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Neuro anesthesia: Lots of action and potential
Nelson Nicolas Algarra MD
Jan 2014
What will not be covered
• Neuro physiology
• Basics of neuroanesthesia
• Prescribe methods or formulas
What will be covered?Anesthetic implication of advances in
• Interventional neuro radiology adults and peds
• Tumor surgery
• Vascular interventions
• Stroke treatment
IR is rapidly expanding
• Coiling of intra cerebral aneurysm
• Balloon assisted coiling
• Stenting
• AV malformation
• Vein of Galen
Evidence
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Endovascular coiling
• Lower rates of delayed cerebral ischemia
• Lower rates of vasospasm
• Decrease LOS
• Small increase risk of re bleeding
• Risk of death at 5 year lower
• Balloon assisted lower embolic events and rupture
Aneurysm coiling
Balloon assisted
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Stents
Anesthesia implications
• Platelet inhibition
• Rupture and bleeding
• Partial or total occlusion of a major vessel
• Blood pressure control
• Direct monitoring and communication
• Permanent implant
• Short history of use
Interventional radiology
• How about pediatric patients
• Many similarities
• Different challenges
• Illustrative cases
Complex IR case #1
• 2 week old
• Change in mental status
• CT shows hemorrhage
• Transferred form the children's hospital
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Case #1 Case #1
Case #1 Complex IR case # 2
• 5 year old
• Headaches
• Vision changes
• No other medical problem
Case #2 Case #2
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Case # 2
• Large aneurysm below the ophthalmic artery
• The whole artery empties into the sac
• Choices to place a stent or coil
• Test occlusion
Anesthetic implications
• Size of the sheath in femoral artery
• Place bilateral feet SpO2
• Blood pressure management
• Post procedure sedation and intubation
Case # 3
• 3 month old
• “looking down all the time”
• Change of mental status
• Hydrocephalus
• Echo no malformation, hyper dynamic
• Vein of galen malformation
Case #3 Case #3
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Approaches and challenges
• Trans torcular
• Trans arterial
• Hyper dynamic
• PE risk
• Control BP, HR
• Narrow window
Branches of right and left pericallosal and left posterior choroidal
Tumor surgery
• Stereotactic surgery
• Functional mapping resection
• Awake craniotomy
• Fluorescein Sodium
Infratentorial hemorrhageVascular interventions
• Extra to intra cerebral bypass
• EDAS (encephalo‐duro‐arterio‐synangiosis)
• Resection of AV malformation
• Intra cerebral endarderectomy
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EDAS
AV malformations
• They cause a mass effect
• Can present as SAH
• Interventional radiology
• Usually incremental treatment
• Strict blood pressure management
• Resection maybe required
Anesthetic implications
• Electrophysiological monitoring
• Intraoperative angiogram
• Therapeutic hypothermia, inner cool
• Blood pressure control
• Burst suppression
• Retrograde Jugular bulb catheter
Stroke treatment
• Intra venous or arterial recombinant tissue plasminogen activator rtPA
• Inclusion criteria
• Exclusion criteria
Endovascular treatments
• MERCI Mechanical embolus removal in cerebral ischemia
• Penumbra
• Trevo
• Solitaire
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Penumbra Trevo
Solitaire
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Anesthesia implications
• Call and response responsibilities
• Designated multidisciplinary teams
• Follow guidelines from stroke
• Blood pressure management
• Active QI and review process
Questions