Transcript REVIEW UPDATE IN NEUROSURGICAL ANESTHESIOLOGY

UPDATED REVIEW IN
NEUROSURGICAL
ANESTHESIOLOGY AND
NEURO-CRITICAL CARE
RAMSIS F. GHALY, MD, FACS
DEPARTMENT OF
ANESTHESIOLGY AND PAIN
MANAGEMENT, ADVOCATE
ILLINOIS MASONIC MEDICAL
CENTER
GHALY NEUROSURGICAL
ASSOCIATES
NEUROANATOMY AND
NEURORADIOLOGY RVIEW FOR
THE ANESTHESIOLOGIST
RAMSIS F. GHALY, MD,
FACS
HEAD, BRAIN AND
CRANIAL NERVES
Anatomy of the Brain
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Approximately 2% of total body weight
Weighs 1400g in average young adult
Weighs 1200g in average elderly person
Major divisions
• Cerebrum
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2 hemispheres
Thalamus
Hypothalamus
Basal Ganglia
–Brain Stem
•Midbrain
•Pons
•Medulla
–Cerebellum
•Located under
the cerebrum
and behind the
brain stem
Meninges
• Dura Mater
• Outermost layer, covers the brain and
spinal cord
• Tough, think, inelastic fibrous, gray
• Epidural space is between the skull and
the dura mater
• Subdural space is between the dura
mater and the arachnoid mater
• Several folds of the dura mater
Meninges
• Arachnoid layer
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Middle membrane
Closely resembles a spider web
Responsible for production of CSF
Substantial vascular supply
Subdural space is between the dura and
the arachnoid layer
• The subarachnoid space is located
between the arachnoid and pia layers and
contains the CSF
Cerebrum – Lobes of brain
• Frontal
• Personality
• Behavior
• Intellectual
functions
• Short-term
memory
• Voluntary motor
function
• Motor speech
(Broca’s area)
• Parietal
• Localization
• Sensory integration/
discrimination
• Object recognition
• Position sense
• Body awareness
• Body image
Cerebrum – Lobes of brain
Temporal
• Emotion
• Processing smell,
hearing, tastes
• Sensory speech
Occipital
• Processing visual input
Brain Stem
• Functions
• Relays messages
between the
brain and lower
levels of the
nervous system
• Is the origin of
all cranial
nerves except
1st and 2nd
Brain Stem
• Midbrain (Mesencephalon)
• Connects the pons and cerebellum with the
cerebral hemispheres
• Center for auditory & visual reflexes
• Origin of 3rd and 4th cranial nerves
• Contains motor and sensory pathways
• Location of reticular activating system
(RAS)
• Responsible for arousal from sleep,
wakefulness, focusing of attention
Cerebellum
• Coordinates muscle movement with
sensory input
• Controls balance
• Influences muscle tone in relation to
equilibrium
• Affects locomotion and posture
• Controls non-stereotyped movements
• Synchronizes muscle action
Neurons
• Dendrites
• Message-receiving
• Cell body
• Axons
• Message-sending
• Both are branching fibers that
reach out in many extensions to
join the neuron to other
neurons
• The junction between the axon
of one cell and the dendrite of
another is a minute gad, which
is called a synapse
Neurotransmitters
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Communication at the synapses
between neurons relies on chemicals
called neurotransmitters
More than 50 different
neurotransmitters identified
Proposed that almost all drugs work
through neurotransmitters
Blood Brain Barrier
• Not a true structure, but is a special
