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AS - N934 Advanced Principles II > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

Preop Considerations

A 
Anticonvulsants - dose, frequency, last taken
Continue DOS + supplementation
NO sedation
Antibiotics ordered/mixed
Diuretics impact on electrolytes
Stress dose steroids
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2
Q

Intraoperative Nerve Monitoring

A

Prevent brain, spinal cord, or nerve injury

MEP
SSEP
EMG

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3
Q

MEPs

A

Motor evoked potentials
Used in surgeries where motor track at risk
Direct & scalp electrodes
More sensitive to ischemia than SSEPs by 15min
Difficult to obtain d/t pre-existing or anesthetic conditions
NO paralytic

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4
Q

SSEPs

A

Somatosensory evoked potentials
Most commonly monitored
Stimulation peripheral sensory nerve
Mapping in spinal cord and sensory cortex
Ischemia detection in cortical tissue
Reduces risk of spinal cord/brainstem mechanical or ischemic insults

Paralytic okay sometimes
Motor monitoring less specific, does not measure motor deficits

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5
Q

EMGs

A

Electromyography
Reduces muscle electrical activity using needle pains
Continuous recording
Triggered responses
Used to detect nerve irritation, nerve mapping, assess nerve function, and monitor cranial nerves

Spinal surgeries to detect when screws are misplaced - passively monitors nerves

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6
Q

Stereotactic NSGY

A 
Brain lab/mapping
Fudicials affixed to patient scalp & forehead
Interferes w/ Pox
Smaller biopsies local or MAC
Large resections require general
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7
Q

Craniotomy Medications

A 
Induction - Fentanyl, Propofol, & Rocuronium
Propofol 40-100mcg/kg/min
Remifentanil 0.2mcg/kg/min
Phenylephrine 0.2mcg/kg/min
Decadron 10mg
Mannitol 50-100g (0.25-0.5g/kg)
Keppra 1g or Vimpat
Vancomycin or Ancef
Tylenol 30min prior wake-up
Hydromorphone or Fentanyl
Caffeine - adenosine receptor antagonist
Physostigmine - anticholinesterase
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8
Q

Intracranial Mass Lesion

Clinical Presentation

A 
Headache
Seizures
Focal neurological deficits
Sensory loss
Cognitive dysfunction
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9
Q

Supratentorial Mass Lesions

A 
Seizures, hemiplegia, aphasia
Frontal
Parietal
Temporal
Occipital
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10
Q

Supratentorial Mass Lesion

Frontal

A

Personality changes, increased risk-taking, difficulty speaking (damage to Broca’s area)

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11
Q

Supratentorial Mass Lesion

Parietal

A

Sensory problems

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12
Q

Supratentorial Mass Lesion

Temporal

A

Problems w/ memory, speech, perception, & language skills

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13
Q

Supratentorial Mass Lesion

Occipital

A

Difficulty recognizing objects, an inability to identify colors, & trouble recognizing words

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14
Q

Infratentorial/Posterior Fossa Mass Lesions

A

Cerebellar dysfunction

Brainstem compression

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15
Q

Infratentorial/Posterior Fossa Mass Lesion

Cerebellar Dysfunction

A

Ataxia/poor balance, nystagmus, dysarthria, cannot perform rapid alternating movements, loss muscle coordination

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16
Q

Infratentorial/Posterior Fossa Mass Lesion

Brainstem Compression

A

Cranial nerve palsy, altered LOC, abnormal respiration

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17
Q

Primary Tumors

A

Glial cells - astrocytoma, oligodendroglioma, glioblastoma
Ependymal cells - ependymoma
Supporting tissues - meningioma, schwannoma, choroidal papilloma

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18
Q

Intracranial Mass Lesions

Anesthetic Considerations

A

Consider tumor location, growth rate, & size (slow growing tumors are often asymptomatic) EBL estimate
ICP elevation
Goals = control & maintain ICP
Anticipate sympathetic response w/ Mayfield head pins placement
Rapid emergence to allow neuro assessment

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19
Q

Intracranial Mass Lesions

Preop

A

Determine ICP
ICU patients w/ EVD
LOC & neuro deficits
Review PMH & general health status
Anticonvulsants & diuretics
Recent labs - glucose, drug levels, electrolytes, Hgb/Hct
Radiological studies - edema, midline shift, or ventricular size
Avoid benzodiazepines/narcotics
Continue corticosteroids & anticonvulsants

