Difference between revisions of "Craniotomy for extracranial-intracranial revascularization"

From WikiAnesthesia
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| considerations_postoperative = Careful control of BP <br/>
| considerations_postoperative = Careful control of BP <br/>
PONV prophylaxis
PONV prophylaxis
}}'''Craniotomy for extracranial-intracranial revascularization''' (also referred to as '''EC-IC bypass''') is a surgical procedure to increase cerebral blood flow. The procedure involves connecting a branch of the external carotid artery (typically the superficial temporal artery) to a branch of the internal carotid artery (typically the middle cerebral artery).  The anastomosis can be achieved via a vein graft or a direct connection.   
}}'''Craniotomy for extracranial-intracranial revascularization''' (also referred to as '''EC-IC bypass''') is a neurosurgical procedure used to augment cerebral blood flow.


EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. In children, this procedure is used to treat Moya-moya disease.  
==Overview==
== Preoperative management ==
===Indications===
=== Patient evaluation ===
EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. This procedure is frequently used to treat Moya-moya disease.
 
===Surgical procedure===
The procedure involves connecting a branch of the external carotid artery (typically the superficial temporal artery) to a branch of the internal carotid artery (typically the middle cerebral artery). The anastomosis can be achieved via a vein graft or a direct connection.
 
==Preoperative management==
===Patient evaluation===
{| class="wikitable"
{| class="wikitable"
|+
|+
Line 30: Line 36:
!Considerations
!Considerations
|-
|-
|Neurologic
| Neurologic
|
|
* Patients typically presenting with focal neurologic symptoms.  Pre-existing deficits should be well characterized and documented.  
*Patients typically presenting with focal neurologic symptoms.  Pre-existing deficits should be well characterized and documented.
|-
|-
|Cardiovascular
|Cardiovascular
|
|  
* Hypertension is a common adaptive response to maintain CPP.  A normal BP may be undesirable in the setting of severe cerebrovascular disease.
*Hypertension is a common adaptive response to maintain CPP.  A normal BP may be undesirable in the setting of severe cerebrovascular disease.
* Patients may have generalized vascular disease, including CAD.  
*Patients may have generalized vascular disease, including CAD.
|-
|-
|Hematologic
|Hematologic
|
|
* Patients often on aspirin through day of surgery
*Patients often on aspirin through day of surgery
* Anticoagulants impacting PT/PTT typically discontinued 1 week prior to surgery
*Anticoagulants impacting PT/PTT typically discontinued 1 week prior to surgery
|}
|}
=== Labs and studies ===
===Labs and studies===


* EKG
*EKG
* Echo (if concern for cardiovascular disease)
*Echo (if concern for cardiovascular disease)
* Coronary angiography (depending on cardiac risk factors)
*Coronary angiography (depending on cardiac risk factors)
* Complete blood count
*Complete blood count
* Chemistry panel
*Chemistry panel
* Coagulation panel
*Coagulation panel
* Cerebral angiography performed to identify cause of neurologic symptoms  
*Cerebral angiography performed to identify cause of neurologic symptoms


=== Operating room setup ===
===Operating room setup===


* Infusion pumps
*Infusion pumps
* Surface cooling device (i.e. cold-water circulating blanket)
*Surface cooling device (i.e. cold-water circulating blanket)
* Warming device  
*Warming device  
** Patient will need aggressive rewarming post-anastomosis  
**Patient will need aggressive rewarming post-anastomosis
** Consider bladder irrigation, warm-water circulating blanket, forced warm air blanket
**Consider bladder irrigation, warm-water circulating blanket, forced warm air blanket
* Consider central heat exchanger, especially if patient has high surface-to-volume ratio
* Consider central heat exchanger, especially if patient has high surface-to-volume ratio


=== Patient preparation and premedication ===
===Patient preparation and premedication ===  


