Difference between revisions of "Craniotomy for intracranial vascular malformations"
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*** Transitional malformations | *** Transitional malformations | ||
** Low-flow venous angiomas | ** Low-flow venous angiomas | ||
*Patients may be symptomatic or asymptomatic | |||
*AVM may have be ruptured or unruptured and can be associated with vasospasm. Can also co exist with aneurysms. Most patients will have anesthesia for preoperative embolization of the AVM. | |||
=== Indications === | === Indications === | ||
| Line 58: | Line 60: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Neurologic symptoms and mental status, signs and symptoms of elevated ICP, seizures | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Commonly associated with hypertension as well as other cardiac abnormalities including ischemia, arrhythmias, left ventricular dysfunction, and pulmonary edema. | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| Line 70: | Line 72: | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Anemia | ||
|- | |- | ||
|Renal | |Renal | ||
| Line 91: | Line 93: | ||
== Intraoperative management == | == Intraoperative management == | ||
=== Overall Goals === | |||
Goals are to provide a stable hemodynamic anesthetic along with reducing/normalizing the ICP and maintaining adequate CPP (at least 70 mmHg) to prevent cerebral ischemia from brain retraction, brain swelling and vasospasm. Perioperative AVM rupture from hypertension is possible, but rare. However, in case of a coexisting aneurysm, hypertension must be avoided. | |||
=== 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 | |||
5-lead ECG | |||
Core temp | |||
UOP | |||
Arterial line | |||
2-3 large bore IVs | |||
Central line if poor peripherals access | |||
Neuromonitoring | |||
=== 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. --> === | ||
* Stable induction of general anesthesia and intubation with fentanyl, propofol, rocuronium, and +/- vasoactive agents to avoid hypo- and hypertension. Typically MAP >65 and SBP <140, however surgical team preferences can vary. | |||
* Moderate hyperventilation (PaCO2 30 mmHg) | |||
=== 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. --> === | ||
Patients typically receive Cefazolin, 10 mg of decadron and 1 gm/kg of mannitol on skin incision (verify all with surgeon). Keppra 1g may also be utilized | |||
Anesthesia can be maintained safely with many different medications, and can be guided primarily by other coexisting conditions. | |||
* An isoflurane/N2O technique offers hemodynamic stability and quick wake up test if needed. This benefit is offset by increased risk of PONV and possibility for N2O closed space expansion. | |||
* TIVA is a reasonable option however it may not allow for a rapid wake up test if needed | |||
* Inhalational and intravenous combination may optimize rapid emergence if needed. | |||
* One example could be propofol infusion (approximately 50mcg/kg/min), remifentanil infusion, vecuronium infusion, and sevoflurane | |||
*Hemodynamic "uppers and downers" should be available. For example: esmolol, labatelol, nitroglycerine, nicardipine infusion. Phenylephrine, norepinephrine drip. Adenosine can also be utilized for temporary cessation of cardiac output if surgical team requests. | |||
=== 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. --> === | ||
Goals are similar to other neurosurgical procedures, including a smooth emergence, avoiding hypertension, coughing, and straining. Intraoperative medications should be titrated down to allow for a rapid return to consciousness to permit neurologic examination prior to leaving the operating room. Alternatively, postoperative CT is sometimes utilized if a neurological exam can not be performed. | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | |||
Perioperative bleeding from AVM, cerebral ischemia from brain swelling, retractor pressure, inadequate CPP (increased ICP, vasospasm), postoperative intracranial hemorrhage, postoperative brain edema. | |||
== 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. --> === | ||
Neuro Critical Care Unit | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
Revision as of 21:32, 10 May 2022
Craniotomy for intracranial vascular malformations
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
Large bore IV x2 Arterial line ± Central line (if arterial nidus) |
| Monitors |
Standard 5-lead ECG Core temp UOP ABG ± CVP (if arterial nidus) Neuromonitoring |
| Primary anesthetic considerations | |
| Preoperative |
Characterize neurologic deficits |
| Intraoperative |
Smooth induction Hemodynamic goals vary Hypotension ↑ risk of steal If arterial nidus:
|
| Postoperative |
Avoid hypertension after excision (risk of hyperemia) |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A craniotomy for intracranial vascular malformations is a neurosurgical procedure performed to remove vascular malformations which are considered high risk for rupture or produce neurologic symptoms.
