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AS - N934 Advanced Principles II > Neurosurgery > Flashcards

Neurosurgery Flashcards

(72 cards)

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1
Q

Preop Considerations

A 
Anticonvulsants - dose, frequency, last taken
Continue DOS + supplementation
NO sedation
Antibiotics ordered/mixed
Diuretics impact on electrolytes
Stress dose steroids
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2
Q

Intraoperative Nerve Monitoring

A

Prevent brain, spinal cord, or nerve injury

MEP
SSEP
EMG

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3
Q

MEPs

A

Motor evoked potentials
Used in surgeries where motor track at risk
Direct & scalp electrodes
More sensitive to ischemia than SSEPs by 15min
Difficult to obtain d/t pre-existing or anesthetic conditions
NO paralytic

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4
Q

SSEPs

A

Somatosensory evoked potentials
Most commonly monitored
Stimulation peripheral sensory nerve
Mapping in spinal cord and sensory cortex
Ischemia detection in cortical tissue
Reduces risk of spinal cord/brainstem mechanical or ischemic insults

Paralytic okay sometimes
Motor monitoring less specific, does not measure motor deficits

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5
Q

EMGs

A

Electromyography
Reduces muscle electrical activity using needle pains
Continuous recording
Triggered responses
Used to detect nerve irritation, nerve mapping, assess nerve function, and monitor cranial nerves

Spinal surgeries to detect when screws are misplaced - passively monitors nerves

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6
Q

Stereotactic NSGY

A 
Brain lab/mapping
Fudicials affixed to patient scalp & forehead
Interferes w/ Pox
Smaller biopsies local or MAC
Large resections require general
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7
Q

Craniotomy Medications

A 
Induction - Fentanyl, Propofol, & Rocuronium
Propofol 40-100mcg/kg/min
Remifentanil 0.2mcg/kg/min
Phenylephrine 0.2mcg/kg/min
Decadron 10mg
Mannitol 50-100g (0.25-0.5g/kg)
Keppra 1g or Vimpat
Vancomycin or Ancef
Tylenol 30min prior wake-up
Hydromorphone or Fentanyl
Caffeine - adenosine receptor antagonist
Physostigmine - anticholinesterase
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8
Q

Intracranial Mass Lesion

Clinical Presentation

A 
Headache
Seizures
Focal neurological deficits
Sensory loss
Cognitive dysfunction
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9
Q

Supratentorial Mass Lesions

A 
Seizures, hemiplegia, aphasia
Frontal
Parietal
Temporal
Occipital
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10
Q

Supratentorial Mass Lesion

Frontal

A

Personality changes, increased risk-taking, difficulty speaking (damage to Broca’s area)

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11
Q

Supratentorial Mass Lesion

Parietal

A

Sensory problems

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12
Q

Supratentorial Mass Lesion

Temporal

A

Problems w/ memory, speech, perception, & language skills

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13
Q

Supratentorial Mass Lesion

Occipital

A

Difficulty recognizing objects, an inability to identify colors, & trouble recognizing words

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14
Q

Infratentorial/Posterior Fossa Mass Lesions

A

Cerebellar dysfunction

Brainstem compression

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15
Q

Infratentorial/Posterior Fossa Mass Lesion

Cerebellar Dysfunction

A

Ataxia/poor balance, nystagmus, dysarthria, cannot perform rapid alternating movements, loss muscle coordination

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16
Q

Infratentorial/Posterior Fossa Mass Lesion

Brainstem Compression

A

Cranial nerve palsy, altered LOC, abnormal respiration

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17
Q

Primary Tumors

A

Glial cells - astrocytoma, oligodendroglioma, glioblastoma
Ependymal cells - ependymoma
Supporting tissues - meningioma, schwannoma, choroidal papilloma

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18
Q

Intracranial Mass Lesions

Anesthetic Considerations

A

Consider tumor location, growth rate, & size (slow growing tumors are often asymptomatic) EBL estimate
ICP elevation
Goals = control & maintain ICP
Anticipate sympathetic response w/ Mayfield head pins placement
Rapid emergence to allow neuro assessment