* Consider pre-op acetaminophen 1000mg PO  
*Consider pre-op acetaminophen 1000mg PO
* Consider pre-op aprepitant if patient has history of severe PONV
*Consider pre-op aprepitant if patient has history of severe PONV
* Consider small dose of anxiolytic
*Consider small dose of anxiolytic
* Detailed discussion with patient regarding anesthetic plan  
*Detailed discussion with patient regarding anesthetic plan


=== Regional and neuraxial techniques <!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===


* Avoid scalp blocks, as they may interfere with donor vessel blood flow
*Avoid scalp blocks, as they may interfere with donor vessel blood flow


== Intraoperative management ==
== Intraoperative management==
=== Monitoring and access <!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===


* Standard ASA monitors
*Standard ASA monitors
* 5-Lead EKG
*5-Lead EKG
* Core temperature
*Core temperature
* Urine output
*Urine output
* Arterial blood pressure
*Arterial blood pressure
* Central venous pressure
*Central venous pressure
* EEG
*EEG


=== Induction and airway management <!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===  


* Smooth induction is essential
*Smooth induction is essential
* Goal is to maintain CPP
* Goal is to maintain CPP
* Have vasopressors ready to maintain CPP during induction
*Have vasopressors ready to maintain CPP during induction
* Use narcotic to blunt response to laryngoscopy
*Use narcotic to blunt response to laryngoscopy
* Muscle relaxant used to facilitate tracheal intubation  
* Muscle relaxant used to facilitate tracheal intubation


=== Positioning <!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===


* Supine
*Supine
* Table typicaly turned 180
*Table typicaly turned 180
* Mayfield skull fixation
*Mayfield skull fixation
* Shoulder roll
*Shoulder roll
* Have all lines directed towards patient's feet, where anesthesiologist typically positioned
*Have all lines directed towards patient's feet, where anesthesiologist typically positioned


=== Maintenance and surgical considerations <!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===


* Remifentanil (2-4mcg/kg) to minimize BP elevations during pinning
*Remifentanil (2-4mcg/kg) to minimize BP elevations during pinning
* Maintenance of anesthesia can be achieved with combination of remifentanil, propofol, and/or volatile agent
*Maintenance of anesthesia can be achieved with combination of remifentanil, propofol, and/or volatile agent
* Keep PaCO2 around 40 mmHg
* Keep PaCO2 around 40 mmHg
** Hypocarbia may cause unwanted cerebral vasoconstriction in these patients
**Hypocarbia may cause unwanted cerebral vasoconstriction in these patients
* Goal net zero fluid balance / Maintain normovolemia
*Goal net zero fluid balance / Maintain normovolemia
* Dexamethasone may be used to decrease PONV
*Dexamethasone may be used to decrease PONV
** Avoid scopolamine for PONV, as it may confound post-op neurologic exams
**Avoid scopolamine for PONV, as it may confound post-op neurologic exams
* Mild hypothermia (33-34°C) can be used to decrease CMRO2 and increase the brain's tolerance to ischemia
*Mild hypothermia (33-34°C) can be used to decrease CMRO2 and increase the brain's tolerance to ischemia
* Confirm pre-incision antibiotics
*Confirm pre-incision antibiotics
* Avoid long-acting opioids
*Avoid long-acting opioids
* Phenylephrine infusion typically used to maintain CPP during procedure
*Phenylephrine infusion typically used to maintain CPP during procedure  
** Phenylephrine typically preferred because it is not arrhythmogenic  
**Phenylephrine typically preferred because it is not arrhythmogenic
* Continuous neuromuscular blockade typically not needed
* Continuous neuromuscular blockade typically not needed
* Establish burst suppression (i.e. propofol 1mg/kg) immediately prior to cross clamping of cerebral artery for anastomosis  
*Establish burst suppression (i.e. propofol 1mg/kg) immediately prior to cross clamping of cerebral artery for anastomosis  
** A bolus dose of phenylephrine and/or ephedrine typically needed to counterbalance hypotensive effect of propofol.  
**A bolus dose of phenylephrine and/or ephedrine typically needed to counterbalance hypotensive effect of propofol.
* Aggressive rewarming should start as soon as revascularization is complete
*Aggressive rewarming should start as soon as revascularization is complete


