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  3. Core Topics in Neuroanaesthesia and Neurointensive Care
  • Cited by 7
  • Edited by Basil F. Matta, Addenbrooke's Hospital, Cambridge, David K. Menon, Addenbrooke's Hospital, Cambridge, Martin Smith, Department of Neuroanaesthesia and Neurocritical Care, the National Hospital for Neurology and Neurosurgery, University College London Hospitals
Publisher:
Cambridge University Press
Online publication date:
December 2011
Print publication year:
2011
Online ISBN:
9780511977558
DOI:
https://doi.org/10.1017/CBO9780511977558
Subjects:
Anesthesia, Intensive Care, Pain Management, Neurology and Clinical Neuroscience, Medicine
Information

Book description

Core Topics in Neuroanesthesia and Neurointensive Care is an authoritative and practical clinical text that offers clear diagnostic and management guidance for a wide range of neuroanesthesia and neurocritical care problems. With coverage of every aspect of the discipline by outstanding world experts, this should be the first book to which practitioners turn for easily accessible and definitive advice. Initial sections cover relevant anatomy, physiology and pharmacology, intraoperative and critical care monitoring and neuroimaging. These are followed by detailed sections covering all aspects of neuroanesthesia and neurointensive care in both adult and pediatric patients. The final chapter discusses ethical and legal issues. Each chapter delivers a state-of-the art review of clinical practice, including outcome data when available. Enhanced throughout with numerous clinical photographs and line drawings, this practical and accessible text is key reading for trainee and consultant anesthetists and critical care specialists.

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Contents

Page 1 of 2

Contents
  • 9 - Multimodality monitoring
    pp 119-127
  • View abstract

    Summary

    This chapter provides some of the key neuroanatomical considerations that may impact on neuroanaesthesia and neurointensive care. There are multiple factors that require consideration when planning an operative approach. A good grasp of neuroanatomy is essential both in the operating room as well as the pre-operative stage in terms of assessing the relative likelihood of pathology causing the clinical symptoms and signs. The chapter discusses the functional significance of the cerebral and cerebellar hemispheres. The frontal lobes are the cerebral hemispheres anterior to the Rolandic fissure. The cerebral circulation is made up of two components. The anterior circulation is fed by the internal carotid arteries, while the posterior circulation derives from the vertebral arteries. Flow of cerebrospinal fluid (CSF) across the ventricular wall into the brain extracellular space is not an important mechanism under physiological conditions.
  • Section 3 - Neuroanaesthesia
    pp 147-270
  • View abstract

    Summary

    The cerebral circulation is protected from systemic blood pressure surges by a complex branching system and two resistance elements: the first of these lies in the large cerebral arteries, and the second in vessels of diameter <100 μm. Endothelial cells in cerebral capillaries contain few pinocytic vesicles and are sealed with tight junctions, without any anatomical gap. Several endogenous substances including catecholamines and vascular growth enhancing factor can dynamically modulate blood-brain barrier (BBB) permeability. Classical cerebral autoregulation assessment does not consider the latency of autoregulatory mechanisms, focusing instead on the maintenance of cerebral blood flow (CBF) at different steady state levels of cerebral perfusion pressure (CPP). Methods of measuring CBF may be regional or global, and may be applicable either to humans or primarily to experimental animals. Severe head injury is accompanied by both direct and indirect effects on CBF and metabolism, which show both temporal and spatial variations.
  • 12 - Anaesthesia for supratentorial surgery
    pp 162-177
  • View abstract

    Summary

    This chapter explains the mechanisms leading to neuronal cell death and the most important neuroprotective strategies. Cerebral ischaemia and/or hypoxia may occur as a consequence of shock, respiratory failure, vascular stenosis or occlusion, vasospasm, neurotrauma or cardiac arrest. Ischaemic or traumatic challenges affect both inadequate delivery of oxygen and glucose, and impairment of mitochondrial function, leading to inadequate production of ATP. Two different types of cell death may occur following brain injury: necrosis and apoptosis. New therapeutic targets could be designed to obtain a correct modulation of the immune system and to reduce cerebral damage after brain injury. The proposed mechanisms of anaesthetic protection include reduction of cerebral metabolism and intracranial pressure (ICP), and suppression of seizures and sympathetic discharge. Hypoxia and ischaemia are recognized as important driving forces of erythropoietin expression in the brain, suggesting that erythropoietin is part of a self-regulating physiological protection mechanism to prevent neuronal injury.
  • 13 - Anaesthesia for intracranial vascular surgery and carotid disease
    pp 178-204
  • View abstract

    Summary

    The intracranial pressure (ICP) has three components: an arterial vascular component; a cerebrospinal fluid (CSF) circulatory component; and a venous outflow component. More generally, multiple variables such as the arterial pulsatile pressure, autoregulation and cerebral venous outflow all contribute to the vascular component. Intracranial compliance is a concept often associated with CSF storage. Measurement of brain compliance is classically performed using a CSF bolus injection. In sedated patients with TBI, continuous ICP monitoring is recommended, and can only be achieved by direct invasive measurement. The gold standard for ICP monitoring is a catheter inserted into the lateral ventricle and connected to an external pressure transducer. Cerebral perfusion pressure (CPP)-oriented therapy has been introduced to decrease the risk of ischaemia in post-injury care. Intracranial pressure waveforms include distinct periodic components: heart pulse waves, respiratory waves and quasi-periodic slow vasogenic waves.
  • 15 - Anaesthesia for spinal surgery
    pp 222-236
  • View abstract

