Anesthesia for Neurosurgery in Infants and Children

Barbara Van de Wiele, M.D. Los Angeles, California

R3

Introduction
Age related differences and procedure related issues different from adult neuroanesthesia

Neuroanatomy Neurophysiology Neuropathophysiology Review anesthesia considerations for selected neurosurgical procedures

Neuroanatomy
Size : Doubles in the first year Weight : 80% of adult weight by the age of two, larger
percent of TBW(10% vs 2%)

Skull suture : not fused Fontanelles

Ant. fontanelles - 2~3month Post. fontanelle 7~19month.

Open fontanelle
Noninvasive assessment of ICP US imaging of intracranial structures Untreated progressive hydrocephalus Fusion of the skull sutures is not complete until adolescence

Spinal Cord
Anatomical position

Infants L3 Adult L1-2 disk

Tethered cord
Spinal cord migration hindered (progressive neurologic deficits)
Middline dimple over spine above the gluteal fold (asymptomatic tethered cord) -Increased risk of neurologic injury with regional anesthesia or diagnositic lumbar puncture

Cerebral Blood Flow and Metabolism

Global cerebral blood flow

neonates < adults < children

neonates < adults < children lower absolute values and over a narrow range Baseline MAP
closer to the lower limit of autoregulation in infants and young children than in older children

Brain oxygen and glucose utilization Autoregulation of CBF in neonate

Pressure Volume Relationship

ICP

Infants : 0~6mmHg Toddlers : 6~11mmHg Adolescents : 13~15mmHg

Slow inc. in intracranium vol. : compensated by expansion of the cranium. Rapid inc. are not well tolerated. Proportional to the volume of the neuroaxis
: ICP rises more rapidly in children than adults

Infants and children

Pressure Volume relationship

Symptoms of Intracranial Hypertension

Symptom of Increased ICP
Neonate and infants

Quite nonspecific : increased irritability and poor feeding

Headache on awakening and vomiting

Children All age group

Lethargy, decreased consciousness, loss of upward gaze and Cushings triad

Neuropathology
Brain tumor

Second m/c malignancy of childhood after leukemia Children supra and infratentorial tumors
Involve midline structures

Pediatric brain tumor

Neuropharmacology
Effects of Inhalation anesthetics and IV anesthetics on CBF and CBV
Similar in children and adults Sevoflurane less inc. in CBV than halothane Isoflurane, sevoflurane, desflurane Quantitatively similar effect on CBF Propofol Dec. CBF velocity in excess of change in MAP consistent CO2 reactivity plateaus at 30mmHg Epileptiform EEG changes Described in children during sevoflurane anesthesia.(>1.5MAC)

Sedation and Induction

Risk and benefic of sedation and induction

Case by case basis

Minimal alteration in vetilation in children Ideally accomplished using an IV hypnotic agent, nondepolarizing m. relaxant and adjuvant therapy prior to laryngoscopy.

Midazolam premedication Induction of the child c intracranial HTN

Fluid Management
Preop dehydration is common

Isotonic crystalloid
Choice for intraop. maintenance and hydration Exacerbate brain edema Increase the risk of neurologic injury Beneficial in resuscitation after traumatic head injury in children

Hypotonic fluid (Ringers lactate 273mOsm/L) Glucose containing fluid Hypertonic saline

Diuretics
Mannitol

Rapid mannitol administration Hypotension in children Recommend rate 0.5gms/kg/20min

Adjunct to mannitol Decrease CSF production and improve cellular water transport

Furosemide (0.3~0.4mg/kg)

Position and Venous Air Embolism

Risk of venous air embolism(VAE)
Supine position
Infants > Adults Similar in children and adults

Sitting position

Risk of hypotension with detectable VAE

Greater in children Increase cerebral venous pressure in children positioned with the head elevated and may assist locating the source of air entrainment

Bilat. Jugular venous pressure

Ventricular Shunts and Related Procedures

Hydrocephalus
Surgical treatment
Ventriculoperitoneal, ventriculatrial, ventriculopleural shunts and endoscopic third ventriculostomy

Acute shunt malfunction in children

Intracranial hypertension and neurologic status deteriorate rapidly.
CSF drainage abrupt decrease in BP Stimulation of the floor of the third ventriculotomy high incidence of bradycardia Arrythmia and tachycardia and rare severe Cx.

