Anesthesiology, September 15 edition

Using stereo-electroencephalography during anesthesia induction, this mechanistic human study demonstrated that propofol-induced loss of consciousness involves temporally dissociable changes across the anterior thalamus, prefrontal cortex, and temporal cortex. Thalamic complexity and spectral changes generally preceded corresponding cortical changes, while local connectivity changes preceded interregional alterations and phase-amplitude coupling shifts.

Impact: This study provides direct human intracranial evidence against the concept that anesthetic loss of consciousness is a single focal event or uniform global suppression. Its temporal ordering of neural changes offers a mechanistic framework for understanding consciousness transitions and may inform future depth-of-anesthesia biomarkers.

Clinical Implications: The findings support development of multiregional, mechanistically informed monitoring rather than reliance on a single electroencephalographic marker. Immediate changes to clinical monitoring are not established, but future anesthetic depth assessment may benefit from markers that capture ordered thalamocortical network transitions.

Future Directions: Future studies should replicate these temporal signatures in larger, clinically diverse cohorts, compare different anesthetic agents, and test whether multiregional network markers improve prediction of loss and recovery of consciousness or guide individualized anesthetic dosing.

In a retrospective cohort of infants born before 29 weeks’ gestation, the number of different FDA-warned anesthetic or sedative agents administered during the early neonatal period was not associated with a clinically meaningful decrease in full-scale intelligence quotient at 36 months’ corrected age. The findings provide important reassurance, while residual confounding and incomplete 3-year assessment remain relevant concerns.

Impact: This study addresses a major safety concern affecting decisions about essential procedures in highly vulnerable premature infants. Its negative result is scientifically valuable because it weakens the assumption that exposure to multiple anesthetic or sedative agents necessarily causes clinically important early cognitive harm.

Clinical Implications: Clinicians should not withhold medically necessary procedures solely because several FDA-warned anesthetic or sedative agents may be required in very preterm infants. Decisions should still minimize avoidable exposure, optimize perioperative physiology, and include developmental follow-up because this observational study cannot establish absence of harm for every individual or exposure pattern.

Future Directions: Prospective multicenter studies should evaluate cumulative dose, developmental timing, repeated procedures, anesthetic combinations, perioperative physiologic insults, and longer-term neurodevelopmental outcomes using standardized assessments.

This narrative review synthesizes contemporary evidence on anesthesia for mechanical thrombectomy in large vessel occlusion stroke. It concludes that procedural sedation has not demonstrated superior functional outcomes over protocol-driven general anesthesia, while general anesthesia may improve reperfusion when accompanied by strict avoidance of hypotension and careful ventilatory management.

Impact: The paper directly addresses a high-stakes anesthesiology controversy affecting acute stroke systems worldwide. It reframes the choice between sedation and general anesthesia as a patient- and institution-specific decision in which hemodynamic performance and procedural conditions may be more important than the anesthetic label itself.

Clinical Implications: Institutions should avoid assuming that procedural sedation is universally preferable. For selected patients, protocol-driven general anesthesia with rapid airway control, tight blood pressure targets, avoidance of hypotension, and appropriate ventilation may support successful thrombectomy and reperfusion.

Future Directions: Ongoing and future randomized trials should define which stroke subtypes and patient profiles benefit from general anesthesia or procedural sedation, establish optimal blood pressure and ventilation targets, and evaluate neuroprotective strategies alongside anesthetic technique.