    Summary

    Monitoring cerebral blood flow (CBF) continues to be a long-standing challenge in the neurocritical care unit. This chapter outlines the methods most commonly employed for the measurement and estimation of CBF in the operating theatre and in intensive care. CBF measurements obtained by Kety-Schmidt method are global and it is not possible to discriminate between grey and white matter or to detect changes in regional CBF. The introduction of radioisotope techniques for the measurement of CBF has allowed the progression from global CBF measurements to the two-dimensional maps of cortical blood flow. CBF can be measured by the exponential pattern of clearance of the gas from the brain. Sampling from the right jugular bulb has commonly been assumed to provide the best estimate of hemispheric blood flow. Jugular thermodilution technique, first used to measure coronary sinus flow, has been successfully adapted to measure CBF with reasonable accuracy.
  • 16 - Anaesthetic management of posterior fossa surgery
    pp 237-245
  • View abstract

    Summary

    A number of technologies aimed at detecting oxygen supply/demand imbalance have been developed of which jugular bulb oximetry is the most mature. More recently, near-infrared spectroscopy and direct brain tissue oxygen measurement have become clinically available. The brain extracts oxygen from arterial blood at a rate to supply its global metabolic requirements leaving an oxygen-poor venous effluent. Jugular venous oxygenation can be measured intermittently by serial blood sampling or continuously by fibre-optic oximetry. Jugular bulb oximetry can be used to detect disorders of both cerebral autoregulation and carbon dioxide reactivity. Cerebral oxygenation has been studied by jugular bulb cannulation during aneurysm clipping surgery. Jugular venous saturation has been studied as a potential prognostic marker in comatose patients in which spontaneous circulation has been restored after cardiac arrest. Experience with brain tissue oxygenation microsensors is increasing and clearly these provide a very direct measurement of tissue metabolism.
  • 17 - Anaesthesia for neurosurgery without craniotomy
    pp 246-270
  • View abstract

    Summary

    Cerebral microdialysis is now widely used as a bedside monitor of brain tissue biochemistry to identify cerebral hypoxia/ischaemia and assess cellular bioenergetics after brain injury. This chapter reviews the principles of cerebral microdialysis and identifies its role in detecting derangements of cerebral metabolism after brain injury. Microdialysis is used for a variety of clinical indications, including tissue monitoring in myocutaneous flap surgery, transplant surgery and bowel anastamoses. The concentration of substances in the dialysate will depend on the balance between substrate delivery to, and uptake from, the brain extracellular fluid (ECF) but also on several other factors. The pathophysiology of acute brain injury is complex, but two factors are of crucial importance: reduction of substrate delivery below critical thresholds, and the inability of brain cells to utilize delivered oxygen and glucose because of failing cellular metabolism.
  • Section 4 - Neurointensive care
    pp 271-497
  • View abstract

    Summary

    Clinical neurophysiology encompasses a variety of diagnostic tests including EEG, nerve conduction studies, electromyography, evoked potentials and polysomnography. This chapter describes the tests that are most widely used for monitoring during neuroanaesthesia and neurocritical care, specifically, EEG, somatosensory evoked potentials (SSEPs), brainstem auditory evoked potentials, motor evoked potentials (MEPs) and electromyography (EMG). The main indications for EEG are in the diagnosis and management of epilepsy, sleep studies and neuromonitoring. Evoked potentials are the electrical response from the nervous system to an external stimulus. There are two types of EPs: sensory and motor. SSEPs monitor the integrity of sensory pathways, including peripheral nerves, and MEPs the motor pathways. Electromyography is a technique used to evaluate the electrical activity in muscle fibres. Two types of EMG monitoring commonly used include: recording spontaneous electrical activity and recording responses generated by stimulation of motor nerves.
  • 19 - Systemic complications of neurological disease
    pp 281-300
  • View abstract

    Summary

    The purposes of multimodality monitoring mimic the aims of monitoring: to continuously measure relevant biological variables, to verify the effects of treatment, to identify trends in the clinical evolution of disease, and to contribute to the assessment of prognosis. Multimodality monitoring may indicate associations between parameters and may contribute to clinical research. This chapter shows that good data concerning adequate oxygen delivery to the organs and maintenance of homeostasis are already part of routine intensive care unit (ICU) monitoring. Cerebral perfusion pressure (CPP) is calculated as the difference between mean arterial pressure (MAP) and intracranial pressure (ICP), and represents the driving force for cerebral blood flow (CBF). Multimodality monitoring integrates multiple sources of information in a number of possible combinations. It is around for over two decades, and it is tempting to try to undertake cost-benefit analysis of this approach to patient management.

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