UPDATED%20REVIEW%20IN%20NEUROSURGICAL%20ANESTHESIOLOGY%20AND%20NEURO-CRITICAL%20CARE

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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

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NEUROANATOMY AND NEURORADIOLOGY RVIEW FOR THE
ANESTHESIOLOGIST

• RAMSIS F. GHALY, MD, FACS

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HEAD, BRAIN AND CRANIAL NERVES
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Anatomy of the Brain

• Approximately 2 of total body weight
• Weighs 1400g in average young adult
• Weighs 1200g in average elderly person
• Major divisions
• Cerebrum
• 2 hemispheres
• Thalamus
• Hypothalamus
• Basal Ganglia

• Brain Stem
• Midbrain
• Pons
• Medulla

• Cerebellum
• Located under the cerebrum and behind the brain
  stem

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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

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Meninges

• Arachnoid layer
• 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

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Cerebrum Lobes of brain

• Frontal
• Personality
• Behavior
• Intellectual functions
• Short-term memory
• Voluntary motor function
• Motor speech (Brocas area)

• Parietal
• Localization
• Sensory integration/ discrimination
• Object recognition
• Position sense
• Body awareness
• Body image

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Cerebrum Lobes of brain

• Temporal
• Emotion
• Processing smell, hearing, tastes
• Sensory speech
• Occipital
• Processing visual input

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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

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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

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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

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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

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Neurotransmitters

• 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

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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

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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

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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

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CTSCAN BRAIN TUMOR
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AP C-SPINE X-RAY
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SYMPATHETIC SYSTEM

• 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

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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)

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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

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PARASYMPATHETIC SYSTEM

• 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

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PERIPERAL AUTONOMIC NERVOUS SYSTEM

• SYMPATHETIC NOREPINEPHERINE AS A NEUROTRANSMITTER
  (ADRENERGIC). ADRENERGIC RECEPTORS (BETA, ALPHA)
• PARASYMPATHETIC ACETYLECHOLINE AS
  NEUROTRANSMITTER (CHOLINERGIC) NICOTINIC AND
  MUSCARINIC RECEPTORS

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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

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AIRWAY OPTIONS

• CONVENTIONAL
• TO AVOID ?ICP?
• MUST BE DEEPLY ANESTHETIZED
• MUST USE FULL NEUROMUSCULAR BLOCKADE
• MAINTAINING GOOD OXYGENATION
• MAINTAINING PACO2 OR lt35
• CONSIDER LOCAL ANESTHETIC SPRAY AND IV
  LIDOCAINE
• AIRWAY VISUALIZATION
• DIRECT LARYNGOSCOPY - VIDEO LARYNGOSCOPY
• FIBEROPTIC SCOPE
• INTUBATION USING REGULAR ENDOTRACHEAL TUBE

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AIRWAY OPTIONS

• INDIRECT LARYNGOSCOPY
• SMOOTH LESS TRAUMA TIC LESS STIMULANT LESS
  COUGH LESS C-SPINE MANIPULATION
• TYPES
• LMA- LMA PROSEAL- FASTRACH INTUBATING
  LMA- VIDEO LARYNGOSCOPIC LMA- LMA WITH
  FIBEROPTIC CONNECTION
• 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

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AIRWAY MANAGEMENT OPTIONS FOR DIFFICULT
INTUBATION

• REMEMBER AVAILABLE READY HANDY
• AWAKE LARYNGOSCOPY
• 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