Anesthesia for minimally invasive neurosurgery
Introduction: Advances in imaging, computing and optics have encouraged the application of minimally invasive surgical approach to a variety of neurosurgical procedures. The advantages include accurate localization of lesions usually inaccessible to conventional surgery, less trauma to healthy brain, blood vessels and nerves, shorter operating time, reduced blood loss, and early recovery and discharge. Nevertheless minimally invasive neurosurgical (MIN) procedures still have potential intra-and post-operative complications that can cause morbidity and mortality.
Objectives: The aim of this study was to review and analyze published literature describing experiences in the anesthetic management of the most commonly performed MIN procedures.
Materials and methods: Neurosurgical and neuroanesthesia literature (1990-2013) were reviewed and description of anesthetic technique/management and perioperative morbidity/mortality reported. We also compared the different authors’ experience with MIN procedures.
Results: The neurosurgical literature dealing with MIN has expanded, but there are few references in relation to anesthetic management. Anesthesia goals remain the same: careful pre-operative assessment and planning, and meticulous cerebral hemodynamic control to ensure adequate cerebral perfusion pressure. The degree of postoperative care depends on local practice, patient factors and postoperative brain imaging.
2. Bilgin H, Basagan ME, Bekar A, Iscimen R, Korfali G. A comparison of effects of alfentanil, fentanyl, and remifentanil on hemodynamic and respiratory parameters during stereotactic brain biopsy. J Neurosurg Anesthesiol. 2006;18:179-84.
3. Bernstein M, Parrent AG. Complications of CT-guided stereotactic biopsy of intra-axial brain lesions. J Neurosurg. 1994;81:165-8.
4. Ali Z, Prabhakar H, Bithal PK, Dash HH. A review of perioperative complications during frameless stereotactic surgery: our institutional experience. J Anesth. 2009;23:358-62.
5. Osborn I, Sebeo J. Scalp block during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 2010;22:187-94.
6. Dammers R, Haitsma IK, Schouten JW, Kros JM, Avezaat CJ, Vincent AJ. Safety and efficacy of frameless and frame-based intracranial biopsy techniques. Acta Neurochir (Wien). 2008;150:23-9.
7. Purzner T, Purzner J, Massicotte EM, Bernstein M. Outpatient brain tumor surgery and spinal decompression: a prospective study of 1003 patients. Neurosurgery. 2011;69:119-26.
8. Johnson DR, O'Neill BP, Decker PA, Kosel ML, Lanzino G, Hammack JE. Mortality and discharge to home after closed brain biopsy: analysis of 3523 cases from the State of California, 2003-2009. World Neurosurg. 2013;79:110-5.
9. Venkatraghavan L, Manninen P. Anesthesia for deep brain stimulation. Curr Opin Anaesthesiol. 2011;24:495-9.
10. Rozet I, Muangman S, Vavilala MS, Lee LA, Souter MJ, Domino KJ, et al. Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson's disease. Anesth Analg. 2006;103:1224-8.
11. Lettieri C, Rinaldo S, Devigili G, Pauletto G, Verriello L, Budai R, et al. Deep brain stimulation: subthalamic nucleus electrophysiological activity in awake and anesthetized patients. Clin Neurophysiol. 2012;123:2406-13.
12. Harries AM, Kausar J, Roberts SA, Mocroft AP, Hodson JA, Pall HS, et al. Deep brain stimulation of the subthalamic nucleus for advanced Parkinson disease using general anesthesia: long-term results. J Neurosurg. 2012;116:107-13.
13. Sutcliffe AJ, Mitchell RD, Gan YC, Mocroft AP, Nightingale P. General anaesthesia for deep brain stimulator electrode insertion in Parkinson's disease. Acta Neurochir (Wien). 2011;153:621-7.
14. Santos P, Valero R, Arguis MJ, Carrero E, Salvador L, Rumia J, et al. Preoperative adverse events during stereotactic microelectrode-guided deep brain surgery in Parkinson's disease. Rev Esp Anestesiol Reanim. 2004;51:523-30.