=== Emergence <!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===


* As anesthetic is titrated down, patient's BP will generally increase
*As anesthetic is titrated down, patient's BP will generally increase
* Beta-blockers (esmolol, labetalol) and vasodilators (clevideipine, SNP) may be needed to maintain tight BP control during emergence  
*Beta-blockers (esmolol, labetalol) and vasodilators (clevideipine, SNP) may be needed to maintain tight BP control during emergence
* Close regulation of blood pressure is essential
*Close regulation of blood pressure is essential
* Reverse any residual neuromuscular blockade
*Reverse any residual neuromuscular blockade
* Prophylactic antiemetics should be given before extubation
*Prophylactic antiemetics should be given before extubation
* Consider IV acetaminophen  
*Consider IV acetaminophen
* If patient begins to buck or cough on ETT, extubate or suppress cough reflex (IV lidocaine)  
*If patient begins to buck or cough on ETT, extubate or suppress cough reflex (IV lidocaine)
* Achieve appropriate core body temperature prior to extubation  
*Achieve appropriate core body temperature prior to extubation


== Postoperative management ==
== Postoperative management==
=== Disposition <!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===


* ICU (typically monitored overnight in ICU)
*ICU (typically monitored overnight in ICU)
* Supplemental O2
*Supplemental O2
* Head of bed at 20-30°
*Head of bed at 20-30°
* Tight BP monitoring and management post-op (typically maintain at baseline levels)
*Tight BP monitoring and management post-op (typically maintain at baseline levels)
* Regular neuro checks post-op
*Regular neuro checks post-op


=== Pain management <!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===


* Multimodal pain management
*Multimodal pain management
* Consider post-op acetaminophen  
*Consider post-op acetaminophen
* Avoid scalp blocks, as they can interfere with donor vessel blood flow
*Avoid scalp blocks, as they can interfere with donor vessel blood flow


=== Potential complications <!-- List and/or describe any potential postoperative complications for this case. --> ===
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===


* Seizures
*Seizures
* Stroke
*Stroke
* Hemorrhage at anastomosis
*Hemorrhage at anastomosis
* Brain swelling can be caused by hyperemia in revascularized areas
*Brain swelling can be caused by hyperemia in revascularized areas


== References ==
==References==
<references />
<references />



Revision as of 05:28, 29 March 2022

Craniotomy for extracranial-intracranial revascularization
Anesthesia type

General

Airway

ETT

Lines and access

PIV x 2
Art line
CVC

Monitors

Standard ASA
5-lead EKG
Core temp
UOP
ABG
CVP
EEG

Primary anesthetic considerations
Preoperative

Characterize neurologic deficits
Consider anxiolytic

Intraoperative

Smooth induction
Maintain CPP
Maximize flow to ischemic areas
Decrease CMRO2
Decrease intracranial volume
Smooth extubation

Postoperative

Careful control of BP
PONV prophylaxis

Article quality
Editor rating
Comprehensive
User likes
2

Craniotomy for extracranial-intracranial revascularization (also referred to as EC-IC bypass) is a neurosurgical procedure used to augment cerebral blood flow.

Overview

Indications

EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. This procedure is frequently used to treat Moya-moya disease.

Surgical procedure

The procedure involves connecting a branch of the external carotid artery (typically the superficial temporal artery) to a branch of the internal carotid artery (typically the middle cerebral artery). The anastomosis can be achieved via a vein graft or a direct connection.

