Processed electroencephalography monitoring in neurosurgical patients and procedures: limitations, pitfalls, and practical solutions

Accessibility to processed electroencephalography (pEEG) in recent years offers a more simplified approach in monitoring the depth of anesthesia, lowering the risks of adverse outcomes. While its utility has been well studied in general surgical populations, its reliability in neurosurgical patients remains uncertain. Intracranial pathologies can substantially alter EEG signals, resulting in variable or misleading pEEG indices. This review focuses on neurosurgery-specific challenges in intraoperative EEG monitoring, including pathological EEG variability, alternatives for frontal probe placement, and signal contamination. This review supports a contextualized approach that integrates proprietary indices, raw EEG interpretation, surgical pathology, anesthetic pharmacology, and clinical judgment. The described strategy may facilitate more effective use of pEEG as a supportive tool in neuroanesthesia care. Further neurosurgical-specific studies are needed to guide pEEG monitoring in this setting.