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19
Q

Intracranial Mass Lesions

Preop

A

Determine ICP
ICU patients w/ EVD
LOC & neuro deficits
Review PMH & general health status
Anticonvulsants & diuretics
Recent labs - glucose, drug levels, electrolytes, Hgb/Hct
Radiological studies - edema, midline shift, or ventricular size
Avoid benzodiazepines/narcotics
Continue corticosteroids & anticonvulsants

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20
Q

Intracranial Mass Lesions

Intraop

A 
Hyperventilation maintain ETCO2 30mmHg
Avoid excessive PEEP < 10
Glucose-free crystalloids or colloids
Replace blood loss w/ blood or colloids
EVD or lumbar drain to control ICP
↑CBF
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21
Q

Intracranial Mass Lesions

Monitors

A 
A-line
Foley
IV access (central line?)
PNS - do NOT monitor on hemiplegic side
Ventriculostomy to monitor ICP (zero at auditory meatus)
Consider IONM
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22
Q

Intracranial Mass Lesions

Positioning

A 
Rotate HOB 90-180° 
Elevate 10-15° 
Supine, lateral, prone, or sitting
Able to access all equipment
IV tubing extension
PNS on lower extremities
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23
Q

Intracranial Mass Lesions

Emergence

A

Slow & controlled
Prevent straining or bucking ↑ICP or worsen cerebral edema
Aggressive BP management systolic < 140-160
Hemorrhage or stroke risk - Clevidipine, Labetalol, and/or Esmolol
Neuro exam immediately after extubation
Do not administer any opioids until cleared by surgical team to prevent any neuro assessment impairment

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24
Q

Intracranial Mass Lesions

Postop

A

Admit to ICU for observation - seizures, neuro deficits, or ↑ICP
Transport w/ HOB elevated 30°
Manage HTN
Transport on O2
Minimal pain post-craniotomy (headache most common)