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20
Q

Intracranial Mass Lesions

Intraop

A 
Hyperventilation maintain ETCO2 30mmHg
Avoid excessive PEEP < 10
Glucose-free crystalloids or colloids
Replace blood loss w/ blood or colloids
EVD or lumbar drain to control ICP
↑CBF
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21
Q

Intracranial Mass Lesions

Monitors

A 
A-line
Foley
IV access (central line?)
PNS - do NOT monitor on hemiplegic side
Ventriculostomy to monitor ICP (zero at auditory meatus)
Consider IONM
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22
Q

Intracranial Mass Lesions

Positioning

A 
Rotate HOB 90-180° 
Elevate 10-15° 
Supine, lateral, prone, or sitting
Able to access all equipment
IV tubing extension
PNS on lower extremities
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23
Q

Intracranial Mass Lesions

Emergence

A

Slow & controlled
Prevent straining or bucking ↑ICP or worsen cerebral edema
Aggressive BP management systolic < 140-160
Hemorrhage or stroke risk - Clevidipine, Labetalol, and/or Esmolol
Neuro exam immediately after extubation
Do not administer any opioids until cleared by surgical team to prevent any neuro assessment impairment

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24
Q

Intracranial Mass Lesions

Postop

A

Admit to ICU for observation - seizures, neuro deficits, or ↑ICP
Transport w/ HOB elevated 30°
Manage HTN
Transport on O2
Minimal pain post-craniotomy (headache most common)

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25
Q

Awake vs. Asleep Craniotomy

A

Awake-awake
Asleep-awake
Asleep TIVA w/ IONM or GETA

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26
Q

Considerations for awake craniotomy patients:

A

Used for epilepsy surgery & tumor resection in frontal & temporal lobes where speech & motor need to be assessed intraop
Airway
Cooperation
Secure A-line & PIVs

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27
Q

Awake-Awake Craniotomy

A

No infusions until closing
Propofol bolus for pins
Hand-holding

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28
Q

Asleep-Awake Craniotomy

A

Start under GA w/ LMA or ETT
Wake patient up once tumor exposed
Propofol 40mcg/kg/min
Remifentanil 0.2-0.4mcg/kg/min

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29
Q

Posterior Fossa Lesions

A

Cerebellum
Brainstem
Cranial nerves I-XII
Venous sinuses

30
Q

Cushing’s Triad

A

↑ICP
Hypertension
Bradycardia
Irregular respirations

Trigeminal nerve stimulation

31
Q

Bradycardia & Hypotension

A

Glossopharyngeal or Vagus nerve stimulation

32
Q

Brainstem Injuries

A

Cushing’s triad
Bradycardia & hypotension
Damage to respiratory center → mechanical ventilation postop
Tumors around glossopharyngeal & Vagus nerves impair gag reflex & ↑aspiration risk
Cranial nerves IX, X, & XI control pharynx & larynx

33
Q

Posterior Fossa Lesions

Anesthetic Considerations

A

Same periop considerations as intracranial lesions

Modified lateral or prone most common

34
Q

Sitting Position

Advantages

A

Back elevated 60° & legs elevated w/ knees flexed
Head fixed in 3-point holder w/ neck flexed
Arms remain at sides w/ hands resting on lap
Improved surgical exposure & more anatomically correct
Less retraction & tissue damage
↓bleeding
Less cranial nerve damage
Improves lesion resection
Access to airway, chest, & extremities
Enhanced CSF & venous drainage

35
Q

Sitting Position

Disadvantages

A

Postural hypotension, arrhythmias, & venous pooling
Pneumocephalus
Nerve injuries - ulnar compression, sciatic nerve stretch, lateral peroneal compression, brachial plexus stretch, cervical spine compression

36
Q

Pneumocephalus

A

Open dura → CSF leak → air enters
After dural closure, air acts as mass lesion as CSF reaccumulates
Usually resolves spontaneously
Burr holes to relieve tension pneumocephalus
S/S include delayed awakening, headache, lethargy, confusion
Discontinue N2O before dural closure

