Anesthesia for

SUPRATENTORIAL
TUMORS NICOLE OZAETA-PROLLAMANTE, MD, DPBA
FELLOW, NEUROANESTHESIA SECTION, RIZAL MEDICAL CENTER
background
SUPRATENTORIAL TUMORS >80%
Half of these are malignant

MOST COMMON:
Gliomas 36%
Meningiomas 32%
Pituitary adenoma 8%

METASTASIS
6% of patients with primary cancer will
develop brain metastasis
General Considerations
Concerns and problems
Signs and symptoms
from local mass effect and generalized increased
ICP
Main surgerical concern
brain exposure without damage from retraction
pressure or mobilization
Main anesthetic concern
Avoidance of secondary brain damage
 General Considerations
Concerns and problems
4. Specific challenges
Intraoperative hemorrhage
Seizures
Air embolism
Monitoring brain function and environment
Rapid versus prolonged emergence from anesthesia
Cardiovascular and pulmonary disease
Paraneoplastic phenomena with metasases
Effects of chemo and radiation therapy
General Considerations
Concerns and problems
General Considerations
Pathophysiology of
elevated icp
General Considerations

Regulation of
cerebral
blood flow
General Considerations

Autoregulation
of cerebral
blood flow
Keeps CBF constant despite changing CPP
Dominant to ICP homeostasis
Normally functinal for CPP 50-150 mmHg
Impaired or affected by intra/extracranial
patologies, and anesthetic drugs
General Considerations

Inadequate
perfusion
Inadequate perfusion
CBF below 20 mL/ 100 g/min
CPP <50 mmHg
Treatment
Restore CPP and CBF
Increase MAP and CO
Decrease ICP and cerebral
metabolic demand
vasodilatory & vasoconstrictive
cascades
General Considerations
PARTIAL PRESSURE
CARBDON DIOXIDE
HYPOCAPNEA
vasoconstriction
Reduce CBF, CBV, ICP
Induces risk of cerebral ischemia
General Considerations

anesthesia:
intravenous
Reduces CMRO2
Cerebral vasoconstrictors
Decrease CBF, CBV, ICP
General Considerations

anesthesia:
Volatiles
Decrease CMRO2
Cerebral vasodilators
Desflurane > Isoflurane > Sevoflurane
MAC <1 to 1.5 = CBF decreases
MAC >1.5 = Dose related CBF increase +
autoregulation impairment
General Considerations
Nitrous oxide
Cerebrostimulatory = Increase CMRO2, CBF

N2O-induced cerebral vasodilation

Controlled by hypocapnia, IV anesthetics
Volatile anesthetics offer no attenuating effect
General Considerations
OPIOIDS
Short-term increase ICP in
large doses
Modest direct crebral
vasodilators
Reflex cerebral
vasodilattioni after
decrease in MAP/CPP
Decrease CMRO2
General Considerations
Neuromuscular
blocking drugs
Succinylcholine
Fasciculations may increase ICP

Other NMB
No effect on ICP

OTHERS:
Avoid vasodilating anti-hypertensive drugs
cerebral vasodilation
General Considerations
Intravenous anesthetics

Reducing icp, Dec CMRO2 CBF -> Dec CBV, ICP -> Dec brain bulk
Hyperventilation
Hyperventilation -> Dec CO2 -> cerebral vasoconstriction

brain bulk, and PaCO2 of 30-35 mmHg

Hyperosmolar drugs

tension Osmotic diuretics -> acute inc blood osmolality -> dec
brain waiter content -> dec brain bulk. ICP, and inc
intracranial compliance
CSF Drainage
Direct puncture of lateral ventricle
Lumbar subarachnoid catheter insertion preopertively
Vasoconstrictive Cascade
Mild inc MAP - > inc CPP - > dec CBV and ICP from
cerebrovasoconstiction
General Considerations
Avoid other factors

