Neurosurgery overview 2 Flashcards by Hannah Garrison

Head injuries can include

deceleration injuries: coup & contrecoup lesions
skull fracture
-linear: subdural or epidural hematomas
-basilar: CSF rhinorrhea, pneumocephalus, and cranial nerve palsies- Battle’s sign, Racoon/Panda eyes
depression: brain contusion

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Primary brain injuries include

biomechanical effect of forces on the brain at time of insult- no treatment, continues to evolve
contusion
concussion
laceration
hematoma

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Secondary brain injuries include

represents complicating processes related to primary injury- minutes, hours, days after primary injury
intracranial: hematoma, increased ICP, seizures, edema, vasospasm

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Prehospital management for head injury includes

starts at the accident site
CAB
stabilize prior to transport
GCS <9: level 1 trauma center

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Airway considerations for a head injury include

assume C-spine injury until otherwise proven radiographically
in-line stabilization
intubate early
full stomach precautions
awake FOI if difficult airway is anticipated
blind nasal intubation is CONTRAINDICATED in presence of basilar skull fracture

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Anesthetic considerations for head injury include

hypotension
bradycardia
maintain HCT >30%
seizure prophylaxis
DIC may be seen with severe head injuries; treat with platelets, FFP, cryoprecipitate as necessary
pituitary dysfunction: diabetes insipidus, SIADH
patient remains intubated
fluid management?

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Nonfunctioning pituitary tumors are

non-secretory

arise from growth of transformed cells of anterior pituitary
generally well tolerated until 90% of gland is non functional

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Functioning pituitary tumors are

secretory
-Cushing's disease (ACTH)
- acromegaly (GH)
prolactinomas (prolactin)
TSH adenomas (TSH)

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Intraoperative considerations for pituitary tumors include

transsphenoidal approach necessitates HOB elevated 10-20 degrees
oral RAE or reinforced ETT
avoid hyperventilation: reductions in ICP result in retraction of pituitary into the sella tursica, making surgical access difficult
potential for mass hemorrhage as the carotid arteries lie adjacent to the suprasellar area
mouth and throat pack: placed to absorb glottic blood and minimize postoperative vomiting of blood
avoid positive airway pressure upon extubation

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Preoperative evaluation for the patient with a pituitary tumor includes

visual field evaluation
s/s increased ICP
endocrine labs
electrolytes
steroids?

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Postoperative management considerations for the patient with a pituitary tumor include

DI is common and is usually self-limiting (resolves within 7-10 days)- treat with vasopressin or DDAVP
SIADH

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______ is the leading cause of intracranial hemorrhage

cerebral aneurysm

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Cerebral aneurysm is commonly located in

the anterior Circle of Willis

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With a cerebral aneurysm, the aneurysm fills with

blood and can rupture, spilling blood into the subarachnoid space, creating a SAH

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Cerebral aneurysms can lead to

permanent brain damage, disability, or death

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Unruptured cerebral aneurysm symptoms include

headache
unsteady gait
visual disturbances (loss, diplopia, photophobia)
facial numbness
pupil dilation
drooping eyelid
pain above or behind eye

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Ruptured cerebral aneurysm symptoms include

sudden, extremely severe HA
N/V
LOC, prolonged coma
focal neuro deficits
hydrocephalus
seizure
s/s of increased ICP

Describe considerations with vasospasm as it relates to ruptured cerebral aneurysm

causes ischemia or infarction
exact mechanism not known
accounts for 14% of M/M
digital subtraction angiography is the gold standard for diagnosis
use calcium channel blockers

With rebleeding with a rupture cerebral aneurysm

rebleeding follows initial SAH peaks seven days post incident
major threat during delayed surgery
accounts for 8% of M/M
antifibrinolytic therapy

Treatment for vasospasm includes

triple H therapy (goal is to treat ischemia with an increased CPP)
hypertension- SBP 160-200 mmHg
hemodilution- Hct 33% provides balance between O2 carrying capacity and viscosity
hypervolemia- aggressive IV infusion of colloids & crystalloids for CVP >10 mmHg or PCWP 12-20 mmHg

