The Modern Interventional Neuroradiological Suite: No Longer a Remote Location

For years, the interventional neuroradiological (INR) suite was viewed as a “remote location,” geographically distant, logistically constrained, and functionally detached from the main operating complex. For neuroanesthesiologists, these settings often meant limited support staff, nonstandard equipment, and restricted access to emergency resources. The concept of providing neuroanesthesia in such a space invoked more apprehension than comfort. However, this perception no longer holds true. The modern INR suite has undergone a remarkable metamorphosis, emerging as a fully integrated, technology-driven operating environment.

Evolution Through Technology and Teamwork

The transformation has been primarily driven by technological innovation and multidisciplinary collaboration. Contemporary biplane angiography systems provide submillimetric, real-time imaging that parallels intraoperative neuronavigation.[1] Infrastructural enhancements have brought these suites at par with operating rooms (ORs), with advanced anesthesia workstations, invasive monitoring capabilities, and comprehensive resuscitation facilities. These developments have redefined INR suites as procedural ORs rather than “radiology rooms.” The workflow, sterility protocols, and perioperative support now mirror those in neurosurgical theaters. Crucially, neuroanesthesiologists are no longer peripheral participants but essential members of a high-functioning INR team.

Modern Radiation-Sparing Technologies and Ergonomic Advances

Modern radiation-sparing technologies and ergonomic advances have significantly enhanced safety in INR suites. The integration of ceiling-mounted lead shields, adjustable mobile barriers, and lead-impregnated glass panels offers superior protection without compromising workflow efficiency. Advanced dose-reduction algorithms, real-time dosimetry, and pulsed fluoroscopy techniques further minimize radiation exposure to both patients and staff. Additionally, ergonomic innovations, such as ceiling-suspended equipment, remote-controlled imaging consoles, and video-linked monitors, enable operators and neuroanesthesiologists to maintain optimal visualization and communication while reducing physical strain and time spent in high-radiation zones. Together, these developments align with the ALARA (as low as reasonably allowable) principle, promoting a safer and more sustainable interventional environment.[2] [3]

Anesthesia Practice in Transition

Anesthesia for INR procedures has matured into a distinct and demanding subspecialty, blending neurophysiological understanding with the dynamics of image-guided interventions. From elective aneurysm coiling and arteriovenous malformations embolization to emergency mechanical thrombectomy, the neuroanesthesiologist's role extends beyond maintaining anesthesia, encompassing cerebral perfusion optimization, precise hemodynamic control, and radiation safety management.[4]

Contemporary neuroanesthesia practice emphasizes real-time neurophysiologic monitoring, including near-infrared spectroscopy, processed electroencephalogram, and advanced cardiac output assessment.[4] This precision-driven approach allows individualized titration of anesthetic depth and cerebral oxygenation, contributing directly to procedural outcomes. The focus has shifted from “providing anesthesia in radiology” to “performing neuroanesthesia in a hybrid operative environment.”

Standardization and Safety: No Longer an Option, but a Norm

The evolution of the INR suite also reflects the growing emphasis on safety equivalence. Guidelines from the American Society of Anesthesiologists and the Society of Neurointerventional Surgery advocate that INR suites must meet the same safety, equipment, and staffing standards as ORs. This includes difficult airway carts, defibrillators, suction, emergency drugs, and reliable backup systems.[5]

In many tertiary centers, integration between INR suites and perioperative services is now seamless. Further, the evolving overlap between neurosurgery and neuroradiology has encouraged mutual skill acquisition. Involvement of neuroanesthesia teams at both interfaces ensures procedural consistency and seamless interdisciplinary coordination. Preprocedural assessment, intraprocedural neuroanesthetic management, and postprocedural care in dedicated neurocritical units form a continuous chain of care, comparable to that for open neurosurgical interventions. This structural and procedural alignment has markedly improved both safety and outcomes.

Training, Collaboration, and the Human Element

With procedural volumes rising and case complexity increasing, the need for formalized training in neurointerventional anesthesia is being increasingly recognized. Simulation-based learning, multidisciplinary case reviews, and shared protocols between neurosurgery, neuroradiology, and neuroanesthesia departments are strengthening interprofessional understanding.

The “remote location” mindset is being replaced by a culture of collaboration. Neuroanesthesiologists participate in designing of INR suites, case planning, understand the neuroradiologist's technical requirements, and contribute to procedural efficiency. This convergence of expertise represents the true essence of modern neuroanesthesia, a discipline that thrives on shared precision.

Bridging Global Disparities

While the transformation is evident in advanced centers, challenges persist in resource-limited settings. Some INR suites still lack fully equipped anesthesia stations, standardized monitoring, or trained personnel. Incorporating high-fidelity, simulation-based training can bridge experiential gaps, allowing neuroanesthesiologists and neuroradiologists to rehearse crisis management and complex procedural scenarios in a risk-free environment. Regular multidisciplinary simulation exercises further strengthen team coordination and preparedness for rare but critical events.[6] Addressing these gaps through structured training, resource allocation, and institutional prioritization is essential for equitable progress. Uniform adherence to safety and practice standards across all levels of care will ensure that every INR suite truly functions as an OR.

The New Normal

The INR is no longer an outpost on the hospital's periphery. It is, in every sense, another OR, technologically sophisticated, team-driven, and patient-focused. As hybrid OR models and endovascular innovations continue to evolve, the boundaries between surgical and interventional domains will further blur.

For the neuroanesthesiologist, adaptability, anticipation, and interprofessional collaboration will remain the cornerstones of safe and effective practice. What was once considered a remote location has now become a central stage, where technology, teamwork, and anesthesia excellence converge for the benefit of the patient.

Conflict of Interest

None declared.

• References

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• 2 Burman S, Das A, Mahajan C, Rath GP. Radiation concerns for the neuroanesthesiologists. J Neuroanaesth Crit Care 2021; 8: 3-11
• 3 Gravino G, Pullicino R, Chandran A, Puthuran M. Reducing radiation exposure in neurointervention through dedicated training on the biplane angiographic system. Clin Radiol 2022; 77 (09) 684-688
• 4 Khandelwal A, Jangra K, Katikar MD, Durga P, Maheswara Rao GSU. Choosing neuroanaesthesia as a career: marching towards new horizons. Indian J Anaesth 2021; 65 (01) 35-42
• 5 Meyers PM, Blackham KA, Abruzzo TA. et al; Society for NeuroInterventional Surgery. Society of NeuroInterventional Surgery Standards of Practice: general considerations. J Neurointerv Surg 2012; 4 (01) 11-15
• 6 Nakatani R, Patel K, Chowdhury T. Simulation in anesthesia for perioperative neuroscience: present and future. J Neurosurg Anesthesiol 2024; 36 (01) 4-10

Publication History

Article published online:
06 January 2026