37
Q

VAE

A 
Venous air embolism
↓ETCO2 ↑PaCO2 
↓SpO2
Spontaneous ventilation
Mill-wheel murmur* (late sign)
ET nitrogen detection
Hypotension
Dysrhythmias
38
Q

VAE Monitoring

A 
TEE detects 0.25mL air (most sensitive)
Precordial doppler
↓ETCO2 w/ 15-25mL air
↑PAP w/ 20-25mL air
CVP
PaCO2
MAP
39
Q

VAE Treatment

A 
100% FiO2
Discontinue N2O
Notify surgeon to flood field or pack wound
Call for help!
Aspirate CVP line 30-60mL
Volume load - fluids wide open
Inotropes/vasopressin
Jugular vein compression
PEEP
Position L lateral decubitus w/ head down (Tredelenburg)
CPR/EMCO
40
Q

Chiari Malformation

A

Cerebellum protrudes through foramen magnum - compresses brainstem & cervical spinal cord
Types I-IV
Syringomyelia (fluid-filled cyst present in spinal cord)

41
Q

Chiari Malformation

Anesthetic Considerations

A

Prone or sitting position
↑EBL d/t large venous sinuses
Vital sign instability d/t brainstem manipulation
Postop pain management

42
Q

1° Head Injury

A

Contusion
Concussion
Laceration
Hematoma

43
Q

2° Head Injury

A 
Hematoma
↑ICP
Seizures
Edema
Vasopressin
44
Q

Skull Fractures Ypes

A

Linear - subdural or epidural hematomas
Basilar - CSF rhinorrhea, raccoon eyes, battle’s sign, pneumocephalus, & cranial nerve palsies
Depressed - brain contusion

45
Q

Head Injury

Airway Management

A 
C-spine precautions until cleared
Manual inline stabilization
Early intubation
Awake fiberoptic intubation
Full stomach precautions
Blind nasal intubation contraindicated when basilar skull fracture present
46
Q

Head Injury

Anesthetic Considerations

A

Seizure prophylaxis
Maintain Hct > 30%
Treat DIC w/ platelets, FFP, & cryo
Pituitary dysfunction

47
Q

Pituitary Tumors

Non-Functioning

A

Non-secretory

  • Arise from growth of transformed anterior pituitary cells
  • Generally well tolerated until 90% gland non-functional
48
Q

Pituitary Tumors

Functioning

A

Secretory

  • Cushing’s disease ACTH
  • Acromegaly (growth hormone)
  • Prolactinomas (Prolactin)
  • TSH adenomas
49
Q

Pituitary Tumors

Preop

A

Visual field evaluation
↑ICP
Endocrine & electrolyte labs
Steroids

50
Q

Pituitary Tumors

Intraop

A 
Transsphenoid approach
HOB elevated 10-20° 
Oral RAE or reinforced ETT
Avoid hyperventilation ↓ICP impedes surgical access
Carotid arteries adjacent to suprasellar area
Document throat pack in/out
Place OG tube
Avoid positive airway pressure
51
Q

Pituitary Tumors

Postop

A

DI common after pituitary surgery & usually resolves w/in 7-10 days
Treatment: Vasopressin or Desmopressin (DDAVP)
SIADH

52
Q

Cerebral Aneurysm

A

Leading cause non-traumatic intracranial hemorrhage
Commonly located in anterior Circle of Willis
→ permanent brain damage, disability, or DEATH

53
Q

Cerebral Aneurysm S/S

Unruptured

A 
Headache
Unsteady gait
Visual disturbances - loss, diplopia, photophobia
Facial numbness
Pupil dilation
Droopy eyelid
Pain above or behind eye
54
Q

Cerebral Aneurysm S/S

Ruptured

A 
Sudden, extremely severe headache
N/V
LOC
Prolonged coma
Focal neuro deficits
Hydrocephalus
Seizure
↑ICP
55
Q

Hess & Hunt

A

Aneurysmal subarachnoid hemorrhage grading system
Grade 0-2 = low mortality rate
3-5 ↑mortality rates

56
Q

Ruptured Cerebral Aneurysm

Vasospasm

A 
Ischemia or infarction
Exact mechanism unknown
14% morbidity & mortality
Not detectable until 72hrs after subarachnoid hemorrhage
Calcium channel blockers
57
Q

