. 2, pp. 90–96. http://doi.org/10.4103/ija.IJA_939_19.

17. Lee S., Islam N., Ladha K. S. et al. Intraoperative hypotension in patients having major noncardiac surgery under general anesthesia: a systematic review of blood pressure optimization strategies. Anesth Analg, 2025, vol. 141, no. 1, pp. 38–60. http://doi.org/10.1213/ANE.0000000000007074.

18. Maheshwari K., Turan A., Mao G. et al. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis. Anaesthesia, 2018, vol. 73, no. 10, pp. 1223–1228. http://doi.org/10.1111/anae.14416.

19. Messina A., Robba C., Calabrò L. et al. Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery. Crit Care, 2021, vol. 25, no. 1, pp. 43. http://doi.org/10.1186/s13054-021-03464-1.

20. Monk T. G., Bronsert M. R., Henderson W. G. et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology, 2015, vol. 123, no. 2, pp. 307–319. http://doi.org/10.1097/ALN.0000000000000756.

21. Riedel K., Thudium M., Boström A. et al. Controlled arterial hypotension during resection of cerebral arteriovenous malformations. BMC Neurol, 2021, vol. 21, no. 1, pp. 339. http://doi.org/10.1186/s12883-021-02362-x.

22. Ryu T. Fluid management in patients undergoing neurosurgery. Anesth Pain Med (Seoul), 2021, vol. 16, no. 3, pp. 215–224. http://doi.org/10.17085/apm.21072.

23. Saka E., Canbaz M., Abdullah T. et al. Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality. Neurosurg Rev, 2022, vol. 45, no. 3, pp. 2151–2159. http://doi.org/10.1007/s10143-021-01722-y.

24. Saugel B., Annecke T., Bein B. et al. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. J Clin Monit Comput, 2024, vol. 38, no. 5, pp. 945–959. http://doi.org/10.1007/s10877-024-01132-7.

25. Saugel B., Bebert E. J., Briesenick L. et al. Mechanisms contributing to hypotension after anesthetic induction with sufentanil, propofol, and rocuronium: a prospective observational study. J Clin Monit Comput, 2022, vol. 36, no. 2, pp. 341–347. http://doi.org/10.1007/s10877-021-00653-9.

26. Sessler D. I., Meyhoff C. S., Zimmerman N. M. et al. Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial. Anesthesiology, 2018, vol. 128, no. 2, pp. 317–327. http://doi.org/10.1097/ALN.0000000000001985.

27. Soghomonyan S., Stoicea N., Sandhu G. S. et al. The role of permissive and induced hypotension in current neuroanesthesia practice. Front Surg, 2017, vol. 4, pp. 1. http://doi.org/10.3389/fsurg.2017.00001.

28. Stephen C. R., Woodhall B., Odom G. L. Induced hypotension for neurosurgical procedures: a critical analysis. Ann Surg, 1956, vol. 143, no. 2, pp. 143–59. http://doi.org/10.1097/00000658-195614320-00001.

29. Südfeld S., Brechnitz S., Wagner J. Y. et al. Post-induction hypotension and early intraoperative hypotension associated with general anaesthesia. Br J Anaesth, 2017, vol. 119, no. 1, pp. 57–64. http://doi.org/10.1093/bja/aex127.

30. Sun L. Y., Wijeysundera D. N., Tait G. A. et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology, 2015, vol. 123, no. 3, pp. 515–523. http://doi.org/10.1097/ALN.0000000000000765.

31. Thygesen K., Alpert J. S., Jaffe A. S. et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol, 2018, vol. 72, no. 18, pp. 2231–2264. http://doi.org/10.1016/j.jacc.2018.08.1038

32. Wesselink E. M., Kappen T. H., Torn H. M. et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth, 2018, vol. 121, no. 4, pp. 706–721. http://doi.org/10.1016/j.bja.2018.04.036.

33. Wijnberge M., Schenk J., Bulle E. et al. Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis. BJS Open, 2021, vol. 5, no. 1, zraa018. http://doi.org/10.1093/bjsopen/zraa018.

34. Writing Committee for the VISION Study Investigators; Devereaux P.J., Biccard B.M. et al. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. JAMA, 2017, vol. 317, no. 16, pp. 1642–1651. http://doi.org/10.1001/jama.2017.4360.

35. Zhang J. J. Y., Ong J. A. H., Tan Y. X. et al. Predictors of 30-day postoperative systemic complications in geriatric patients undergoing elective brain tumor surgery. J Clin Neurosci, 2021, vol. 85, pp. 72–77. http://doi.org/10.1016/j.jocn.2020.12.023.