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Postoperative and Intensive Care Including Head Injury and Multisystem Sequelae

Critical care, including postoperative care, of the neurologically ill patient involves application of the general critical care principles of management with an added focus on prevention and treatment of secondary brain injury. Systemic and neurologic monitoring is typically required and the knowledge and implementation of emergent, timely intervention is paramount. Neurologic injuries, including traumatic brain injuries (TBI), may incur complications or sequelae , which result from…

Neurologic Disease and Anesthesia

Huntington’s disease Huntington’s disease is a universally fatal neurodegenerative disorder affecting the central nervous system that results from an autosomal dominant mutation in the huntingtin gene. It is characterized by movement and psychiatric disorders as well as dementia and occurs in 4–10 per 100,000 population. The genetic defect is due to a mutation in the Huntingtin gene (HTT) on the short arm of chromosome 4, resulting…

Neurosurgical Diseases and Trauma of the Spine and Spinal Cord: Anesthetic Considerations

The first descriptions of spine disorders were recorded nearly 4000 years ago in Egypt, when patients with such afflictions were left bedridden and death was considered unavoidable. One of the first extensive series on surgery of the spine was reported by Elsberg in 1925, in which the surgical treatment of spinal cord tumors was described. Since those early reports, spine surgery has made remarkable advancements, particularly…

Pediatric Neuroanesthesia and Critical Care

Neurosurgical lesions in infants and children have distinct manifestations and management issues. Age-related differences in the surgical lesions, anatomy and physiological responses to surgery and anesthesia underlie the clinically relevant differences between pediatric patients and their adult counterparts. Technical advances in neurosurgery and subspecialization in pediatric neurosurgery, anesthesiology and critical care have dramatically improved the outcome in pediatric patients with surgical lesions of the central nervous…

Perioperative Management of Adult Patients with Severe Head Injury

Epidemiology of head injury A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. TBI is one of the most serious, life-threatening conditions in trauma victims. It is a leading cause of disability and death in children and adults. An estimated 1.5 million people sustain TBIs every year in…

Stereotactic Surgery, Deep Brain Stimulation, Brain Biopsy, and Gene Therapies

Introduction Stereotactic surgery is a minimally invasive surgical intervention used for the treatment of functional disorders and in the diagnosis of intracranial lesions. The anesthesiologist plays a key role in the management of patients undergoing stereotactic surgery. The techniques of anesthesia will vary depending on the patient and the traditions and requirements of each institution performing these procedures. The purpose of this chapter is to familiarize…

Awake Craniotomy, Epilepsy, Minimally Invasive and Robotic Surgery

Awake craniotomy Awake craniotomy refers to surgery that is performed on the brain while the patient is in a state of awareness and that allows for cooperation with functional testing of the cortex. It is usually performed when eloquent cortical tissue—tissue that is involved in motor, visual, or language function—is located in close proximity to the area to be resected. This may include resection of tumor…

Occlusive Cerebrovascular Disease: Anesthetic Considerations

Carotid endarterectomy (CEA) was initially introduced in the early 1950s. An intuitively appealing procedure, the number of procedures rose steadily until 1985, when CEA was ranked the third most common operation performed in the United States. Its popularity shifted over the subsequent years as questions arose regarding its efficacy and the wide variation in reported morbidity and mortality associated with the procedure. However, several large, well-designed,…

Anesthetic Considerations for Surgical Resection of Brain Arteriovenous Malformations

Surgical management of brain arteriovenous malformations (AVMs) is one of the most challenging in neurosurgery and, despite the relative rarity of the disease, the subject of a disproportionally large fraction of the literature on surgical cerebrovascular disease. Perioperative and anesthetic management is optimal when the anesthesiologist has familiarity with the strategic goals of therapy and familiarity with AVM pathophysiology. This chapter will summarize these topics and…

Interventional Neuroradiology Anesthetic Management

Acknowledgments The authors would like to thank their colleague William Young MD who was responsible for much of the original text of this chapter. Interventional neuroradiology (INR) is the discipline that uses endovascular procedures to treat vascular conditions of the central nervous system. Other names for the field are neurointerventional surgery, surgical neuroangiography, and endovascular neurosurgery. INR is firmly established in the management of cerebrovascular disease,…