The rationale for vasospasm treatment includes

intended to increase CBF in brain areas that become ischemic due to intense vascular narrowing
normally, increased CBF would not result from increased BP, however with vasospasm the vascular bed becomes passive
therefore increasing CPP by increased volume or by systemic administration of vasoactive drugs may reverse symptoms of cerebral ischemia

Endovascular coiling considerations include

GETA with complete muscle paralysis
control CPP
minimal narcotic needs since minimally invasive
a-line preferred
minimal to no blood loss
heparin may be used for ACT 200-250
same postop concerns and with clipping

Endovascular aneurysm coiling involves

detachable coil inserted into aneurysm
standard arteriogram is performed to locate aneurysm
catheter is passed, often through femoral vessels, and coil is advanced

Advantages to endovascular aneurysm coiling includes

shorter stay, less anesthetic requirements, uncomplicated positioning, minimally invasive

Complications of endovascular aneurysm coiling include

aneurysm rupture/subarachnoid hemorrhage- rapid transport to OR for clipping is necessary vasospasm CVA incomplete coiling

A cerebral aneurysm presenting to the operating room is most commonly treated by

microsurgical clip ligation craniotomy approach; parent vessel giving rise to aneurysm is identified aneurysm neck is isolated, and a clip is placed across the neck, excluding it from circulation deep circulatory arrest may be necessary with giant aneurysms

Goals of anesthesia for cerebral aneurysm intraoperative management include

maintain optimum CPP decrease CPP rapidly if rupture occurs during surgical clipping maintain transmural pressure (MAP-ICP) decrease intracranial volume (blood and tissue); provide "slack" brain minimize CMRO2

Preinduction for the patient with cerebral aneurysm includes

``` limit sedation (hypercapnia) a-line 2 large bore PIVs T&C 2-4 units PRBCs remember HOB will be turned 90-180 degrees ```

Induction for the patient with cerebral aneurysm includes

smooth induction- difficult airway, full stomach | aggressive BP & HR control- narcotics, BB, deepen anesthesia

Describe maintenance for the patient with cerebral aneurysm

may use TIVA or anesthetic gases temporary occlusion of a cerebral artery maintain BP 15-20% below baseline to prevent vasospasm, decrease EBL and allow for better exposure & visualization employ methods for cerebral protection and to reduce ICP if necessary

Fluid management for the patient with cerebral aneurysm includes

run pt dry <10 mL/kg + UOP expand blood volume with colloids have PRBCs available no GLUCOSE CONTAINING SOLUTIONS

Describe control of BP for the patient with cerebral aneurysm

control of BP is critical to successful outcome of case surgeon may ask for temporary increase in MAP to 80-100 mmHg to provide for collateral flow if a feeder vessel is clamped for a short period to allow for clipping of aneurysm post clipping, MAP is usually kept at 80-100 mmHg

Likely times of aneurysm rupture include

dural incision excessive brain retraction aneurysm dissection during clipping or releasing of clip

Treatment of intraoperative aneurysm rupture includes

immediate, aggressive fluid resuscitation and replacement of blood loss propofol bolus for brain production, to decrease MAP, and decrease blood loss decrease MAP to 40-50 mmHg (clevidipine, labetalol, esmolol) surgeon may apply temporary clip on parent vessel to control bleeding, restore BP after clipping to improve collateral flow

Arteriovenous malformation considerations include

AVM is congenital abnormality that involves a direct connection from an artery to a vein "nidus" without a pressure modulating capillary bed -most common presentation intracranial hemorrhage*****

Treatment for AVM includes

intravascular embolization, surgical excision or radiation

Preoperative considerations for AVM include

same as with aneurysm | potential for significant blood loss is much higher (upwards of 3L)

Cranial nerve decompression treats

disorders of cranial nerves such as trigeminal neuralgia, hemifacial spasm, & glossopharyngeal neuralgia unilateral usually caused by compression of a vascular structure

Describe positioning for cranial nerve decompression

lateral, prone or supine

Describe monitoring for cranial nerve decompression

facial nerve, brainstem auditory evoked response, EMG

Describe anesthesia for cranial nerve decompression

TIVA brain relaxation PONV- multimodal

Spinal cord surgeries include

``` spinal cord stimulators- MAC intrathecal pumps- asleep in lateral scoliosis ALIF/TLIF ACDF ```