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INTRACEREBRAL VASCULAR PROCEDURES AND ANESTHESIA

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INTRACEREBRAL VASCULAR PROCEDURES AND ANESTHESIA Martha Richter, MSN, CRNA mlr 2007 * * * * * * 2 ANEURYSMS IN THE MIDDLE CEREBRAL ARTERY * * * * * * Monitoring for ... – PowerPoint PPT presentation

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Title: INTRACEREBRAL VASCULAR PROCEDURES AND ANESTHESIA


1
INTRACEREBRAL VASCULAR PROCEDURES AND ANESTHESIA
  • Martha Richter, MSN, CRNA

2
OBJECTIVES
  • The student will
  • Review considerations re carotid surgery, AVMs
    and cerebral aneurysms
  • Apply principals of anesthetic management to
    formulate sound anesthesia plans
  • Understand the effects of anesthesia management
    during these surgical procedures

3
CEREBRAL CIRCULATION
  • A review
  • L Carotid comes off Aortic Arch
  • R Carotid comes off Brachiocephalic
  • Each bifurcates to form internal and external
    branches
  • Vertebrals comes off subclavian arteries
  • Vertebrals join at base of brain to form basilar
    a.
  • Bifurcates each side gives rise to posterior
    communicating from posterior cerebral

4
CEREBRAL CIRCULATION
  • Post communicating a.s join internal carotids
    after the ICs have given off ophthalmic br.
  • Middle cerebral a.s exit ICs

5
CIRCLE OF WILLIS
  • Circle of Willis is formed by anterior
    communicating a. connecting middle cerebral a.s,
    and 2 posterior communicating a.s connect the
    internal carotid with posterior cerebral a.

6
CEREBRAL CIRCULATION
7
CEREBRAL CIRCULATION
8
CAROTID ARTERY STENOSIS
  • Most common cause atherosclerosis
  • Part of generalized effects of disease process
  • Placque rupture may lead to stroke
  • Remember the effects of atherosclerosis on other
    organ systems!

9
CAROTID ARTERY STENOSIS
  • TIA often prelude to event usually resolve
    within 24 hours
  • CVA
  • 80 ischemic
  • 20 hemorrhagic
  • Deficit lasts gt24 hours

10
CAROTID ARTERY DISEASE
  • Stroke risk
  • 30 2 years after TIA
  • 55 12 years after TIA

11
CAROTID ARTERY DISEASE
  • Risk factors
  • Advanced age
  • Hypertension
  • Tobacco
  • Hyperlipidemia
  • DM

12
CAROTID ARTERY DISEASE
  • Surgical mortality 1-4
  • Primary issue CAD
  • Neuro morbidity intraop 4-10
  • More prominent when pre existing deficits are
    present

13
CAROTID ARTERY DISEASE
  • Highest MM (intraop)
  • agegt75
  • Symptomatic
  • Uncontrolled HTN
  • Angina
  • DM
  • Thrombus/occlusion near carotid siphon

14
CAROTID ARTERY DISEASE
  • Symptoms depend on collaterals
  • May include visual symptoms (sm emboli in
    ophthalmic branches)
  • MCA
  • Usually larger emboli
  • Contralateral M S deficits
  • ACA
  • Contralateral M S deficits with greater effect
    on legs

15
DIAGNOSTIC TESTING
  • CT Scan
  • MRA
  • Angiography

16
ANGIOGRAPHIC CONFIRMATION
17
SURGICAL OPTIONS
  • STENTING
  • Interventional lab
  • OR
  • CAROTID ENDARTERECTOMY
  • OR
  • Open procedure

18
STENTING
19
STENTING
  • May be performed with GA or MAC
  • May be preferred for patients at very high risk
  • Requires anesthetic management considerations
  • Invasive monitoring
  • IV access
  • 5 lead EKG monitoring
  • Considerations if EEG monitoring is used

20
ANESTHESIA CONSIDERATIONS
  • Be prepared with ASO4! Bradycardia is common and
    may be severe during balloon inflation!
  • Heparin

21
CEA
22
CEA
  • Asymptomatic stenosis gt60 (severe)
  • TIAs with ipsilateral severe stenosis
  • Severe stenosis with incomplete stroke
  • 30-70 occlusion with ipsilateral sx
  • May indicate ulcerated plaque

23
ANESTHESIA CONSIDERATIONS
  • Neurological status
  • Thorough and complete documentation
  • Stable vs unstable
  • CAD status
  • Status of dipridamole-thallium studies
  • No redistribution-gtproceed
  • Redistribution?coronary angio?intervention as
    needed?CEA
  • Any other systems affected by atherosclerosis?

