Brain Tumors

Question 1

What is the significance of the neurologic signs and symptoms in a patient presenting for brain tumor related surgery?

Answer 1

HA, N/V, ataxia, syncope, visual changes, papilledema are all signs of intracranial hypertension that may require immediate treatment before anesthesia or special consideration during anesthesia.

Question 2

How does the brain compensate for an expanding mass lesion?

Answer 2

First by displacement of venous blood, then by displacement of CSF unless obstructive hydrocephalus exists and finally by displacement of the brain (i.e., herniation).

Question 3

How would you treat a symptomatic intracranial lesion?

Answer 3

The fastest way is to withdraw CSF if a ventriculostomy were in place. Barring (or in addition to) that, hyperventilation.

Question 4

Would you administer steroids prior to resection of brain tumor?

Answer 4

In general, yes. Vasogenic edema - the type that forms around tumor beds - is said to be responsive to glucocorticoid therapy.

Question 5

Would you place a patient with intracranial hypertension in the trendelenberg’s position to place a central line.

Answer 5

I would try to avoid doing so and would look at the femoral or a long-arm antecubital. But if necessary, I may briefly place the patient in trendelenberg’s.

Question 6

What is the difference between a supra- and infratentorial tumor?

Answer 6

For the anesthesiologist, important distinctions of infratentorial tumors include the greater likelihood of brainstem involvement, more frequent intraoperative hemodynamic instability from brainstem manipulation, and the need for sitting or prone positioning.

Of note: both supra and infratentorial tumors can cause hydrocephalus and increased ICP)

Question 7

Are you concerned about VAE with removal of a supratentorial tumor?

Answer 7

There’s always a concern with intracranial surgery due to exposure of the diploic vessels of the skull but I am less concerned if the supine position is used.

Question 8

What are the benefits of sitting position for intracranial surgery?

Answer 8

Less bleeding, improved surgical conditions, visualization of the head and face, access to the extremities, increased pulmonary compliance and lower airway pressures, preservation of FRC.

Question 9

What are your concerns about the sitting position for intracranial surgery?

Answer 9

1. Ischemia of the cervical spine can occur with neck flexion (a minimum distance of 2 finger breadths is recommended