810 MINERVA ANESTESIOLOGICA July 2012 REVIEW N eurological recovery after major acute neu- rosurgical conditions, such as traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage (SAH) and ischemic/hemorrhagic stroke, is dependent on the extent and the sever- ity of initial cerebral insult and the amount of so- called secondary brain injury. Secondary brain injury consists of the number of pathological events (including brain edema, cerebral hypoxia/ ischemia, brain energy dysfunction, nonconvul- sive seizures) that occur in the early phase fol- lowing initial insult and may add further burden to primary brain injury. Secondary brain insults are frequent and may aggravate neurological re- covery. Over the last decade, in parallel with the introduction and constant development of spe- cialized neuroscience intensive care units (ICU), multimodal neuromonitoring – consisting in the integration of cerebral physiological variables derived from invasive (i.e. intracranial pressure [ICP], brain tissue oxygen tension [PbtO 2 ], cer- ebral microdialysis, regional cerebral blood flow [rCBF]) and non-invasive (i.e. transcranial Dop- pler [TCD], near-infrared spectroscopy [NIRS], electroencephalography [EEG]) monitoring de- vices – has increasingly evolved with the aim to optimize the management of secondary brain surgery and guide therapy to patient-specific pathophysiology. Recent clinical investigations by several independent groups show feasibil- Neuromonitoring after major neurosurgical procedures M. MESSERER 1 , R. T. DANIEL 1 , M. ODDO 2 1 Division of Neurosurgery,Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital and Faculty of Biology and Medicine, Lausanne, Switzerland; 2 Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital and Faculty of Biology and Medicine, Lausanne, Switzerland ABSTRACT Postoperative care of major neurosurgical procedures is aimed at the prevention, detection and treatment of sec- ondary brain injury. is consists of a series of pathological events (i.e. brain edema and intracranial hypertension, cerebral hypoxia/ischemia, brain energy dysfunction, non-convulsive seizures) that occur early after the initial insult and surgical intervention and may add further burden to primary brain injury and thus impact functional recovery. Management of secondary brain injury requires specialized neuroscience intensive care units (ICU) and continuous advanced monitoring of brain physiology. Monitoring of intracranial pressure (ICP) is a mainstay of care and is recommended by international guidelines. However, ICP monitoring alone may be insufficient to detect all episodes of secondary brain insults. Additional invasive (i.e. brain tissue PO 2 , cerebral microdialysis, regional cerebral blood flow) and non-invasive (i.e. transcranial doppler, near-infrared spectroscopy, EEG) brain monitoring devices might complement ICP monitoring and help clinicians to target therapeutic interventions (e.g. management of cerebral perfusion pressure, blood transfusion, glucose control) to patient-specific pathophysiology. Several independent studies demonstrate such multimodal approach may optimize patient care after major neurosurgical procedures. e aim of this review is to evaluate some of the available monitoring systems and summarize recent important data showing the clinical utility of multimodal neuromonitoring for the management of main acute neurosurgical condi- tions, including traumatic brain injury, subarachnoid hemorrhage and stroke. (Minerva Anestesiol 2012;78:810-22) Key words: Intracranial pressure - Microdialysis - Cerebrovascular circulation - Electroencephalography - Critical care - Brain injuries. COPYRIGHT © 2012 EDIZIONI MINERVA MEDICA This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.