Reducing icp, Hypovolemia

Hypoxia
Volatile anesthetics >1 to 1.5 MAC

brain bulk, and Poor patient positioning

tension
 General
Anesethetic
Management
Preoperative assesment
NEurologic state of the patient
Preoperative assesment
General state of the patient
CARDIOVASCULAR SYSTEM
Brain perfusion/oxygenation

RESPIRATORY SYSTEM
Hyperventilation to decrease ICP, CBF, and brain tension

OTHER SYSTEMS
Renal system, endocrine system, gastrointestinal system
Paraneoplastic or chemo/radiation therapy-associated syndromes

COAGULATION PROFILE
Must be NORMAL
Aspirin 7 days before surgery
Clopidogrel 10 days before surgery
Preoperative assesment
General state of the patient
LABORATORY
Coagulation
Hemogloblin
Platelet count
Potassium
Sodium
Caclcium
Preoperative assesment
planned operative intervention
SURGICAL APPROACH
Tumor size/location
Proximal structures
Vascular involvement
Radical excision
PLANNED DURATION
PATIENT POSITIONING
Supine
Prone
Sitting
Lateral
Preoperative assesment
planned operative intervention
MENINGIOMA
large sized, difficult location, radical excision, long duration, significant bleeding
Anesthetic priority:
maximal reduction in brain tension
Keep hematocrit above 28%

GLIOMA
Simple debulking
Little risk of bleeding
WOF postoperative intracranial hypertension from edema

PITUITARY ADENOMA BY TRANSSPHENOIDAL RESECTION

extracranial operation in head-up position

OTHERS
ventricle colloid cysts = Inc ICP at induction
Colloid cysts, basal cisternal epidermoids, transcranially-resected pit ad= max brain relax!
Preoperative assesment
determination of anesthetic plan
VASCULAR ACCESS
Risk of bleeding, venous air embolism
Need for hemodynamic and metabolic monitoring
Replacement of intravascular volume, and infusion of vasoactive and anesthetic drugs

FLUID THERAPY
Normovolemia/normtension
Avoid hypo-osmolar (PLR) and glucose-containing solutions
(hyperglycemia -> inc ischemic brain injury)

ANESTHETIC REGIMEN
VOLATILE BASED
"simple" procedurres = low risk of ICP, little need for brain relaxation
TIVA with Propofol
"high-risk" procedures = antipitaed ICP problems, need for deep brain relaxation
Preoperative Preparation
premedication
RISK ASSESSMENT
Sedation -> hypercapnia, hypoxemia, upper-airway obsturction -> INC ICP
Stress -> inc CPP/CBP/CMRO2 , inc ICP and develop vasogenic edema

IV ANALGESIA/SEDATION:
midazolam 0.5 to 2 mg +/- fentanyl 25-100 mcg OR sufentanil 2.5 to 10 mcg

CONTINUE MEDICATIONS
Steroids
Anticonvulsants (Except ACE inhibitors), consider starting if none initiated
loading dose of phenytoin 15 mg/kg or fosphenytoin 20mg/kg over 30 mintes
other cardiac drugs
Preoperative Preparation
vascular access
CENTRAL VENOUS ACCESS
Recommended for long operations (>6 hours)
Significant cardiovascular compromise
Significant risk of venous air embolism
significant risk for bleeding
Ned for continuous infusion of vasoactive drugs

ARTERIAL CANNULATION
Obligatory for full craniotomy
Positioning of the transducer at the mid-ear/circle of Willis level
Frequent determination of arterial PaCO2
Measurement of plasma glucose, potassium, and sodium
Preoperative Preparation
Monitoring
CARDIOVASCULAR
ECG
arterial and CVP
Trans esophageal echocardiography
pulse oximetery
urinary catheter

AIR EMBOLISM
Precordial Doppler
End-tidal nitrogen
ETCO2 with trans esophageal echocardiography

