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Bioscience II Neuro > Intracranial Neurosurgery ppt 2 > Flashcards

Intracranial Neurosurgery ppt 2 Flashcards

1
Q

Intracranial aneurysms are defined as:

A

focal protrusions arising from weakened arterial walls usually at major bifurcations of the arteries at the base of the brain

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2
Q

Intracranial aneurysms are most commonly treated by:

A

endovascular coiling (>50%) or microsurgical clip ligation.

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3
Q

Most important surgical considerations for intracranial aneurysms:

A

clinical presentation, aneurysm size and location, patient age, neurologic status, and medical comorbidities

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4
Q

Most common intracranial aneurysm clinical presentation:

A

Aneurysm rupture

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5
Q

System used for prognostic clinical outcome

A

Hunt Hess grading system (1 asymptomatic, 5 deep coma)

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6
Q

anterior intracranial aneurysms position:

A

supine, mayfield headrest, turned 30-45* to side away from aneurysm

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7
Q

posterior intracranial aneurysms position:

A

supine or lateral with mayfield headrest

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8
Q

EBL intracranial aneurysm:

A

250-1000 ml

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9
Q

Intracranial aneurysms considerations:

A

arterial clipping, mild hypothermia, intro angiography with access to femoral artery, electrophysiologic monitoring, brain relaxation, lumbar subarachnoid CSF drainage, decadron IV

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10
Q

intracranial aneurysm prep anesthesia considerations:

A
  • 23% have neurogenic pulmonary edema
  • PVCs, T wave inversion and ST depression are common
  • Decreased Magnesium
  • May present with increased ICP or cerebral vasospasm
  • Digital subtraction angiography is gold standard for detection
  • Pt should be Euvolemic
  • hyponatremia from SIADH
  • aline for tight BP control
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11
Q

increase in BP in intracranial aneurysm pt preop

A

rebleed, permanent neurologic deficits, or death

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12
Q

substantial decrease in BP in intracranial aneurysm prep:

A

cerebral ischemia or infarction

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13
Q

intracranial aneurysms induction:

A
  • Smooth induction
  • Decrease cerebral blood volume by inducing cerebral vasoconstriction
  • Pts on nimodine may require pressors ie phenylephrine during and after induction
  • Patients may benefit from moderate hyperventilation during induction
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14
Q

intracranial aneurysms maintenance:

A
  • Iso or Sevo ½ Mac if EP monitoring
  • Avoid N2O
  • Propofol gtt: ↓ cerebral blood volume, ↓ cerebral metabolism, and ↓ CMRO2
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15
Q

↓ PaCO2 leads to:

A

↓ cerebral vascular volume (better surgical access) + ↑ CBF to ischemic areas (“Robin Hood” effect) + ↓ anesthetic requirements + ↑ lactic acid buffering.

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16
Q

Mannitol/furosemide leads to:

A

↓ K+; monitor level and replace as necessary.

17
Q

If mannitol is administered too rapidly, what could occur?

A

↓ BP may occur, 2° peripheral vasodilation.

18
Q

Mild hypothermia (33–34°C) is used to:

A

to ↓ CMRO2and to ↓ susceptibility to ischemic injury during temporary clip application.

19
Q

At 30*C, CMRO2 decreases

A

~ 30%

20
Q

BP control: During aneurysm exposure

A

decrease MAP to ~80% baseline

21
Q

BP control: During temporary clipping

A

increase MAP to ~120% of baseline

22
Q

BP control: postclipping

A

MAP typically 70-90 mmHg

23
Q

BP control: if aneurysm ruptures

A

decrease MAP to 40–50 mm Hg

consider carotid compression

24
Q

Deep hypothermia and CPBP is used only with what aneurysms?

A

> 2.5 cm in diameter

25
Q

intracranial hemorrhage emergence:

A

Hunt Hess 4 and 5- remain intubated and sedated post-op
Hunt Hess 1-3- titrate BB and vasodilators as needed
smooth emergence, no cough
HOB elevated 30* on transport

26
Q

Intra-op Concerns for AVM

A

Fiberoptic awake intubation if patient arrives with stereotactic frame.
Stereotactic frame is placed in pre-op awake with local anesthesia then patient goes to CT or MRI.
VAE Central line
Aline
Mild hypothermia
Brain Relaxation (decrease PaCO2, mannitol/furosemide)

27
Q

Emergence for AVM

A

Increases in BP treat with B-Blockers or vasodilators
Close regulation of BP is key
Suppress cough with lidocaine IV
HOB elevated 20-30 degrees
BP should be maintained 10% below baseline

28
Q

Craniotomy for Tumor Pre-Op Considerations

A

Neurogenic pulmonary edema

Increase ICP leading to Cushings Triad (HTN, Resp Depression & Bradycardia)

29
Q

Anesthesia for Craniotomy

A

Stereotactic frame are placed on the patient’s head
The patient is taken to CT/MR for determination of the exact tumor site.
Surgeons may visualize certain tumors by utilizing iv fluorescent dyes (e.g., fluorescein)
When used in conjunction with a specialized operating microscope, these compounds allow greater definition of the tumor and its boundaries with normal brain tissue.
Anaphylactic reactions can occur with the use of these agents.

30
Q

Stereotactic Surgery Considerations

A

Risk of air embolus
Brain stem manipulation causes BP and pulse instability
Dural patch is used to expand dura at foramen magnum

31
Q

Craniotomy Intraoperative concerns

A 
Awake Fiberoptic Intubation if stereotactic frame present
Minimize Increases in ICP and MAP
Pre-cordial doppler
BAER, SSEP, MEP
CVP
32
Q

Emergence Craniotomy

A

Increases in BP treat with B-Blockers or vasodilators
Close regulation of BP is key
Suppress cough with lidocaine IV
HOB elevated 20-30 degrees
Surgeon may request transient increase in MAP 90-100mmHg to test hemostasis after the tumor is resected

33
Q

Awake Craniotomy

A

May be used for epilepsy
Tumors involving motor or speech
Done under MAC or (asleep- awake- asleep) technique
LMA or ET

34
Q

Awake Craniotomy- Premapping

A 
Mannitol slow IV infusion
Midazolam & Dexmedetomidine
Propofol gtt
Scalp block
Aline
Foley
Mayfield headrest under Local anesthesia
35
Q

ventricular shunt- diagnosis:

A

hydrocephalus

36
Q

2 approaches to ventricular shunt:

A

Ventriculoperitoneal or Ventriculoatrial

37
Q

Ventricular shunt pre-op:

A

Cushings triad
Headache with ICP > 15mmHg
No pre-op med required

38
Q

Ventricular shunt induction:

A

minimize ICP

maintain normovolemia

39
Q

Ventricular shunt maintenance:

A

PeCO2 35-40 mmHg
Hyperventilation and hypocarbia make cannulation of vessel difficult
Maintain normotension: Catheter tunneling is stimulating

Bioscience II Neuro (3 decks)

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