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25
Awake vs. Asleep Craniotomy
Awake-awake Asleep-awake Asleep TIVA w/ IONM or GETA
26
Considerations for awake craniotomy patients:
Used for epilepsy surgery & tumor resection in frontal & temporal lobes where speech & motor need to be assessed intraop Airway Cooperation Secure A-line & PIVs
27
Awake-Awake Craniotomy
No infusions until closing Propofol bolus for pins Hand-holding
28
Asleep-Awake Craniotomy
Start under GA w/ LMA or ETT Wake patient up once tumor exposed Propofol 40mcg/kg/min Remifentanil 0.2-0.4mcg/kg/min
29
Posterior Fossa Lesions
Cerebellum Brainstem Cranial nerves I-XII Venous sinuses
30
Cushing's Triad
↑ICP Hypertension Bradycardia Irregular respirations Trigeminal nerve stimulation
31
Bradycardia & Hypotension
Glossopharyngeal or Vagus nerve stimulation
32
Brainstem Injuries
Cushing's triad Bradycardia & hypotension Damage to respiratory center → mechanical ventilation postop Tumors around glossopharyngeal & Vagus nerves impair gag reflex & ↑aspiration risk Cranial nerves IX, X, & XI control pharynx & larynx
33
Posterior Fossa Lesions | Anesthetic Considerations
Same periop considerations as intracranial lesions | Modified lateral or prone most common
34
Sitting Position | Advantages
Back elevated 60° & legs elevated w/ knees flexed Head fixed in 3-point holder w/ neck flexed Arms remain at sides w/ hands resting on lap Improved surgical exposure & more anatomically correct Less retraction & tissue damage ↓bleeding Less cranial nerve damage Improves lesion resection Access to airway, chest, & extremities Enhanced CSF & venous drainage
35
Sitting Position | Disadvantages
Postural hypotension, arrhythmias, & venous pooling Pneumocephalus Nerve injuries - ulnar compression, sciatic nerve stretch, lateral peroneal compression, brachial plexus stretch, cervical spine compression
36
Pneumocephalus
Open dura → CSF leak → air enters After dural closure, air acts as mass lesion as CSF reaccumulates Usually resolves spontaneously Burr holes to relieve tension pneumocephalus S/S include delayed awakening, headache, lethargy, confusion Discontinue N2O before dural closure
37
VAE
``` Venous air embolism ↓ETCO2 ↑PaCO2 ↓SpO2 Spontaneous ventilation Mill-wheel murmur* (late sign) ET nitrogen detection Hypotension Dysrhythmias ```
38
VAE Monitoring
``` TEE detects 0.25mL air (most sensitive) Precordial doppler ↓ETCO2 w/ 15-25mL air ↑PAP w/ 20-25mL air CVP PaCO2 MAP ```
39
VAE Treatment
``` 100% FiO2 Discontinue N2O Notify surgeon to flood field or pack wound Call for help! Aspirate CVP line 30-60mL Volume load - fluids wide open Inotropes/vasopressin Jugular vein compression PEEP Position L lateral decubitus w/ head down (Tredelenburg) CPR/EMCO ```
40
Chiari Malformation
Cerebellum protrudes through foramen magnum - compresses brainstem & cervical spinal cord Types I-IV Syringomyelia (fluid-filled cyst present in spinal cord)
41
Chiari Malformation | Anesthetic Considerations
Prone or sitting position ↑EBL d/t large venous sinuses Vital sign instability d/t brainstem manipulation Postop pain management
42
1° Head Injury
Contusion Concussion Laceration Hematoma
43
2° Head Injury
``` Hematoma ↑ICP Seizures Edema Vasopressin ```
44
Skull Fractures Ypes
Linear - subdural or epidural hematomas Basilar - CSF rhinorrhea, raccoon eyes, battle's sign, pneumocephalus, & cranial nerve palsies Depressed - brain contusion
45
Head Injury | Airway Management
``` C-spine precautions until cleared Manual inline stabilization Early intubation Awake fiberoptic intubation Full stomach precautions Blind nasal intubation contraindicated when basilar skull fracture present ```
46
Head Injury | Anesthetic Considerations
Seizure prophylaxis Maintain Hct > 30% Treat DIC w/ platelets, FFP, & cryo Pituitary dysfunction
47
Pituitary Tumors | Non-Functioning
Non-secretory - Arise from growth of transformed anterior pituitary cells - Generally well tolerated until 90% gland non-functional
48
Pituitary Tumors | Functioning
Secretory - Cushing's disease ACTH - Acromegaly (growth hormone) - Prolactinomas (Prolactin) - TSH adenomas
49
Pituitary Tumors | Preop
Visual field evaluation ↑ICP Endocrine & electrolyte labs Steroids
50
Pituitary Tumors | Intraop
``` Transsphenoid approach HOB elevated 10-20° Oral RAE or reinforced ETT Avoid hyperventilation ↓ICP impedes surgical access Carotid arteries adjacent to suprasellar area Document throat pack in/out Place OG tube Avoid positive airway pressure ```