NEUROMUSCULAR BLOCKADE
Do not monitor hemiplegic extremities (resistant to nondepolarizing msucle relaxant
Contralateral hemiparesis from a supratentorial tumor is NOT associated with hyperkalemia
May use succinylcholine
Preoperative Preparation
Monitoring
METABOLIC
Glucose
Temperature
Hematocrit, coagulation profile
Serum sodium. potassium

INTRACRANIAL ENVIRONMENT, CEREBRAL FUNCTION

Evoked potential
Electroencephlagram
adequacy of cerebral perfusion, presence of ischemia, depth of anesthesia

ICP MONITORING
Rare for eelctive neurosurgery
 Induction of Anesthesia
Goals
VENTILARTORY CONTROL
Early mild hyperventilatorion
Avoid hypercapnia, hypoxemia

SYMPATHETIC/BLOOD PRESSURE CONTROL

Adequate pain control and hypnosis
Treat postinudction hypotension

OPTIMAL HEAD AND NECK POSITION

Avoid venous outflow obstruction
 Induction of Anesthesia
induction scheme
TYPICAL INDUCTION
Induction of Anesthesia
muscle relaxants
NONDEPORALIZING DRUGS
Minimial effect on intracranial hemodynamics
Chronic (>7 days) phenytoin/carbamazepine treatment needs to increase dose by 50-60%
NMB monitoring on hemiplegic extremities is avoided
Long acting muscle relaxants are avoided
 Induction of Anesthesia
patient positioning
PIN HOLDER APPLICATION
Analgesia
Remifentanil 0.25 - 1 mcg/kg
Fentanyl 1 to 3 mcg/kg
Sufentanil 0.2-0.3 mcg/kg
Anesthesia
Propofol 0.5mg/kg
Infiltrate pin site with local anesthetic
Antihypertensives
Esmolol 0.5 to 1 mg/kg
Labetolol -.075 to 0.15 mg/kg
 Induction of Anesthesia
patient positioning
SECURE
Endotracheal tube
Areas of the body that are susceptible to
pressure, abrasion, or movement injury
Tape eyes

OTHERS
Mild head-up position
Mild knee flexion

AVOID
Severe lateral extension of flexion of head on the neck
Extreme flexion of head
Contralateral shoulder roll should be placed
Maintenace of Anesthesia
maintenance
Maintenace of Anesthesia
goals
CONTROL OF BRAIN TENSION
CNS arousal prevention
adequate anesthesia and analgesia
CNS arousal treatment
sympatholysis and antihypertensives
Chemical Brain Retractor Concept
Maintenace of Anesthesia
goals
NEUROPROTECTION
Optimal intracranial environment
Adquate CPP, PaCO2, and rterial oxygen saturation
Match cerebral substrate demand and supply

NORMOTHERMIA
Hypothermia
Increases blood loss and risk of infection
Maintenace of Anesthesia
choice of technique
VOLATILE ANESTHESIA INTRAVENOUS ANESTHESIA
Pros Pros
Easy to use and control intact CBF-CMRO2 coupling
Extensive experience with successful Dec CBF, ICP, and brain bulk
outcomes Propofol blnts N2O cerebrostimulation
Predictability facilitates early awakening Cons
Cons more difficult to use
CBF-CMRO2 uncoupling prolonged, unpredictable awakening
Inc CBP, ICP, and brain bulk Recommendations
Recommendations for cases with high probability of elevated
for cases with no anticipated problems in ICP and brain bulk problems
ICP, ishcemia, or brain bulk use TCI and short-acting drugs
early institution of moderate
hyperventilation
avoid combination with
N2O(cerebrostimulator)
Maintenace of Anesthesia
management of inc icp and brain bulk
Maintenace of Anesthesia
management of inc icp and brain bulk
OTHER MEASURES
CNS arousa and hemodynamic hyperdynamism
Esmolol 0.5 to 1 mg/kg
Labetalol 0.075 to 0.15 mg/kg

ANTIBIOTIC PROPHYLAXIS
Vancomyin or second gen cephalosporin prior skin incision
Clindamycin for beta-lactam allergy