Preoperative management

Patient evaluation

System Considerations
Neurologic
  • Patients typically presenting with focal neurologic symptoms. Pre-existing deficits should be well characterized and documented.
Cardiovascular
  • Hypertension is a common adaptive response to maintain CPP. A normal BP may be undesirable in the setting of severe cerebrovascular disease.
  • Patients may have generalized vascular disease, including CAD.
Hematologic
  • Patients often on aspirin through day of surgery
  • Anticoagulants impacting PT/PTT typically discontinued 1 week prior to surgery

Labs and studies

  • EKG
  • Echo (if concern for cardiovascular disease)
  • Coronary angiography (depending on cardiac risk factors)
  • Complete blood count
  • Chemistry panel
  • Coagulation panel
  • Cerebral angiography performed to identify cause of neurologic symptoms

Operating room setup

  • Infusion pumps
  • Surface cooling device (i.e. cold-water circulating blanket)
  • Warming device
    • Patient will need aggressive rewarming post-anastomosis
    • Consider bladder irrigation, warm-water circulating blanket, forced warm air blanket
  • Consider central heat exchanger, especially if patient has high surface-to-volume ratio

Patient preparation and premedication

  • Consider pre-op acetaminophen 1000mg PO
  • Consider pre-op aprepitant if patient has history of severe PONV
  • Consider small dose of anxiolytic
  • Detailed discussion with patient regarding anesthetic plan

Regional and neuraxial techniques

  • Avoid scalp blocks, as they may interfere with donor vessel blood flow

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • 5-Lead EKG
  • Core temperature
  • Urine output
  • Arterial blood pressure
  • Central venous pressure
  • EEG

Induction and airway management

  • Smooth induction is essential
  • Goal is to maintain CPP
  • Have vasopressors ready to maintain CPP during induction
  • Use narcotic to blunt response to laryngoscopy
  • Muscle relaxant used to facilitate tracheal intubation

Positioning

  • Supine
  • Table typicaly turned 180
  • Mayfield skull fixation
  • Shoulder roll
  • Have all lines directed towards patient's feet, where anesthesiologist typically positioned

Maintenance and surgical considerations

  • Remifentanil (2-4mcg/kg) to minimize BP elevations during pinning
  • Maintenance of anesthesia can be achieved with combination of remifentanil, propofol, and/or volatile agent
  • Keep PaCO2 around 40 mmHg
    • Hypocarbia may cause unwanted cerebral vasoconstriction in these patients
  • Goal net zero fluid balance / Maintain normovolemia
  • Dexamethasone may be used to decrease PONV
    • Avoid scopolamine for PONV, as it may confound post-op neurologic exams
  • Mild hypothermia (33-34°C) can be used to decrease CMRO2 and increase the brain's tolerance to ischemia
  • Confirm pre-incision antibiotics
  • Avoid long-acting opioids
  • Phenylephrine infusion typically used to maintain CPP during procedure
    • Phenylephrine typically preferred because it is not arrhythmogenic
  • Continuous neuromuscular blockade typically not needed
  • Establish burst suppression (i.e. propofol 1mg/kg) immediately prior to cross clamping of cerebral artery for anastomosis
    • A bolus dose of phenylephrine and/or ephedrine typically needed to counterbalance hypotensive effect of propofol.
  • Aggressive rewarming should start as soon as revascularization is complete

Emergence

  • As anesthetic is titrated down, patient's BP will generally increase
  • Beta-blockers (esmolol, labetalol) and vasodilators (clevideipine, SNP) may be needed to maintain tight BP control during emergence
  • Close regulation of blood pressure is essential
  • Reverse any residual neuromuscular blockade
  • Prophylactic antiemetics should be given before extubation
  • Consider IV acetaminophen
  • If patient begins to buck or cough on ETT, extubate or suppress cough reflex (IV lidocaine)
  • Achieve appropriate core body temperature prior to extubation

Postoperative management

Disposition

  • ICU (typically monitored overnight in ICU)
  • Supplemental O2
  • Head of bed at 20-30°
  • Tight BP monitoring and management post-op (typically maintain at baseline levels)
  • Regular neuro checks post-op

Pain management

  • Multimodal pain management
  • Consider post-op acetaminophen
  • Avoid scalp blocks, as they can interfere with donor vessel blood flow

Potential complications

  • Seizures
  • Stroke
  • Hemorrhage at anastomosis
  • Brain swelling can be caused by hyperemia in revascularized areas

References