Complication of procedure

Craniotomy for Surgical Treatment of Intracranial Vascular disease

Craniotomy for AVM(arteriovenous malformation)
Infant c large cerebral AVM CHF in neonatal period

Craniotomy for aneurysm very rare procedure

Located in the post. circulation

Selective Dorsal Rhizotomy

Reduce spasticity and improve function with spastic cerebral palsy Anesthetic consideration
Cerebral palsy, testing for selection of n. roots, postop. pain , low birth weight and IVH GER, poor laryngeal and pharyngeal reflexes, and seizure disorder Laminectomy, division of post. rootlets (M. relaxant cannot be used) Inhalation anesthesia is superior to N2O-propofol
M. spasm during stimulation of n. rootlets

Procedure

Elevation of body temperature Significant postop. Pain

Intrathecal and epidural analgesics

Encephalocele Repair
Herniation of cranial contents

M/C located in the occipital region Undertaken in the early neonatal period High incidence of anomalies of other organ system Avoiding trauma to the lesion during airway management may be challenging. Substantial blood loss from vascular structures within occipital encephaloceles.

Anesthetic consideration

Myelomeningocele Repair
Protrusion of meninges and dysplastic neural tissue through midline bony defects of the spine

M/C lumbosacral region Neurologic function is impaired distal to the lesion

Early neonatal period

Repair Features
Congenital heart defect(ASD) 1/3 Short trachea 1/3 Arnold Chiari malformation present in most pt. with myelomeningocele
Intraop. N. stimulation
Necessary to reverse neuromuscular blockade. Repair of large lesions

Anesthetic consideration
Significant fluid requirements and transfusion

Surgical Treatment of Craniosynostosis

Definition
Premature fusion of one or more cranial sutures sagittal suture (m/c) Skull growth is restricted and deformity ensues Assoc. with difficult airway management

Repair

In the first six months (Improves skull geometry and allows for normal brain growth ) Strip craniectomy, calvarial reconstruction and endoscopic craniectomy

Feature of craniosynostosis
Intracranial hypertension 23% Elevated ICP more common in multiple suture
synostosis

Surgical Treatment of Craniosynostosis

Anesthetic consideration
Major blood loss Multiple suture craniosynostosis repair and calvarial reconstructive procedures
Single strip craniectomy 25% Metopic craniosynostosis 42% Bicoronal synostosis 65% Multiple suture 85% In excess of 100cc/kg asso. With coagulopathy Blood loss and incidence VAE reduced

Percentage of estimated blood vol.

Endoscopic precedure

Encephalodurosynangiosis
Moya Moya
Progressive occlusive cerebrovascular Transient or permanent neurologic deficits d/t inadequate cerebral blood flow Transposing the temporal artery to the surface of the brain via a small craniotomy
Stimulate formation of collateral vessels.

Surgical procedure

Goal of anesthesia
Minimize neurologic morbidity
By avoiding agitation, hyperventilation,increase in cerebral metabolism assoc. with painful stimuli, By maintaining normacarbia, maintaing systemic blood pr.

Encephalodurosynangiosis
Postop period

Risk for cerebral ischemia and stroke (As collateral circulation develops) Avoiding dehydration, fever, hyperventilation and agitation d/t pain
Excellent in most children after cranial revascularization

Long term prognosis

Neurosurgical Treatment of Pediatric Epilepsy

Procedure
Temporal lobectomy, Focal cortical resection, callosotomy, hemispherectomy, and placement of vagal n. stimulators Antiepileptic drugs Anticonvulsant and proconvulsant effect Metabolic acidosis
Topiramate more common in children Ketogenic diet

Anesthetic consideration

Vagal n. stimulation (new treatment)

Refractory to medical treatment Severe bradycardia(1/1000), Hoarseness d/t unilat. Vocal cord paralysis (1%)

Traumatic Brain Injury

Focused on mitigating secondary insult
Poor outcome
Hypotension(SBP < 50% 70mmHg + 2age) Hypoxemia(PaO2 < 60-65 or SaO2 < 90%) Cerebral perfusion pr < 40mmHg Severe elevation in ICP

Guideline
Tx of cerebral perfusion pr. And Hypotension Tx of ICP > 20mmHg, correction of hypoxia Avoidance of prophylactic hyperventilation

Option

Recommended therapy