42328958 2026 06 23 1537-1921 2026 Jun 23 Journal of neurosurgical anesthesiology J Neurosurg Anesthesiol Comparison of Intraoperative Hypotension Outcomes With and Without Hypotension Prediction Index Tool in Patients Undergoing Brain Tumor Surgery: A Randomized Controlled Trial. 10.1097/ANA.0000000000001145 Intraoperative hypotension (IOH) can affect patient outcomes following craniotomy. The Hypotension Prediction Index (HPI) can predict IOH in advance, enabling early, proactive management. We evaluated whether an HPI-integrated hemodynamic management protocol reduces IOH during brain tumor surgery. This single-center, parallel-group randomized controlled trial was registered prospectively with the Clinical Trial Registry-India (CTRI/2024/07/069939, dated 04/07/2024) and funded by the Indian Council of Medical Research. Consenting adult patients undergoing brain tumor decompression were randomized 1:1 to HPI-guided (n=90) or conventional care (control) (n=90) hemodynamic management. The primary outcome was duration of IOH (MAP<65 mm Hg). Secondary outcomes included time-weighted average (TWA) of IOH, episodes, severity, and timing of IOH, vasopressor use, myocardial ischemia, acute kidney injury, delirium, intensive care unit (ICU) stay, and hospital stay. Of 180 enrolled patients, 176 were analyzed (HPI n=86; control n=90). HPI guidance significantly reduced IOH duration (MAP<65 mm Hg: 600 [180 to 960] vs. 1820 [420 to 4620] s; P <0.001), TWA of MAP <65 mm Hg (0.10 [0.03 to 0.22] vs. 0.32 [0.07 to 1.01] mm Hg; P <0.001), and number of hypotensive episodes (4 [2 to 7] vs. 6 [2 to 13]; P =0.004). TWA of MAP<60 mm Hg and <55 mm Hg was also significantly lower in the HPI group ( P <0.001). The IOH duration was lesser in the HPI group than in the control group during both presurgical and surgical phases. Postoperative outcomes did not differ between groups. HPI-guided hemodynamic management significantly reduced the burden of IOH during brain tumor surgery. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved. Francis Thomas T National Institute of Mental Health and Neurosciences, Bangalore, India. Sriganesh Kamath K Mishra Rajeeb Kumar RK Chakrabarti Dhritiman D eng Journal Article 2026 06 23 United States J Neurosurg Anesthesiol 8910749 0898-4921 IM brain neoplasms hemodynamics hypotension intraoperative care neurosurgical procedures The authors have no funding or conflicts of interest to disclose. 2026 2 10 2026 4 9 2026 6 22 13 43 2026 6 22 13 43 2026 6 22 8 53 aheadofprint 42328958 10.1097/ANA.0000000000001145 00008506-990000000-00250 Dobson GP. Trauma of major surgery: a global problem that is not going away. Int J Surg Lond Engl. 2020;81:47–54. doi:10.1016/j.ijsu.2020.07.017 10.1016/j.ijsu.2020.07.017 Shirmohamadi E, Dolama RH, Mohammadzadeh N, et al. 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