51
Pituitary Tumors | Postop
DI common after pituitary surgery & usually resolves w/in 7-10 days Treatment: Vasopressin or Desmopressin (DDAVP) SIADH
52
Cerebral Aneurysm
Leading cause non-traumatic intracranial hemorrhage Commonly located in anterior Circle of Willis → permanent brain damage, disability, or DEATH
53
Cerebral Aneurysm S/S | Unruptured
``` Headache Unsteady gait Visual disturbances - loss, diplopia, photophobia Facial numbness Pupil dilation Droopy eyelid Pain above or behind eye ```
54
Cerebral Aneurysm S/S | Ruptured
``` Sudden, extremely severe headache N/V LOC Prolonged coma Focal neuro deficits Hydrocephalus Seizure ↑ICP ```
55
Hess & Hunt
Aneurysmal subarachnoid hemorrhage grading system Grade 0-2 = low mortality rate 3-5 ↑mortality rates
56
Ruptured Cerebral Aneurysm | Vasospasm
``` Ischemia or infarction Exact mechanism unknown 14% morbidity & mortality Not detectable until 72hrs after subarachnoid hemorrhage Calcium channel blockers ```
57
Rupture Cerebral Aneurysm | Re-Bleeding
Peaks 7 days post incident 8% morbidity & mortality Antifibrinolytic therapy
58
Vasospasm Treatment
Triple H - HTN goal systolic 160-200 (MAP 80-100) - Hemodilution ideal Hct 33% balance b/w O2 carrying capacity & viscosity - Hypervolemia aggressive IV crystalloid and colloid infusion (CVP > 10mmHg or PCWP 12-20)
59
IR Endovascular Aneurysm Coiling | Anesthetic Considerations
``` GETA w/ complete muscle paralysis Control CPP (lower BP during surgery) Minimal narcotic needs - minimally invasive A-line preferred Minimal to no blood loss Heparin ACT 200-250 ``` Coil inserted via femoral vessels into aneurysm Standard angiogram to locate aneurysm
60
Coiling Complications
``` Aneurysm rupture Subarachnoid hemorrhage Vasospasm CVA Incomplete coiling ```
61
Cerebral Aneurysm | Surgical Treatment
Microsurgical clip ligation Craniotomy approach Large aneurysms > 2.5cm may require deep circulatory arrest
62
Cerebral Aneurysm | Pre-Induction
``` Limit sedation (hypercapnia) Monitors: - A-line - PIV x2 Type & cross 2-4 units PRBCs available ```
63
Cerebral Aneurysm | Induction
Smooth induction Consider difficult airway or full stomach Aggressive BP & HR control w/ narcotics, β blockers, deepen anesthetic
64
Cerebral Aneurysm | Intraop & Maintenance
``` Rotate HOB 90-180° TIVA or anesthetic gases Temporary cerebral artery occlusion Maintain BP 15-20% below baseline to prevent vasospasm, ↓EBL, & allows improved exposure & visualization Cerebral protection methods to ↓ICP Optimum CPP ↓CPP occurs rapidly during surgery when aneurysm ruptures Maintain transmural pressure MAP - ICP Decrease intracranial volume (blood & tissue) to provide "slack" Minimize CMRO2 (oxygen demand) Fluids < 10mL/kg + UOP Expand volume w/ colloids NO GLUCOSE CONTAINING SOLUTIONS ```
65
Cerebral Aneurysm | BP Management
↓BP to prevent aneurysm rupture risk Temporarily ↑MAP per surgeon request to provide collateral flow to feeder vessel clamped to allow clipping Post-clipping maintain MAP 80-100mmHg
66
When is an aneurysm most likely to rupture intraoperatively?
Dural incision Excessive brain retraction Aneurysm dissection During clipping or releasing the clip
67
Aneurysm Rupture Treatment
Immediate, aggressive fluid resuscitation & replace blood loss Propofol bolus to ↓MAP & blood loss Surgeon may apply temporary clip on parent vessel to control bleeding Restore BP after clipping to improve collateral flow
68
AVM
Arteriovenous malformation Congenital abnormality that involves direct connection from an artery to vein "nidus" w/o pressure modulating capillaries Most common presentation = intracranial hemorrhage Same preop considerations as aneurysm Significant blood loss potential up to 3L
69
AVM Treatment
Intravascular embolization Surgical excision Radiation
70
Cranial Nerve Decompression
Treat cranial nerve disorders - trigeminal neuralgia, hemifacial spasm, & glossopharyngeal neuralgia Unilateral Usually caused by vascular structure compression
71
Cranial Nerve Decompression | Anesthetic Considerations
``` Position lateral, prone, or supine TIVA or brain relaxation Facial nerve or EMG monitoring Brainstem auditory evoked response Multimodal PONV ```
72
Spinal Cord Surgeries
``` Spinal cord stimulators Intrathecal pumps Scoliosis Anterior/transforaminal lumbar interbody fusion Anterior cervical discectomy & fusion ```

AS - N934 Advanced Principles II (18 decks)

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