Rupture Cerebral Aneurysm

Re-Bleeding

A

Peaks 7 days post incident
8% morbidity & mortality
Antifibrinolytic therapy

58
Q

Vasospasm Treatment

A

Triple H

  • HTN goal systolic 160-200 (MAP 80-100)
  • Hemodilution ideal Hct 33% balance b/w O2 carrying capacity & viscosity
  • Hypervolemia aggressive IV crystalloid and colloid infusion (CVP > 10mmHg or PCWP 12-20)
59
Q

IR Endovascular Aneurysm Coiling

Anesthetic Considerations

A 
GETA w/ complete muscle paralysis
Control CPP (lower BP during surgery)
Minimal narcotic needs - minimally invasive 
A-line preferred
Minimal to no blood loss
Heparin ACT 200-250

Coil inserted via femoral vessels into aneurysm
Standard angiogram to locate aneurysm

60
Q

Coiling Complications

A 
Aneurysm rupture
Subarachnoid hemorrhage
Vasospasm
CVA
Incomplete coiling
61
Q

Cerebral Aneurysm

Surgical Treatment

A

Microsurgical clip ligation
Craniotomy approach
Large aneurysms > 2.5cm may require deep circulatory arrest

62
Q

Cerebral Aneurysm

Pre-Induction

A 
Limit sedation (hypercapnia)
Monitors:
- A-line 
- PIV x2
Type & cross 2-4 units PRBCs available
63
Q

Cerebral Aneurysm

Induction

A

Smooth induction
Consider difficult airway or full stomach
Aggressive BP & HR control w/ narcotics, β blockers, deepen anesthetic

64
Q

Cerebral Aneurysm

Intraop & Maintenance

A 
Rotate HOB 90-180° 
TIVA or anesthetic gases
Temporary cerebral artery occlusion
Maintain BP 15-20% below baseline to prevent vasospasm, ↓EBL, & allows improved exposure & visualization
Cerebral protection methods to ↓ICP 
Optimum CPP
↓CPP occurs rapidly during surgery when aneurysm ruptures
Maintain transmural pressure MAP - ICP
Decrease intracranial volume (blood & tissue) to provide "slack"
Minimize CMRO2 (oxygen demand)
Fluids < 10mL/kg + UOP
Expand volume w/ colloids
NO GLUCOSE CONTAINING SOLUTIONS
65
Q

Cerebral Aneurysm

BP Management

A

↓BP to prevent aneurysm rupture risk
Temporarily ↑MAP per surgeon request to provide collateral flow to feeder vessel clamped to allow clipping
Post-clipping maintain MAP 80-100mmHg

66
Q

When is an aneurysm most likely to rupture intraoperatively?

A

Dural incision
Excessive brain retraction
Aneurysm dissection
During clipping or releasing the clip

67
Q

Aneurysm Rupture Treatment

A

Immediate, aggressive fluid resuscitation & replace blood loss
Propofol bolus to ↓MAP & blood loss
Surgeon may apply temporary clip on parent vessel to control bleeding
Restore BP after clipping to improve collateral flow

68
Q

AVM

A

Arteriovenous malformation
Congenital abnormality that involves direct connection from an artery to vein “nidus” w/o pressure modulating capillaries
Most common presentation = intracranial hemorrhage
Same preop considerations as aneurysm
Significant blood loss potential up to 3L

69
Q

AVM Treatment

A

Intravascular embolization
Surgical excision
Radiation

70
Q

Cranial Nerve Decompression

A

Treat cranial nerve disorders - trigeminal neuralgia, hemifacial spasm, & glossopharyngeal neuralgia
Unilateral
Usually caused by vascular structure compression

71
Q

Cranial Nerve Decompression

Anesthetic Considerations

A 
Position lateral, prone, or supine
TIVA or brain relaxation
Facial nerve or EMG monitoring
Brainstem auditory evoked response
Multimodal PONV
72
Q

Spinal Cord Surgeries

A 
Spinal cord stimulators
Intrathecal pumps
Scoliosis
Anterior/transforaminal lumbar interbody fusion
Anterior cervical discectomy & fusion

AS - N934 Advanced Principles II (18 decks)

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