24
ANESTHESIA CONSIDERATIONS
  • EEG monitoring?
  • Follow recommendations
  • Any other neuro monitoring?
  • Follow recommendations
  • Carotid stump pressures (distal) lt 50mmHgneeds a
    shunt!
  • May be done with GA, local or regional techniques

25
ANESTHESIA CONSIDERATIONS
  • Maintain BP within pre-established parameters
    patient dependent
  • Art line
  • 5 lead EKG
  • Pressors as needed
  • Phenylephrine
  • Nitroglycerine
  • nitroprusside

26
ANESTHESIA CONSIDERATIONS
  • Protective effects of barbs
  • May be asked to give thiopental prior to
    occlusion (usually in absence of shunt)
  • Induction agents as usual
  • Blunt hypertensive response to intubation!
  • Isocerebroprotective
  • Nicardipine may be chosen for HTN control
    protective in focal ischemia

27
ANESTHESIA CONSIDERATIONS
  • Carotid body manipulation bradycardia
  • Lidocaine by surgeon
  • ASO4/glyco
  • Normocarbia (remember the effects of
    hypo/hypercarbia on CBF)
  • Usually low blood loss (potential for high)
  • No requirement for large amounts fluids

28
ANESTHESIA CONSIDERATIONS
  • Smooth emergence with tight B/P control
  • May require pressors
  • Postoperative neuro checks document!
  • Severe hypertension may occur postop b/o
    denervation of carotid sinus/too much IV flds
  • Peaks 2-3 hrs postop, may persist 24 hrs as
    baroreceptors adapt

29
ANESTHESIA CONSIDERATIONS
  • Have heparin and protamine in room
  • Superficial/deep cervical plexus blocks
  • Awake patient neuromonitor
  • Remember possible effect on phrenic n.

30
AVMs
  • Arteriovenous malformations
  • Masses of vessels that are abnormal
  • Nidus (nest) allows arteries to connect directly
    to veins
  • May be congenital
  • With time, malformation becomes a mass of
    wormlike structures

31
AVMs
32
AVMs
  • Highest likelihood for bleed ages 10-55
  • Hemorrhage incidence 3-4/yr
  • Morbidity 1
  • After first hemorrhage, risk of rebleed is 20
    (1st year out), then down to 3-4
  • 140100,000 in US

33
AVMs
  • What happens when they bleed?
  • Headache
  • Loss of neurologic function (stroke)
  • Bruit
  • Muscle weakness
  • Paresthesias, ataxia, apraxia, dysesthesias
  • Memory deficit, confusion , subtle learning
    disorders

34
AVMs
  • Diagnosed by
  • CT scan
  • MRA
  • MRI
  • Cerebral angiography

35
AVMs
36
AVMs
  • Methods of treatment
  • Radiation
  • Embolization
  • Surgery
  • Nothing

37
Treatment
  • Radiation
  • Stereotactic radiosurgery (Gamma Knife)
  • May be chosen for small masses deep in brain
  • Over time, mass will shrink/disappear
  • Requires placement of headframe (uncomfortable)
  • Mild sedation
  • Requires hours for placement, scans,
    determination of angles and depths for beam
    placement

38
GAMMA KNIFE
39
GAMMA KNIFE
40
GAMMA KNIFE
41
GAMMA KNIFE
42
GAMMA KNIFE
43
AVMs
44
EMBOLIZATION
  • Endovascular approach
  • Transfemoral
  • Interventional neuroradiology
  • GA

45
EMBOLIZATION
  • Malformation is filled with
  • Coils
  • Glues
  • Plastic spheres
  • balloons

46
EMBOLIZATION
  • May be only Rx required
  • Able to be repeated for multiple AVMs

47
EMBOLIZATION AND ANESTHESIA
  • Art line
  • 2 large bore IVs
  • Pressors for tight B/P control-in line
  • Nitroprusside
  • Neosynephrine
  • Normocapnia
  • Heparin/protamine in room

48
EMBOLIZATION AND ANESTHESIA
  • Thiopental and brain protection
  • Iso
  • NDMR
  • Long procedure
  • To ICU postop
  • As always, preop neuro check with full
    documentation.

