Paediatric anaesthesia for neurosurgical procedures

Paediatric neurosurgical procedures request special considerations for the anaesthetic management. Due to patients age and diagnostic findings certain therapeutic procedures are performed under anaesthetic care. Main reasons for craniotomy are hydrocephalus, intracranial tumors and craniofacial synostosis. Neurosurgical therapy of newborn children is related mostly to hereditary spinal dysraphism. In spinal surgery and specific intracranial procedures for monitoring reasons sensory and/or motor evoked potentials (SEP, MEP) are used to improve surgical outcome. Due to sensibility for anaesthetic drugs these techniques request sound knowledge of physiologic and pharmacologic interaction. Cerebrovascular malformations are today usually treated using radiologic interventional procedures. Operative access will be performed for selected cases additionally to embolization, but is associated with risk of massive bleeding. Severe traumatic craniocerebral injury leads to compromised cerebral blood flow and hypoxic ischemia. The article imparts funded knowledge of surgical as well as anaesthetic rationale and techniques in neuropaediatric therapies.     

Neuromonitoring after major neurosurgical procedures

Postoperative care of major neurosurgical procedures is aimed at the prevention, detection and treatment of secondary brain injury. This consists of a series of pathological events (i.e. brain edema and intracranial hypertension, cerebral hypoxia/ischemia, brain energy dysfunction, non-convulsive seizures) that occur early after the initial insult and surgical intervention and may add further burden to primary brain injury and thus impact functional recovery. Management of secondary brain injury requires specialized neuroscience intensive care units (ICU) and continuous advanced monitoring of brain physiology. Monitoring of intracranial pressure (ICP) is a mainstay of care and is recommended by international guidelines. However, ICP monitoring alone may be insufficient to detect all episodes of secondary brain insults. Additional invasive (i.e. brain tissue PO2, cerebral microdialysis, regional cerebral blood flow) and non-invasive (i.e. transcranial doppler, near-infrared spectroscopy, EEG) brain monitoring devices might complement ICP monitoring and help clinicians to target therapeutic interventions (e.g. management of cerebral perfusion pressure, blood transfusion, glucose control) to patient-specific pathophysiology. Several independent studies demonstrate such multimodal approach may optimize patient care after major neurosurgical procedures. The aim of this review is to evaluate some of the available monitoring systems and summarize recent important data showing the clinical utility of multimodal neuromonitoring for the management of main acute neurosurgical conditions, including traumatic brain injury, subarachnoid hemorrhage and stroke.     

Cerebral protection before, during and after neurosurgical procedures.

Not only the pathology but also the neurosurgical procedure itself can lead to an impairment of cerebral structures. This may cause neurological symptoms like confusion, disorientation or cognitive deficits which have hardly been noticed until now. Neuroprotective substances can help to reduce this. As an example of the effectiveness, based on our own experiences and international trials, two different medical drugs, Nimodipine and Cerebrolysin, are presented. In conclusion one has to realize that nowadays neurosurgeons have to focus their interest more and more to neuroprotective adjuvant treatment possibilities.     

Stability of the arterial to end-tidal carbon dioxide difference during anaesthesia for prolonged neurosurgical procedures

This study was undertaken to examine the variation of the arterial to end-tidal PCO₂ (Pa-PetCO₂ difference during prolonged neurosurgical anaesthesia. Hyperventilation is often used to reduce intracranial pressure in neurosurgical patients. Continuous end-tidal CO₂ monitoring is used as a guide between arterial CO₂ measurements. We examined the stability of the Pa-PetCO₂ difference in 21 patients undergoing elective craniotomies lasting greater than four hours. A balanced neuroanaesthetic technique was used with the ventilation variables at the discretion of the attending anaesthetist. Once patients were positioned for surgery, simultaneous samples of arterial PCO₂ through an arterial catheter, and end-tidal PCO₂ via a mass spectrometer were obtained. The Pa-PETCO₂ differences of each patient were plotted against time and a slope was derived with simple linear regression. The mean slope for all patients was then computed. There were no changes in the Pa-PETCO₂ difference with time (P > 0.05) suggesting a constant relationship between the arterial and end-tidal PCO₂ measurements over time. We conclude that end-tidal PCO₂ can be used as a reliable guide to estimate arterial PCO₂ during neurosurgical procedures of greater than four hours duration once the Pa-PetCO₂ difference has been established.     

Anesthetic considerations for thoracic neurosurgical procedures

Anesthetic considerations for thoracic and thoracoscopic neurosurgical procedures are considered, emphasizing the need to provide anesthetic stability during prolonged periods of one-lung ventilation, while optimizing conditions for intraoperative monitoring of spinal cord integrity.     

Indications of neurosurgical procedures for spasticity

Neurosurgery for spasticity requires perfect knowledge of all the mechanisms involved in the control of movement. Spasticity should be clearly checked in all these aspects: phasic, tonic and flexor reflexes. Its contribution to the patient's handicap should be assessed. Motor block or intrathecal injections of baclofen are useful tests to evaluate the surgical indications for well defined goal and understood by the patient himself. The choice of the procedure depends on the patient and the type of spasticity. Post-operative assessment is very important to improve the surgical procedures in the future, going towards motor restoration.     

Early postoperative complications following neurosurgical procedures

Purpose  

To assess the incidence and characteristics of early postoperative complications in patients following neurosurgical procedures.     