Anesthetic Management of Cerebral Aneurysm Surgery

Although it is simplistic, the statement by the British neurosurgeon J. Gillingham that “in the early years anesthetists spent their time pushing the brain out of the skull while in recent times they have been sucking it back in” underscores the importance and contribution of neuroanesthesia to the improved results of the surgical treatment of cerebral aneurysms. Other advances are the improvements in microsurgical instrumentation such…

Anesthetic Management for Posterior Fossa Surgery

The confines of the posterior fossa and the myriad of neuronal and vascular structures that traverse it create a challenge for the anesthesiologist, whose intraoperative goals are to facilitate surgical access, minimize nervous tissue trauma, and maintain respiratory and cardiovascular stability. This discussion focuses on the anesthetic considerations for posterior fossa surgery in adult patients; preoperative evaluation and preparation; general monitoring considerations; choice of surgical position;…

Supratentorial Masses: Anesthetic Considerations

Epidemiology According to the Central Brain Tumor Registry of the United States (CBTRUS) for the years 2007–2011, the incidence of primary brain and central nervous system (CNS) tumors is 21.42/100,000 per year. For children and adolescents 0–19 years of age, the incidence is 5.42 The incidence is 27.85/100,000 for adults (> 20 years). For the year 2015, the estimate is 68,470 primary brain and CNS new…

Care of the Acutely Unstable Patient

Most neurologic emergencies that require the intervention of an anesthesiologist are caused by head and spine trauma, leading to traumatic brain injury (TBI) and traumatic spinal cord injury (SCI). NonTBIs which can cause acute patient instability include nontraumatic intracranial hemorrhage, ruptured cerebral aneurysms or arteriovenous malformations, acute arterial hypertension, or chronic anticoagulation therapy; acute hydrocephalus; intracranial tumors with impending brain herniation; and ischemic stroke. Likewise, tumors…

Fluid Management During Craniotomy

Acknowledgment The authors wish to thank Dr. Michael M. Todd for the inspiration for Figs. 9.4, 9.5 , and 9.6 and Dr. Mark Zornow for permission to use Figs. 9.7 A and B . The intraoperative fluid management of neurosurgical patients presents special challenges for the anesthesiologist. Neurosurgical patients often experience rapid changes in intravascular volume caused by hemorrhage, the administration of potent diuretics, or the…

Multi-modality Neurologic Monitoring

Introduction Monitoring systemic and central nervous system physiology is fundamental to the perioperative and critical care management of patients with neurologic disease. The clinical neurologic examination remains the cornerstone of neuromonitoring. In addition, several techniques are available for global or regional monitoring of cerebral hemodynamics, oxygenation, metabolism, and electrophysiology. The pathophysiology of acute brain injury (ABI) is complex, and involves changes in cerebral blood flow (CBF),…

Transcranial Doppler Ultrasonography in Anesthesia and Neurosurgery

Introduced in 1982 by Aaslid and colleagues, transcranial Doppler (TCD) ultrasonography, sometimes termed a “stethoscope for brain,” has become one of the most useful methods of noninvasive examination of cerebral circulation. Provided that the limitations of this technology are recognized, information about cerebral hemodynamics can be obtained that can be used in the perioperative and intensive care of neurologically injured patients (those with head injury, subarachnoid…

Evoked Potentials

The use of evoked electrophysiological responses during surgery on the nervous system has become a common tool in the operating room. It is used to map the location of structures and to monitor the functional status of neural pathways to enhance intraoperative decision making and improve outcome. These techniques can be used during altered states of consciousness such as during anesthesia or coma. A wide variety…

Modern Neuroradiology Relevant to Anesthetic and Perioperative Management

Introduction Imaging, with its diverse array of modalities, forms an integral part of decision making in patients with neurological disorders. Diagnostic, prognostic, and pathophysiological information is provided in broadly two forms, anatomical (structural) and functional (physiologic). Anatomic or structural imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) provides information about normal anatomic structures of skull, meninges, brain parenchyma, vascular supply, cerebrospinal (CSF)…

Effects of Anesthetic Agents and Other Drugs on Cerebral Blood Flow, Metabolism, and Intracranial Pressure

Introduction The major goals in neurosurgical anesthesia are to provide adequate tissue perfusion to the brain (and spinal cord) so that the regional metabolic demand is met and to provide adequate surgical conditions (a “relaxed brain”). If anesthetic drugs or anesthetic techniques are improperly used, they can worsen the existing intracranial pathologic condition and may produce new damage. Some anesthetics or anesthetic techniques may help protect…