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Neurosurgical Anaesthesia Preevaluation

Presentation by : Dr Prabhakar Moderator : Dr B.N. Seth

Neuroanaesthesia provides its own set of unique challenges. Its aims are to maintain cerebral perfusion and oxygenation, whilst providing optimum operating conditions. Surgery is performed mainly for space occupying and vascular lesions. The pathology and any preexisting neurological deficit should be carefully assessed because they influence the conduct of anaesthesia and postoperative care.

A balanced anaesthetic technique that maintains haemodynamic stability prevents a harmful elevation in intracranial pressure (ICP) or decreases in cerebral perfusion pressure. To prevent raised ICP, maintenance of Paco2 between 4.0 and 4.5 kPa, prevention of hypertensive surges, and patient positioning to allow good venous drainage from the head are important.

Adequate cerebral perfusion and oxygenation are achieved by preventing hypotension and maintaining Pao2 above 13 kPa. Intraoperative fluid regimes should avoid dextrosecontaining solutions, which may exacerbate cerebral ischaemia and lead to cerebral oedema. The choice of crystalloids is contentious, with advocates for both ringers lactate and normal saline. There may be a need to acutely reduce ICP intraoperatively; this can be achieved temporarily with mannitol, furosemide or cautious hyperventilation.

Anaesthetic techniques should allow rapid emergence to allow postoperative neurological assessment. Some patients will require close monitoring. Pain relief is best achieved with a multimodal approach, consisting of local anaesthetic infiltration, regular paracetamol, opioid analgesic agents, and non-steroidal antiinflammatory agents if appropriate.

The range of elective neurosurgical procedures is large, but most involve the removal of space-occupying lesions. Although cranial and spinal vascular malformations are increasingly managed by interventional radiological techniques, some require open surgical operations. In contrast, emergency neurosurgery is usually performed for traumatic or spontaneous intracranial haemorrhage; however, it is sometimes indicated for the urgent treatment of space-occupying lesions that result in dangerous increases in ICP.

Tumours: Gliomas are the most common type (60%) of primary tumour found in the anterior cranial fossa, and most are astrocytomas. These range from the relatively benign pilocytic astrocytomas to the highly malignant glioblastoma multiformae. Meningiomas are also common. Secondary tumours are less common, with the lung and breast being the most frequent primary tumour sites. Tumours found in the posterior fossa include meningiomas, acoustic neuromas, haemangioblastomas, and arachnoid and epidermoid cysts. Renal, lung, breast and skin malignancy may metastasize to the cerebellum.

Vascular lesions: aneurysms arise more commonly in the anterior circulation (90%) And are usually found in the Anterior and Posterior communicating arteries. Rupture causes subarachnoid haemorrhage, Resulting in primary cerebral damage and the subsequent risk of ischaemic damage due to vasospasm in 3040% of cases. In addition, hydrocephalus may occur if blood enters the ventricular system and prevents cerebrospinal fluid (CSF) from draining. Arteriovenous malformations are more common in the supratentorial region (7090%).

Preoperative assessment of the neurosurgical patient

The operation to be performed, the extent and nature of the lesion to be operated on and its location can have an impact on anaesthetic technique and predict postoperative problems.

Supratentorial lesions are more likely to present with epileptic seizures, neurological deficits or raised ICP. These lesions may be very large and exert a significant mass effect in a relatively asymptomatic patient.

Posterior fossa lesions often present with lower cranial nerve symptoms and signs, including poor bulbar function with aspiration of stomach contents, cardiorespiratory problems or decreased level of consciousness. Small lesions in this region tend to have a devastating effect because of the limited compliance of this space and the important structures lying within it.

It is important to assess and document any neurological deficit preoperatively because there may be postoperative deterioration due to oedema or intraoperative damage. Thus, the patient with pre-existing swallowing or respiratory problems may be expected to have a greater deficit in the immediate postoperative period, with the possible need for mechanical ventilation. Plans should be made for this eventuality.

After documenting any pre-existing gross neurological deficit (including the Glasgow Coma Score), it is important to document any expressive or receptive speech deficit. These forms of speech are essential for an accurate postoperative assessment of the patient in recovery.

Examination of radiological images to determine the size and location of the lesion is important because it can provide information about the likelihood of raised ICP as well as the relationship of the lesion to other vital structures.

Preoperative medication may include anticonvulsant and corticosteroid therapy, and these must be continued periopera tively. A history of other medical conditions and functional status is important. Cardiac and respiratory disease should be treated preoperatively if possible as failure to do so may impact on the ability to optimize cerebral oxygenation and perfusion.

Aims of preoperative period

assess and document any pre-existing neurological deficit review available imaging for site and nature of lesion optimize pre-existing medical conditions continue anticonvulsant and corticosteroid medication identify and correct fluid and electrolyte imbalances

Thank you