UNIT-3

Pharmacology of
Neurosurgery
Basic principles of neurophysiology
There are three interrelated components that are
important to the practice of neuroanesthesia. They are:

cerebral blood flow (CBF)
cerebral perfusion pressure (CPP)
intracranial pressure (ICP)
Cerebral blood flow
Cerebral blood flow, or CBF, is the blood supply to the brain in a
given time.

In an adult, CBF is typically 750 millilitres per minute or 15% of
the cardiac output

CBF is autoregulated that is, blood flow is maintained over a wide
range
(~50 150 mmHg) of perfusion pressures in order to avoid ischemia when
blood pressure is reduced and edema or hemorrhage at higher blood
pressures.
Too much blood (a condition known as hyperemia) can
raise intracranial pressure (ICP), which can compress and damage
delicate brain tissue.

Too little blood flow (ischemia) results if blood flow to the brain is below
18 to 20 ml per 100 g per minute, and tissue death occurs if flow dips
below 8 to 10 ml per 100 g per minute.

Medical professionals must take steps to maintain proper CBF in
patients who have conditions like shock, stroke, Cerebral edema,
and traumatic brain injury
Cerebral blood flow

cerebral blood flow increases proportionally to the mean arterial
pressure. This response of the cerebral vasculature to alterations in the
mean arterial pressure to maintain a constant cerebral blood flow Is
termed autoregulation


Cerebral Perfusion Pressure
CPP is the difference between mean arterial pressure (MAP) and
intracranial pressure (ICP) [CPP = MAP ICP]

CPP is Normally between 70-150 mmHg

too little pressure could cause brain tissue to become ischemic (having
inadequate blood flow)

too much could raise intracranial pressure (ICP)

Too much blood (a condition known as hyperemia) can
raise intracranial pressure (ICP), which can compress and damage
delicate brain tissue.

Too little blood flow (ischemia) results if blood flow to the brain is below
18 to 20 ml per 100 g per minute, and tissue death occurs if flow dips
below 8 to 10 ml per 100 g per minute.

Medical professionals must take steps to maintain proper CBF in patients
who have conditions like shock, stroke, Cerebral edema, and traumatic
brain injury
Intracranial Pressure
Intracranial pressure (ICP) is the pressure inside the skull and thus
in the brain tissue and cerebrospinal fluid (CSF)

ICP is measured in millimeters of mercury (mmHg) and, at rest, is
normally 715 mmHg for a supine adult

Intracranial hypertension, commonly abbreviated IH, IICP or raised ICP,
is elevation of the pressure in the cranium. ICP is normally 715 mm Hg; at
2025 mm Hg, the upper limit of normal, treatment to reduce ICP may be
needed.

Causes of Intracranial hypertension

mass effect such as brain tumor
generalized brain swelling
obstruction to CSF flow and/or absorption
increased CSF production can occur in meningitis


Intracranial Pressure

Signs and symptoms of Intracranial hypertension

headache
vomiting without nausea
ocular palsies
altered level of consciousness
back pain and papilledema.
Irregular respiration

Treatment of ICH

Mannitol has become the mainstay of ICP management protocols.
It is an osmotic diuretic
Mannitol draws water from the brain and other tissues into the
intravascular compartment.
Mannitol may also lower ICP by decreasing blood viscosity and
expanding plasma volume which increase CBF.

Effect of anesthetics on Cerebral blood Flow, Cerebral
Perfusion pressure and Intracranial tension

Volatile anesthetic

They are potent cerebral vasodilators.

At concentrations above 0.5 MAC, these anesthetic
agents increase cerebral blood flow in a dose-dependent
manner, most likely through the direct relaxation of vascular
smooth muscle leading to vasodilatation

Normally, a reduction in cerebral metabolic rate would
produce a reduction in cerebral blood flow through flow-
metabolism coupling.

Therefore, volatile anesthetics uncouple the normal
physiologic relationship between cerebral blood flow and
metabolism.

These effects may lead to increases in intracranial pressure
and cerebral edema.
Effect of anesthetics on Cerebral blood Flow, Cerebral
Perfusion pressure and Intracranial tension
Nitrous oxide

increases cerebral blood flow through cerebral vasodilation

Ketamine

ketamine appears to increase Paco2, cerebral blood flow,
and intracranial pressure, limiting its use for patients with
increased Intracranial pressure.

These effects appear to be attenuated, however, In the
presence of other anesthetic agents and controlled ventilation

Thiopental

decreases cerebral blood flow via cerebral vasoconstriction. It
also decreases cerebral metabolic oxygen requirements and
reliably decreases the intracranial pressure
Effect of anesthetics on Cerebral blood Flow, Cerebral
Perfusion pressure and Intracranial tension

Propofol

Propofol decreases cerebral blood flow via cerebral
vasoconstriction

it also decreases cerebral metabolic oxygen rtquirenwrits arid
reliably decreases the intracranial pressure.

Etomidate

Etomidate is effective in reducing ICP without causing
reduction of CPP in patients with intracranial tumors and in head-
injured patients.

decreases cerebral blood flow arid cerebral metabolic
oxygen


Effect of anesthetics on Cerebral blood Flow, Cerebral
Perfusion pressure and Intracranial tension

Benzodiazepines

minimally decrease cerebral blood flow arid cerebral
metabolic rate and do not appear to cause an increase in
intracranial pressure

it also decreases cerebral metabolic oxygen rtquirenwrits arid
reliably decreases the intracranial pressure.

Opioids

Opioids either very minimally decrease cerebral blood flow
arid intracranial pressure or produce no effect

decreases cerebral blood flow arid cerebral metabolic
oxygen


Effect of anesthetics on Cerebral blood Flow, Cerebral
Perfusion pressure and Intracranial tension
Succinlycholine
minimally decrease cerebral blood flow arid cerebral
metabolic rate and do not appear to cause an increase in
intracranial pressure

it also decreases cerebral metabolic oxygen rtquirenwrits arid
reliably decreases the intracranial pressure.

Opioids

may increase intracranial pressure through stimulation of
muscle spindles, which then increases cerebral metabolic rate
and cerebral blood flow. T

These effects are not consistent, and may be attenuated
through a deep level of anesthesia during the administration of
succinylcholine.

Nondepolarizing neuromuscular blocking drugs (10 not
generally affect intracranial pressure except through the
potential release of histamine, leading to cerebral vasodilalion.