Overview
Background
- Intracranial vascular malformations are congenital defects
- Typically present in young adulthood (most commonly 15-40 years old)
- Wide anatomic variability[1]
- High-flow arteriovenous malformations (AVM)
- Low-flow angiographically occult vascular malformations (AOVM)
- Cavernous malformations
- "Cryptic" AVMs
- Capillary telangiectasias
- Transitional malformations
- Low-flow venous angiomas
- Patients may be symptomatic or asymptomatic
- AVM may have be ruptured or unruptured and can be associated with vasospasm. Can also co exist with aneurysms. Most patients will have anesthesia for preoperative embolization of the AVM.
Indications
- The Spetzler-Martin AVM grading system estimates morbidity and mortality of surgery[2]
Surgical procedure
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | Neurologic symptoms and mental status, signs and symptoms of elevated ICP, seizures |
| Cardiovascular | Commonly associated with hypertension as well as other cardiac abnormalities including ischemia, arrhythmias, left ventricular dysfunction, and pulmonary edema. |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | Anemia |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
Intraoperative management
Overall Goals
Goals are to provide a stable hemodynamic anesthetic along with reducing/normalizing the ICP and maintaining adequate CPP (at least 70 mmHg) to prevent cerebral ischemia from brain retraction, brain swelling and vasospasm. Perioperative AVM rupture from hypertension is possible, but rare. However, in case of a coexisting aneurysm, hypertension must be avoided.
Monitoring and access
Standard ASA
5-lead ECG
Core temp
UOP
Arterial line
2-3 large bore IVs
Central line if poor peripherals access
Neuromonitoring
Induction and airway management
- Stable induction of general anesthesia and intubation with fentanyl, propofol, rocuronium, and +/- vasoactive agents to avoid hypo- and hypertension. Typically MAP >65 and SBP <140, however surgical team preferences can vary.
- Moderate hyperventilation (PaCO2 30 mmHg)
Maintenance and surgical considerations
Patients typically receive Cefazolin, 10 mg of decadron and 1 gm/kg of mannitol on skin incision (verify all with surgeon). Keppra 1g may also be utilized
Anesthesia can be maintained safely with many different medications, and can be guided primarily by other coexisting conditions.
- An isoflurane/N2O technique offers hemodynamic stability and quick wake up test if needed. This benefit is offset by increased risk of PONV and possibility for N2O closed space expansion.
- TIVA is a reasonable option however it may not allow for a rapid wake up test if needed
- Inhalational and intravenous combination may optimize rapid emergence if needed.
- One example could be propofol infusion (approximately 50mcg/kg/min), remifentanil infusion, vecuronium infusion, and sevoflurane
- Hemodynamic "uppers and downers" should be available. For example: esmolol, labatelol, nitroglycerine, nicardipine infusion. Phenylephrine, norepinephrine drip. Adenosine can also be utilized for temporary cessation of cardiac output if surgical team requests.
Emergence
Goals are similar to other neurosurgical procedures, including a smooth emergence, avoiding hypertension, coughing, and straining. Intraoperative medications should be titrated down to allow for a rapid return to consciousness to permit neurologic examination prior to leaving the operating room. Alternatively, postoperative CT is sometimes utilized if a neurological exam can not be performed.
Potential complications
Perioperative bleeding from AVM, cerebral ischemia from brain swelling, retractor pressure, inadequate CPP (increased ICP, vasospasm), postoperative intracranial hemorrhage, postoperative brain edema.
Postoperative management
Disposition
Neuro Critical Care Unit
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (6 ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404.CS1 maint: others (link)
- ↑ Spetzler, R. F.; Martin, N. A. (1986-10). "A proposed grading system for arteriovenous malformations". Journal of Neurosurgery. 65 (4): 476–483. doi:10.3171/jns.1986.65.4.0476. ISSN 0022-3085. PMID 3760956. Check date values in:
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Top contributors: Chris Rishel and Mitchel DeVita