permeability characteristic of brain
capillaries and choroid plexus
• Functions
• Acts to limit transfer of certain substances
into ECF or CSF of the brain
• May hinder the effective use of certain drug
therapies in the treatment of neurologic system
problems
• May be altered by trauma, infection,
intracranial tumor, brain irradiation
Cerebral Circulation
Anterior Circulation
(Internal Carotid)
• Anterior Cerebral
• Frontal & parietal lobes
(superior surface)
• Basal ganglia
• Corpus callosum
• Hypothalamus
• Middle Cerebral
• Parietal, frontal, &
temporal lobes (lateral
surfaces
• Superior surface of
temporal lobe
Posterior Circulation
(Vertebral system)
• Basilar arteries
• Most of brain stem
• Cerebellum
• Posterior cerebral
arteries
• Thalamus
• Medial portion of
occipital
• Inferior portion of
temporal
Venous System
• Cerebrum has external veins that lie in the
subarachnoid space on surfaces of
hemispheres and internal veins that drain
the central core of the cerebrum and lie
beneath the corpus callosum
• Both external and internal venous systems
empty into venous sinuses that lie between
dural layers
• The internal jugular veins collect blood
from the dural venous sinuses
CTSCAN: BRAIN TUMOR
AP C-SPINE X-RAY
SYMPATHETIC SYSTEM
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SYMPATHETIC, PREGANGLIONIC FIBERS ARISE FROM THE
THORACOLUMBAR PORTION OF THE SPINAL CORD FROM FIRST
THORACIC TO THIRD LUMAR SEGMENT OF THE SPINAL CORD
PREGANGLIONIC FIBERS HAVE CELL BODIES WITHIN
INTERMEDIOLATERAL COLUMNS OF THE SPINAL GRAY
MATTER.
NERVE FIBERS FROM THESE CELL BODIES EXTEND TO 3 TYPES
OF GANGLIA, PAIRED SYMPATHETIC CHAINS, UNPAIRED
DISTAL PLEXUSES OR TERMINAL/ COLLATERAL CLOSE TO
TARGET ORGAN.
AUTONOMIC GANGLION, A NUMBER OF CELL BODIES ACT AS
SYNAPSE BETWEEN PREGANGLIONIC AND POSTGANGLIONIC
FIBERS
22 PAIRED GANGLIA ALONG EITHER SIDE OF THE SPINE.
NERVE TRUNKS CONNECT THESE GANGLIA TO EACH OTHER
AND GRAY RAMI COMMUNICANTES TO THE SPINAL NERVES
SYMPATHETIC SYSTEM
• PREGANGLIONIC FIBERS LEAVE ANTERIOR NERVE
ROOTS → SPINAL NERVE TRUNK→ GANGLION
THROUGH WHITE MYELINATED RAMUS
POSTSYNAPTIC FIBERS → SPINAL NERVE
THROUGH GRAY RAMUS → PILOMOTOR,
SUDOMOTOR EFFECTORS, BLOOD VESSELS,
SKELETAL MUSCLE AND SKIN
• SYMPATHETIC INNERVATION OF TRUNK AND
LIMBS CARRIED BY SPINAL NERVES
• POSTGANGLIONIC SYMPATHETIC FIBERS ARE
DISTRIBUTED THROUGHOUT THE BODY.
• HEAD AND NECK SUPPLIED BY CERVICAL
SYMPATHETIC CHAIN THREE GANGLIA (SUPERIOR,
MIDDLE AND INFERIOR)
SYMPATHETIC SYSTEM
• STELLATE GANGLION IS FORMED BY FUSION OF
INFERIOR CERVICAL GANGLION WITH FIRST
THORACIC GANGLION
• UNPAIRED PREVERTEBRAL GANGLIA RESIDE IN
ABDOMEN AND PELVIS ANTERIOR TO VERTEBRAL
COLUMN: CELIAC, SUPERIOR MESENTERIC,
AORTICORENAL AND INFERIOR MESENTERIC
GANGLIA
• CELIAC GANGLION INNERVATED BY T5 THROUGH
T12
PARASYMPATHETIC
SYSTEM
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PARASYMPATHETIC, PREGANGLIONIC FIBERS ARISE FROM THE
CERVICOSACRAL PORTION OF THE SPINAL COIRD. IT ARISES
FROM CRANIAL NERVES III, VII, IX, AND X. PREGANGLIONIC
FIBERS ARISE FROM MIDBRAIN (EDINGER-WESTPHAL N.),
MEDULLA OBLONGATA. PARASYMPATHETIC SACRAL TWO TO
SACRAL FOURTH SEGMENTS TO PELVIC SPLANCHNIC NERVES.