49
NO THERAPY
  • May be best choice after balance risk/benefit
  • Large AVM in brainstem
  • Extreme age with extensive significant
    co-morbidities

50
SURGICAL EXCISION
  • Cure total excision
  • Prepare for possible large blood loss!
  • A-line
  • 2 large bore IVs
  • Methods for warming/cooling patient
  • Be aware of positional needs
  • Where is it? Posterior prone or sitting?
  • What additional items do you need for this
    consideration?

51
SURGICAL EXCISION
  • Have the blood in the room and checked
  • Follow serial labs
  • ABG
  • H/H, pltlets

52
SURGICAL EXCISION
  • Remember airway considerations if this is
    stereotactic guided!
  • FOB with difficult cart
  • Awake intubation (sedation and topical)

53
STEREOTACTIC THOUGHTS
54
STEREOTACTIC THOUGHTS
55
STEREOTACTIC THOUGHTS
56
MORE ANESTHESIA CONSIDERATIONS
  • Goals
  • Maintain CPP
  • MAP-ICP
  • Decrease CMRO2
  • Hypothermia
  • Pentothal
  • Limit fluids normovolemia
  • Mannitol
  • CSF drain

57
ANESTHESIA CONSIDERATIONS
  • Controlling the B/P (and CPP)
  • Agent
  • Pressor infusion
  • Esmolol
  • Nitroprusside
  • normovolemia

58
FINISHING THE CASE
  • Rewarm
  • Prophylaxis for hypertension on emergence
  • Blunt reflexes
  • HOB raised 30 degrees
  • Antiemetics
  • Awake in OR for neuro checks

59
INTRACEREBRAL ANEURYSMS
  • Weakening of vessel wall ? expansion
    (outpouching)?further weakening?may lead to
    rupture

60
ANEURYSMS
  • Predisposing factors
  • congenital malformations
  • mycotic infections
  • HTN
  • Atherosclerosis
  • trauma
  • smoking
  • ? Drug abuse
  • ? Contraceptive drugs

61
ANEURYSMS
  • 10-30 have more than one
  • Typically found at bifurcation of large arteries
    at base of brain
  • Turbulence
  • Most of these in anterior circle of Willis

62
ANEURYSMS
  • 2-5 population
  • MF 32
  • Any age group

63
ANEURYSMS
  • Berry
  • Resembles a pouch or berry hanging from vine.
    All 3 layers are involved in sack
  • Most common
  • Fusiform
  • Widening occurs along all walls
  • Lateral
  • One side of vessel involved

64
ANEURYSMS
65
ANEURYSMS
66
ANEURYSMS
67
ANEURYSMS
  • Unruptured
  • Unsymptomatic
  • Coincidental
  • Procedure or invention
  • Size
  • Location
  • Risk
  • Age of pt
  • General health status

68
ANEURYSMS
  • RUPTURE
  • SAH stroke
  • worst headache I ever had
  • /- deficits

69
ANEURYSMS
  • Vasospasm
  • Main cause of MM
  • May occur up to 14 days post bleed
  • Thought to be d/t blood in subarachnoid sp

70
ANEURYSMS
  • RUPTURE
  • rebleed mortality 60
  • Surgery immediately performed

71
ANEURYSMS
  • ANESTHETIC GOALS
  • Prevent rupture (if unruptured)
  • Prevent rebleed
  • Maintain CPP
  • Minimize hemodynamic issues
  • Maintain required operating conditions

72
ANEURYSMS
  • ANESTHETIC TECHNIQUES
  • Neuromonitoring
  • EEG
  • SSEP
  • MEPS

73
ANEURYSMS
  • ANESTHETIC TECHNIQUES
  • 0.5 MAC agent
  • Narcotic supplement
  • Remi infusion
  • Painful stimuli
  • intubation
  • Pins
  • Incision
  • Bone flap

74
ANEURYSMS
  • B/P control
  • Stability control transmural pressure of
    aneurysm
  • Esmolol
  • NTG
  • Nitroprusside