Avoiding complications in neurosurgical interventional procedures

The aim of this paper is to describe common complications during neurosurgical interventional procedures. We describe our experience and review the literature about how to avoid complications during diagnostic cerebral angiography and neurosurgical interventional procedures. Recent technological advances have expanded the therapeutic options of neuroendovascular interventions. However, with higher complexity there is also an increased risk of complications. Common complications include hematoma at the puncture site, arterial dissection and microembolism. Treatment of complex aneurysms and arteriovenous malformations involves a higher complication rate. Standardized training and operator's certification reduces the risk of complications. It is also important to work with specialized ancillary staff and to provide dedicated neurocritical care after the neuroendovascular intervention.     

The history of neurosurgical procedures for the relief of pain

Pain has been a major medical problem from the beginning of recorded history. Since the earliest medical writings, there have been innumerable procedures designed to relieve pain and its suffering. In this study, we have reviewed both the early medical writings of various civilizations and the first modern publications, to compile a history of neurosurgical procedures for the relief of pain.     

Urinary retention following routine neurosurgical spine procedures

BACKGROUND: The rate and duration of urinary retention after routine cervical and lumbar spine procedures were studied. METHODS: Preoperative, intraoperative, and postoperative factors related to urinary retention (age, sex, duration of operation, medications, Foley use, hospital stay, and cost) were analyzed in a retrospective review of 503 patients' charts. RESULTS: Urinary retention occurred 38% of the time following cervical and lumbar spine procedures. Advanced age and preoperative beta blockers contributed to a higher incidence of urinary retention. Preoperative anti-inflammatory medications and narcotic analgesics reduced the frequency of urinary retention. The duration of urinary retention was prolonged in older patients and patients who underwent intraoperative Foley catheterization. Urinary retention contributed to longer hospitalization and increased hospital costs. CONCLUSIONS: Transient urinary retention is a common complication of routine neurosurgical spine procedures that prolongs hospital stays and increases the costs of hospitalization.     

C-reactive protein levels following standard neurosurgical procedures

Summary ¶Background. The aim of the present study was to establish the magnitude and time-course of C-reactive protein increases following routine neurosurgical procedures in the absence of clinical and laboratory signs of infection. Method. C-reactive protein levels were studied daily following ventriculo-peritoneal shunt implantation, anterior cervical fusion, vestibular schwannoma operation, supratentorial glioma surgery, endovascular intracranial aneurysm treatment and open cerebral aneurysm surgery. Findings. The magnitude of the C-reactive protein increase depended on the extent of surgical trauma and peak-levels were recorded between postoperative day one and four after which the levels tapered off. Interpretation. Increases occurring after the fourth postoperative day are likely to be caused by complications of surgery, e.g. infection.Published online July 23, 2003     

Cervical synovial sarcoma necessitating multiple neurosurgical procedures

Synovial sarcoma is a rare mesenchymal tumour with the worst prognosis among soft tissue tumours. Although chemosensitive, it can only be cured by complete surgical resection, often limited by its anatomical relations. We present a patient with a cervical synovial sarcoma. Three operations were performed followed by equal recurrences.     

Transient parotid gland swelling after neurosurgical procedures

Two cases of benign transient postoperative parotid gland enlargement are reported. The clinical presentation and etiology of this unusual complication are reviewed.     

Factor XIII deficiency and postoperative hemorrhage after neurosurgical procedures

BACKGROUND: Factor XIII is of physiological importance for hemostasis, especially in patients undergoing surgery. It catalyzes the enzymatic cross-linking of fibrin monomers into stable polymers and protects polymers from plasmatic and nonspecific degradation. Postoperative hemorrhage in patients with congenital and acquired Factor XIII deficiencies has been described in various surgical fields. However, there are no data about the incidence and clinical relevance of decreased Factor XIII after neurosurgical procedures. The objective of our study was to investigate the association between Factor XIII deficiency and postoperative hemorrhage after intracranial surgery. METHODS: A total of 1264 patients who underwent intracranial operations were reviewed retrospectively. Standard coagulation parameters were monitored during the perioperative course in all patients. Factor XIII testing was performed postoperatively in 34 patients in whom coagulopathies were suspected despite normal platelets, fibrinogen, prothrombin, and partial thromboplastin time. Data were analyzed to evaluate the association of Factor XIII deficiency and major postoperative hemorrhage. RESULTS: In this series of 1264 patients, a total of 20 patients (1. 6%) suffered from a major postoperative hemorrhage. Of the 34 patients with suspected coagulopathies and postoperative Factor XIII testing, 11 had a major postoperative hemorrhage. Normal levels of Factor XIII, defined as more than 60%, were found in 26 of the 34 patients. Factor XIII deficiency, defined as less than 60%, was found in eight patients. All patients with Factor XIII deficiency (n = 8) had a major postoperative hemorrhage. Of the remaining 26 patients with normal Factor XIII levels only three had a postoperative hemorrhage (p < 0.00001, Fisher's exact test). CONCLUSIONS: Decreased Factor XIII activity may be associated with an increased risk of postoperative hemorrhage after intracranial surgery.     

盐酸右美托咪啶在神经外科麻醉的应用进展

背景 盐酸右美托咪啶(dexmedetomidine,DEX)为高效、高选择性的α2肾上腺素能受体激动剂,具有剂量依赖性镇静、镇痛、抗焦虑、交感神经抑制等作用,它不增加颅内压,可保持良好的血流动力学稳定,减少其他麻醉药的需要量,尤其是阿片类药物,除此之外DEX还具有潜在的神经保护作用. 目的 综述其在神经外科麻醉的应用进展,为该药在神经外科麻醉中的应用提供参考. 内容 文章分别从作用机制及临床应用等方面综述了DEX的药理学特性及脑保护作用. 趋向 DEX作为一种新型的麻醉辅助药,其在神经外科麻醉中的应用具有广泛的前景.