Difference between revisions of "Craniotomy for extracranial-intracranial revascularization"
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| considerations_postoperative = Careful control of BP <br/> | | considerations_postoperative = Careful control of BP <br/> | ||
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}}'''Craniotomy for extracranial-intracranial revascularization''' (also referred to as '''EC-IC bypass''') is a | }}'''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. | ==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
Anesthesia type |
General |
---|---|
Airway |
ETT |
Lines and access |
PIV x 2 |
Monitors |
Standard ASA |
Primary anesthetic considerations | |
Preoperative |
Characterize neurologic deficits |
Intraoperative |
Smooth induction |
Postoperative |
Careful control of BP |
Article quality | |
Editor rating | |
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 |
|
Cardiovascular |
|
Hematologic |
|
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
Top contributors: Chris Rishel and Barrett Larson