FLUID THERAPY
Goals
normovolemia, normotension, normoglycemia, low-nomral
hematocrit ~30%, mild hyperosmolality(<320 mOsm/kg)
Recommendations
Avoid glucose-contaning solutions, Ringer's lactate (ypo-osmolar)
Use isotonic crystalloids or 6% hydroexyethel starch
Emergence from Anesthesia
Effects and aims of emergence
HEMODYNAMIC AROUSAL
lasts for 10-25 minutes
rise in oxygen consumption
mediated by increased catecholamine levels and nocicpetve stimuli
Increased by 5x by pain, shivering, and non-shivering
20% elective craniotomies develop intracranial hypertension
systemic hypertension = increased risk of postoperative intracranial hemorrhage

AIMS
Maintain intra/extracrnial homeostasis
Prevent postcraniotomy pain
oid factors leading to intracranial bleeding
Patient should be calm, cooperative and responsive to verbal commands
Emergence from Anesthesia
early vs delayed emergence
 Emergence from Anesthesia
early vs delayed emergence
INDICATIONS FOR DELAYED EMERGENCE
Preoperative obtunded consciousness, inadequate airway control
Intraoperative massive bleeding
Signifcant risk of brain edema and increased ICP
Long (>6 hours) procedures with extensive dissection and major blood loss
Repeat surgery
Operations involving or close to vital brain areas
Surgery associated with significant brain ischemia
 Emergence from Anesthesia
early vs delayed emergence
PRECONDITIONS FOR EARLY EMERGENCE
 Emergence from Anesthesia
early vs delayed emergence
PRECONDITIONS FOR EARLY EMERGENCE
 Emergence from Anesthesia
early vs delayed emergence
 Emergence from Anesthesia
early vs delayed emergence
PAIN CONTROL
need for postoperative analgesia before awakening
if remifentanil, use of longer-acting opioids should be given
Scalp infiltration with local anesthetics
First line IV agents
morphine and fentanyl, titrated to avoid resp depression
acetaminophen (paracetamol)
Tramadol
decreases seizure threshold
associated with PONV
NSAIDS (e.,g., ketorolac)
theoretically increase risk of bleeding
 Emergence from Anesthesia
early vs delayed emergence
DIFFERENTIAL DIAGNOSIS OF UNPLANNED DELAYED EMERGENCE
10-20 minutes of cessation of short-acting drugs
Consider use of
Transcranial Doppler ultrasound : assess cerebral perfusion
CT scan : identify neurosurgical complications
EEG : non-conclusive seizures
Metabolic or eletroclyte disturbances
 Emergence from Anesthesia
early vs delayed emergence
NEUROLOGIC EVALUATION
baseline neuroligc evaluation
motor responses of arms and legs
size of pupils and reactivity to light
adequate undestanding of simple words and verbal response
orietnation to time and space

Delayed extubation
temporary awakening for assessment of neurologic status should be considered under
close hemodynamic control
 specific
Anesethetic
Management
predicted
difficult airway
Avoid hypoxemia > preventing ICP increase
Use of fiberoptic intubation or videolaryngoscopy
good local anesthesia of nasopharynx and airways
judicious light sedation:
midazolam 0.5 to 1 mg +/- fentanyl 25 to 50 mcg
Propofol infusion 1-2 mg/kg/hr
Hypertension treated with esmolol, labetalol, or clonidine
infectious
tumors or abscess
often accomanied by low-grade fever
Risk factors
contiguous infections (sinus.ear)
right-to-left cardiac shunt
immunosupression (extrinisic/intrinsic)
IV drug abuse
Treatment
Antibiotics + corticosteroids
Craniotomy with evacuation of abscess
surgery
craniofacial skull-base
tracheostomy or oral intubation
Extensive bony involvement
increased bleeding
emorrhagic diathesis
venous air embolism
cranial nerve monitoring
WOF for repeat procedures: limited mouth opening
Anesthesia for
INTRACRANIAL
HEMATOMAS
General Considerations
Concerns and problems
Slow: chronic subdural hematomas
subtle neurologic signs
small increase in ICP
Anesthetic technique similar to supratentorial tumors
Mostly occurs in elderly (>70 yo)