15. Venkatraghavan L, Manninen P, Mak P, Lukitto K, Hodaie M, Lozano A. Anesthesia for functional neurosurgery: review of complications. J Neurosurg Anesthesiol. 2006;18:64-7.
16. Binder DK, Rau GM, Starr PA. Risk factors for hemorrhage during microelectrode-guided deep brain stimulator implantation for movement disorders. Neurosurgery. 2005;56:722-32.
17. Poston KL, Frucht SJ. Movement disorder emergencies. J Neurol. 2008;255 Suppl. 4:2-13.
18. Stagg P, Grice T. Nasogastric medication for perioperative Parkinson's rigidity during anaesthesia emergence. Anaesth Intens Care. 2011;39:1128-30.
19. Valero R, Martin N, Hurtado P, Hervias A, Rumia J, Fàbregas N. Is fast track after deep brain stimulation surgery (DBS) a safe alternative to "overnight intensive care"? J Neurosurg Anesthesiol. 2011;23:447-8.
20. Teo C, Kadrian D, Hayhurst C. Endoscopic management of complex hydrocephalus. World Neurosurg. 2013;79:S21-7.
21. Zymberg ST. Neurocysticercosis. World Neurosurg. 2013;79:S24-8.
22. Derbent A, Ersahin Y, Yurtseven T, Turhan T. Hemodynamic and electrolyte changes in patients undergoing neuroendoscopic procedures. Childs Nerv Syst. 2006;22:253-7.
23. Margetis K, Souweidane MM. Endoscopic treatment of intraventricular cystic tumors. World Neurosurg. 2013;79:S19-21.
24. Fabregas N, Valero R, Carrero E, Tercero J, Caral L, Zavala E, et al. Episodic high irrigation pressure during surgical neuroendoscopy may cause intermittent intracranial circulatory insufficiency. J Neurosurg Anesthesiol. 2001;13:152-7.
25. Kalmar AF, van Aken J, Struys MM. Exceptional clinical observation: total brain ischemia during normal intracranial pressure readings caused by obstruction of the outflow of a neuroendoscope. J Neurosurg Anesthesiol. 2005;17:175-6.
26. Kalmar AF, van Aken J, Caemaert J, Mortier EP, Struys MM. Value of Cushing reflex as warning sign for brain ischaemia during neuroendoscopy. Br J Anaesth. 2005;94:791-9.
27. van Aken J, Struys M, Verplancke T, de Baerdemaeker L, Caemaert J, Mortier E. Cardiovascular changes during endoscopic third ventriculostomy. Minim Invasive Neurosurg. 2003;46:198-201.
28. Salvador L, Valero R, Carrero E, Caral L, Fernandez S, Marin JL, et al. Cerebrospinal fluid composition modifications after neuroendoscopic procedures. Minim Invasive Neurosurg. 2007;50:51-5.
29. Cinalli G, Spennato P, Ruggiero C, Aliberti F, Zerah M, Trischitta V, et al. Intracranial pressure monitoring and lumbar puncture after endoscopic third ventriculostomy in children. Neurosurgery. 2006;58:126-36.
30. Fabregas N, Craen RA. Pressure inside the neuroendoscope should be measured on the inflow channel. J Neurosurg Anesthesiol. 2006;18:161-3.
31. Ganjoo P, Sethi S, Tandon MS, Singh D, Pandey BC. Perioperative complications of intraventricular neuroendoscopy: a 7-year experience. Turk Neurosurg. 2010;20:33-8.
32. Salvador L, Hurtado P, Valero R, Tercero J, Carrero E, Caral L, et al. Importance of monitoring neuroendoscopic intracranial pressure during anesthesia for neuroendoscopic surgery: review of 101 cases. Rev Esp Anestesiol Reanim. 2009;56:75-82.