WHILE DISTRIBUTION OF PARASYMPATHETIS IS DISCRET AND
CLOSE TO THE ORGANS INNERVATED
PERIPERAL AUTONOMIC
NERVOUS SYSTEM
• SYMPATHETIC NOREPINEPHERINE AS A
NEUROTRANSMITTER (ADRENERGIC).
ADRENERGIC RECEPTORS (BETA, ALPHA)
• PARASYMPATHETIC ACETYLECHOLINE AS
NEUROTRANSMITTER (CHOLINERGIC) NICOTINIC
AND MUSCARINIC RECEPTORS
AIRWAY MANAGEMENT
FIELD ENJOYED MANY CHANGES
AND NEW TECHNIQUES HAVE
DEVELOPED AS WELL AS BEING
DEVELOPED
POSITIVE IMPACT ON AIRWAY
SAFTEY AND THE OVERALL CLAIMS
DUE TO IRREVERSIBLE ANOXIC
BRAIN DAMAGE FROM
AIRWAY OPTIONS
• CONVENTIONAL
• TO AVOID ↑ICP→
MUST BE DEEPLY ANESTHETIZED
MUST USE FULL NEUROMUSCULAR BLOCKADE
MAINTAINING GOOD OXYGENATION
MAINTAINING PACO2= OR <35
CONSIDER LOCAL ANESTHETIC SPRAY AND IV
LIDOCAINE
• AIRWAY VISUALIZATION
DIRECT LARYNGOSCOPY - VIDEO LARYNGOSCOPY
FIBEROPTIC SCOPE
• INTUBATION USING REGULAR ENDOTRACHEAL
TUBE
AIRWAY OPTIONS
INDIRECT LARYNGOSCOPY
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SMOOTH LESS TRAUMA TIC
LESS C-SPINE MANIPULATION
LESS STIMULANT LESS COUGH
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TYPES:
LMA- LMA PROSEAL- FASTRACH INTUBATING LMA- VIDEO
LARYNGOSCOPIC LMA- LMA WITH FIBEROPTIC CONNECTION
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EXAMPLES WHEN TO USE IN NEUROANESTHESIA:
INTERMITTENTLY DURING AWAKE CRANIOTOMY
NEURORADIOLOGY
ECT, DBS SURGERY
TO REPLACE ETT JUST BEFORE EMERGENCE AS A
TRANSITION FROM ETT TO PREVENT COUGHING AND ALLOW
SMOOTH EMERGENCE
AIRWAY MANAGEMENT:
OPTIONS FOR DIFFICULT
INTUBATION
REMEMBER
AVAILABLE
READY
HANDY
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AWAKE LARYNGOSCOPY
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AWAKE LMA FASTRACH
AWAKE FIBEROPTIC SCOPE
AWAKE VIDEO LARYNGOSCOPY
AWAKE BLIND NASAL INTUBATION
THE GUM ELASTIC BOUGIE
THE LIGHT WAND
RETROGRADE TRACHEAL INTUBATION
RIGID BRONCHOSCOPY
COMBITUBE (ESPHOGEAL INTUBATION) CAN BE PLACED IN
ANY POSITION, NO NEED FOR LARYNGOSCOPY OR NECK
MANIPULATION.
TRANSTRACHEAL JET VENTILATION
INVASIVE AIRWAY ACCESS
CRICOTHYROIDOTOMY - TRACHEOSTOMY OPEN OR
PERCUTANEOUS AT BEDSIDE
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THE END
THANK YOU
?QUESTIONS