Intraoperative electroencephalographic burst suppression: a narrative review and clinical framework for interpretation and management.

Burst suppression is common during general anaesthesia yet remains one of the most confusing electroencephalography (EEG) patterns for practicing anaesthetists. The literature alternately frames burst suppression as neuroprotective, harmful, or clinically neutral, leaving clinicians uncertain about how to interpret its appearance and respond in real time. This narrative review reframes burst suppression as a context-dependent biomarker of cortical energy balance rather than a uniformly protective or purely iatrogenic phenomenon. From a mechanistic perspective, physiologic burst suppression reflects activity-dependent neuronal downregulation, whereas pathologic burst suppression is increasingly linked to neuronal energy failure and blood-brain barrier disruption, raising concern that burst suppression might exacerbate perioperative neuronal stress instead of preventing it in susceptible brains. Despite the importance of burst suppression, anaesthetists often rely on processed EEG indices that can underestimate burst suppression or misclassify artifact. In contrast, direct visualisation of the raw EEG provides more reliable detection and interpretation of burst suppression. We synthesise the mechanisms, clinical associations, and vulnerable EEG phenotypes into a clinically actionable framework that links raw EEG interpretation to real-time anaesthetic and physiologic decision-making when burst suppression arises. This approach will help clinicians recognise and respond to burst suppression promptly to support brain health.