33. Lai L, Morgan MK, Trooboff S, Harvey RJ. A systematic review of published evidence on expanded endoscopic endonasal skull base surgery and the risk of postoperative seizure. J Clin Neurosci. 2013;20:197-203.
34. Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery. 2008;62:1006-15.
35. Mosca S, Paolillo S, Colao A, Bossone E, Cittadini A, Iudice FL, et al. Cardiovascular involvement in patients affected by acromegaly: an appraisal. Int J Cardiol. 2013;167:1712-8.
36. Berg C, Petersenn S, Lahner H, Herrmann BL, Buchfelder M, Droste M, et al. Cardiovascular risk factors in patients with uncontrolled and long-term acromegaly: comparison with matched data from the general population and the effect of disease control. J Clin Endocrinol Metab. 2010;95:3648-56.
37. Dunn LK, Nemergut EC. Anesthesia for transsphenoidal pituitary surgery. Curr Opin Anaesthesiol. 2013;26:549-54.
38. Nemergut EC, Zuo Z. Airway management in patients with pituitary disease: a review of 746 patients. J Neurosurg Anesthesiol. 2006;18:73-7.
39. Schmitt H, Buchfelder M, Radespiel-Troger M, Fahlbusch R. Difficult intubation in acromegalic patients: incidence and predictability. Anesthesiology. 2000;93:110-4.
40. Gemma M, Tommasino C, Cozzi S, Narcisi S, Mortini P, Losa M, et al. Remifentanil provides hemodynamic stability and faster awakening time in transsphenoidal surgery. Anesth Analg. 2002;94:163-8.
41. Ali Z, Prabhakar H, Bithal PK, Dash HH. Bispectral index-guided administration of anesthesia for transsphenoidal resection of pituitary tumors: a comparison of 3 anesthetic techniques. J Neurosurg Anesthesiol. 2009;21:10-5.
42. Mariano ER, Watson D, Loland VJ, Chu LF, Cheng GS, Mehta SH, et al. Bilateral infraorbital nerve blocks decrease postoperative pain but do not reduce time to discharge following outpatient nasal surgery. Can J Anaesth. 2009;56:584-9.
43. Van Noord BA, Stalker CL, Roffey P, Thangathurai D. The use of regional cerebral oximetry monitoring during controlled hypotension: a case series. J Clin Monit Comput. 2014;28:319-23.
44. Moerman A, Denys W, De SF, Wouters PF, De Hert SG. Influence of variations in systemic blood flow and pressure on cerebral and systemic oxygen saturation in cardiopulmonary bypass patients. Br J Anaesth. 2013;111:619-26.
45. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg. 2013;118:621-31.
46. Jakimovski D, Bonci G, Attia M, Shao H, Hofstetter C, Tsiouris AJ, et al. Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg. 2013, pii: 10.1016/j.wneu.2013.06.005. [Epub ahead of print]
47. De Witte O, Carlot S, Devuyst E, Choufani G, Hassid S. Minimally invasive endoscopic unilateral transsphenoidal surgery for pituitary adenomas. B-ENT. 2011;7 Suppl. 17: 27-32.
48. >Nemergut EC, Dumont AS, Barry UT, Laws ER. Perioperative management of patients undergoing transsphenoidal pituitary surgery. Anesth Analg. 2005;101:1170-81.
49. Ensenat J, Alobid I, de Notaris M, Sanchez M, Valero R, Prats-Galino A, et al. Endoscopic endonasal clipping of a ruptured vertebral-posterior inferior cerebellar artery aneurysm: technical case report. Neurosurgery. 2011;69, onsE121-7.
50. Castillo R, Hurtado P, Valero R, Serna G, Gracia I, Fàbregas N. Rationalization of the postoperative care in transphenoidal pituitary surgery: application of a risk scale protocol. Eur J Anesthesiol. 2012;29, http://dx.doi.org/10.1097/01.EJA.0000412496.74513.6c (S49) A 50.
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