Fast: acute epidural (e.g., traumatic), subdural, and

intracerebral hematoms
massive neurologic impairment
acutely life-threatening increase in ICP
Aneshtetic technique: Involves aggressive measures to
decrease ICP, preserve brain oxgenation and perfusion
rapid transfer to operating room
 Anesthetic Management
Induction
BASICS
Ensure oxygenation, secure airway, hyperventilate with 100%, perform brief, ataumatic
intubation
Avoid coughing, arterial hypertension/light anesthesia, hypotension
For hypotension and hypovolemic patients
decrease hypnotic and analgesic drugs
restore circulating blood volume
For patients with full stomach
aspiration prophylaxis
cricoid pressure
WOF fracture of cervical spine
 Anesthetic Management
Induction
PHARMACOLOGIC OPTIONS CONTROL ICP AND BRAIN SWELLING
Deeply comatose patient Mannitol
intubaation without drugs is acceptable 0.7 - 1.4 g/kg

Semiconscious, struggling patient

etomidate 0.2 - 0.5 mg/kg
propofol 0.5 - 1.5 mg/kg
thiopental 2 -4 mg/kg

Conscious and stable patient

rapid sequence intubation
succinylcholine
rocuronium 1 mg/kg
 Anesthetic Management
maintenance
MONITORING
Cardiovascular monitong
direct arterial-pressure monitoring
ECG
brain-myocardial injury interaction
risk for arrythmias

ICP monitoring
initiated once hematoma has been evacuated

Laboratory analyses
blood gas analysis
glucose
coagulation profile
lood osmolalitb
 Anesthetic Management
anesthetic technique
INTRAVENOUS ANESTHETICS
mainstay of anesthesia

VOLATILE ANESTHETICS
NOT recommended
risk of markedly increasing ICP and brain tension -> acute transtentorial herniation

MUST EVALUATE
Deep coma and signs of brain herniation
Use muscle relaxation, 100% oxygen, titrate anesthesia to blood pressure
Coma but with no signs of herniation/inc ICP
Propofol TCI + muscle relaxation + air/oxygen
Conscious patient with mass effect on CT scan
rapid sequence induction + proporol TC, opioids, muscle relaxation + air/oxygen
 Anesthetic Management
cardiovascular control
AVOID ARTERIAL HYPOTENSION
Balance maintenance
CPP to areas of the brain redered ishcemic from the compression of hematoma
Risk of more vasogenic brain edema or bleeding

REDUCTION IN SYSTEMIC ARTERIAL PRESSURE

Analgesia with opioids
Deepen anesthesia
Give anti-hypertensive treatment
Avoid cerebrovasodilators

SEVERE HYPOTENSION AFTER BRAIN DECOMPRESSION

disappearance of cushing's response
Treat with rapid fluid loading + pressors
 Anesthetic Management
emergence
AFTER EVACUATION
Significant brain injury with significant potential for and actual brain swelling
Slow weaning and delayed extubation
Sizure prophylaxis

CHRONIC SUBDURAL HEMATOMA

Minimal neurologi impairment preoperatively
can be awakened and extubated immediately after surgery
 conclusions
Preserve uninjured cerebral territories
Balance CBF autoregulation, MAP, vasoreactivity to PaCO2
Achieving and maintaining brain relaxation
Dec CMRO2, CBF, CBV
Mod hyperventilation (PaCO2 35 mm Hg)
Inhaled anesthetics <1-1.5 MAC or IV anes
Strict maintenance of CPP
Osmotherapy and/or CSF draining
Timely awakening
Recovery:
Analgesia, PONV prevention, hemodynamic control
 conclusions
Anesthesia for acute cerebral hematoma
ICP and brain swelling ctonrol
Hemodynamic control
Time management
Thank you
good afternoon