[Yao's Anesthesiology] Reading Notes day9 Brain Tumor and Craniotomy

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Yao's Anesthesiology, which has been long-awaited, has finally renewed.
Thank you teachers for your attention and support for patients with brain tumors and craniotomy, female, 47 years old, Health in the past
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The patient was admitted to the hospital with headaches for four months, intermittent diplopia and ataxia for one month, vomiting, and lethargy
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Physical examination revealed bilateral papilledema, nystagmus, and mild symptoms of right cranial nerves V and VII
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Magnetic resonance imaging revealed a tumor in the right posterior fossa, consistent with a petrous clivus meningioma, and compressing the pons and fourth ventricle
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CT angiography showed a giant hemangioma originating from the pharyngeal branch of the external carotid artery
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The patient was scheduled to undergo elective craniotomy to remove the tumor
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Cerebral angiography and tumor embolization were performed two days before surgery
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The patient's anesthesia was uneventful
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Surgical records showed that there were more residual blood supplying arteries
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A.
Diseases and Differential Diagnosis‍1.
What factors determine intracranial pressure (ICP)? 2.
How does a patient's intracranial tumor alter their intracranial pressure (ICP)? 3.
What factors determine cerebral blood flow (CBF)? What are the effects of intracranial tumors on CBF? 4.
What are the characteristics of posterior fossa lesions? 5.
What is cerebral steal syndrome? 6.
What is the role of preoperative embolization? B.
Preoperative evaluation and preparation 1.
How to perform preoperative evaluation for posterior fossa craniotomy? In addition to the preoperative evaluation required in all anesthetized patients, craniotomy involves several questions closely related to anesthesia management: • What is this patient's intracranial pressure (ICP), and how is ICP related to the intracranial compliance curve? • How do pathological changes and chronic blood pressure changes affect autoregulation? • Does the patient have electrolyte and hormonal abnormalities associated with intracranial lesions? • Is the lesion rich in blood vessels and is it difficult to surgically remove it? • What position is possible and is there a risk of venous air embolism (VAE) and jugular venous return obstruction? • Does neurological status affect extubation after general anesthesia, or does it affect early neurological assessment after general anesthesia? • Anesthesia techniques need to be adjusted to meet special monitoring, including EEG, electrocorticography, brainstem auditory evoked responses, sensory evoked potentials? 2.
If the patient has demonstrated intracranial hypertension, what needs to be done before surgery treatments, and how do these treatments affect anesthesia management? Patients with elevated intracranial pressure (ICP) will be monitored and treated very aggressively preoperatively; preoperative evaluation may be performed in the intensive care unit
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Anesthesiologists should be aware of the impact of preoperative management of intracranial hypertension on anesthesia management
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Possible preoperative grades and their common effects on anesthesia management are as follows: • Corticosteroids
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It can lead to hyperglycemia and requires aggressive treatment
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• Head high
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Rapid lowering of the head should be avoided when carrying
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• Diuretics (mannitol, furosemide) can cause disturbances in electrolyte or acid-base balance
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A reduction in preload increases the risk of hypotension during induction of anesthesia
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• Isotonic or hypertonic saline treatment
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Can lead to hypernatremia, or high chloride, anion gap metabolic acidosis
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• Intubation and hyperventilation
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Cerebral blood flow (CBF) regulation may diminish or disappear if hyperventilation is prolonged for a long time, and if hyperventilation is discontinued abruptly, there is a risk of increased CBF and ICP
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Hyperventilation can lead to potential compensatory metabolic acidosis
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Hypoventilation should be avoided during transport
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• Ventriculostomy drainage
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Since it is difficult to maintain a proper plane during handling, the drainage tube should be clamped
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Release the drain immediately upon arrival in the operating room, as even relatively short-term clipping may result in increased ICP
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• Adjust body blood pressure to optimize cerebral perfusion pressure (CPP)
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Drug infusion should be maintained during handling to avoid rebound hypertension or hypotension
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• Therapeutic hypothermia
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Indicates a severe neurological condition
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Intraoperative temperature management needs to be discussed with the neurosurgeon, as hypothermia facilitates neuroprotection but at the same time leads to coagulation disturbances
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3.
How will intraoperative electromyography (EMG), sensory evoked potential (SEP), and brainstem auditory evoked response (BAER) monitoring affect anesthesia management? 4.
How to choose the patient's position during posterior fossa surgery? 5.
What are the main disadvantages of conventional posterior fossa surgical positioning? 6.
How is the patient's position finally determined? 7.
If the surgeon insists on performing the procedure in a sitting position, how does this affect the preoperative assessment and anesthesia planning? 8.
Does this patient require premedication? Except in rare cases, patients with intracranial lesions should avoid standard premedication
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Benzodiazepines and other psychotropic drugs can affect functional assessment of the nervous system
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Opioids can induce hypoventilation, leading to hypercapnia and increased cerebral blood flow (CBF); in patients with poor intracranial compliance reserve, such as this patient, even a slight increase in CBF can lead to intracranial pressure (ICP) ) increased significantly
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A professional and detailed preoperative visit by an anesthesiologist remains the best way to reduce preoperative anxiety
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Predict what will happen in the future, and look at the next decomposition
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