75
ANEURYSMS
  • ELECTIVE HYPOTENSION
  • Contra in pts with CV , renal disease
  • Being used less often today
  • With use of pharmacological agents, MAP is
    dropped
  • Particularly useful during isolation of aneurysm,
    preparation for clipping, accidental rupture

76
ANEURYSMS
Temporary clips may not require hypotension
77
ANEURYSMS
78
ANEURYSMS
  • PROTECTING THE BRAIN
  • Controlled hypotension ? dec blood loss
  • Burst suppression
  • Hemodilution
  • slack brain
  • Deliberate hypothermia
  • CMRO2 dec with temps lt34 C
  • CBF dec 5-7/degree C temp drop
  • Rewarm at end

79
ANEURYSMS
  • Use of Burst Suppression
  • Prior to clamping
  • During clamp, hope for adequate collaterals to
    prevent ischemia
  • Dec CMRO2
  • Pentothal 100 mg increments until suppressed per
    EEG
  • Infusion 1-4mg/kg/hr
  • Propofol 50-150 ucg/kg/hr

80
ANEURYSMS
  • Hemodilution controversial
  • Imp cerebral perf w/ Hct 30-35
  • May reduce perioperative vasospasm
  • May follow normovolemia?clip?hypervolemia
  • Caution in patients with LVD

81
ANEURYSMS
  • Producing the slack brain
  • Mannitol
  • Hyperventilation
  • HOB elevated
  • CSF drainage

82
ANEURYSMS
  • Mannitol
  • After bone flap raised
  • Avoid tearing bridging veins
  • After dura opened
  • May inc possibility of aneurysm rupture
  • Caution in pts with LVDysfunction

83
ANEURYSMS
  • Hyperventilation
  • Rapid results
  • Dec CBF
  • Reverse steal (Robin Hood)
  • ABG will give gradient
  • PaCO2 lower 2-5 mmHg than ETCO2
  • Surgeon evaluates brain tension when dura open

84
ANEURYSMS
  • CSF DRAINAGE
  • Via lumbar catheter
  • May be required in addition to other techniques
    to dec brain size (mass, CSF, CBF)
  • Max rate of removal 5 ml/min

85
ANEURYSMSPREOP
  • Usual evaluation head to toe
  • Sedation if no ICP issues
  • Ruptured? Leaking?
  • Document any deficits if present
  • Full labs for evaluation
  • EKG
  • r/o MI changes are normally seen!

86
ANEURYSMS
  • Have the blood in the room!
  • Bair hugger
  • Enough infusion pumps for the case
  • Invasive monitoring pre induction
  • Art line
  • CVP

87
ANEURYSMS
  • Get drips ready for
  • Esmolol
  • Nitroprusside
  • NTG
  • Nicardipine
  • Thiopental/Propofol

88
ANEURYSMS
  • Other drugs
  • Labetolol
  • Decadron
  • Mannitol

89
ANEURYSMS
  • Want a smooth induction, intubation, progress
    leading up to finding aneurysm
  • Decision for hypothermia, hypotension, etc., made
    by team interactions
  • Temporary clipping after burst suppression?EEG
    assess?do not exceed 10 min (eval for ischemia)
  • Permanent clip may require angio on table

90
ANEURYSMS
  • AFTER CLIPPING
  • B/P up slightly
  • Flds/blood as appropriate
  • Begin rewarming

91
ANEURYSMS
  • Emergence
  • No bucking!
  • Smooth
  • Blunt
  • Antihypertensives
  • Neuro evaluation in OR
  • To extubate or not!

92
ANEURYSMS
  • Key points
  • The importance of preventing vasospasm!
  • TRIPLE- H THERAPY
  • HEMODILUTION
  • HYPERVOLEMIA
  • HYPERTENSION

93
COILING THE ANEURYSMS
  • Interventional Radiology
  • Considerations the same as for open clipping
  • Access via groin catheters
  • Additionally need Heparin and Protamine
  • May be chosen in unruptured, very ill

94
COILING THE ANEURYSMS
95
COILING THE ANEURYSMS
96
COILING THE ANEURYSMS
97
ANEURYSMS
  • To Neuro ICU
  • /- ETT
  • Relaxants
  • Infusions to maintain unconscious state
  • Awake with satisfactory neuro checks
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