Core Topics in Neuroanaesthesia and Neurointensive Care http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 Core Topics in Neuroanaesthesia and Neurointensive Care Edited by Basil F Matta Divisional Director, Emergency and Perioperative Care, and Associate Medical Director, Cambridge University Foundation Trust Hospitals, Cambridge, UK David K Menon Head of the Division of Anaesthesia, University of Cambridge, and Consultant, Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK Martin Smith Consultant and Honorary Professor, Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 ca mb rid ge u niversi t y press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Tokyo, Mexico City Cambridge University Press he Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521190572 © Cambridge University Press 2011 his publication is in copyright Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published 2011 Printed in the United Kingdom at the University Press, Cambridge A catalogue record for this publication is available from the British Library Library of Congress Cataloguing in Publication data Core topics in neuroanaesthesia and neurointensive care / [edited by] Basil F Matta, David K Menon, Martin Smith p ; cm Includes bibliographical references and index ISBN 978-0-521-19057-2 (hardback) Anesthesia in neurology Nervous system–Surgery Neurological intensive care I Matta, Basil F II Menon, David K III Smith, Martin, 1956– [DNLM: Anesthesia–methods Brain–surgery Central Nervous System–physiopathology Intensive Care–methods Monitoring, Physiologic–methods WO 200] RD87.3.N47C67 2011 617.9Ј6748–dc23 2011026296 ISBN 978-0-521-19057-2 Hardback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every efort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every efort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation he authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 Contents List of contributors page vii Preface xi Acknowledgements xiii Section Applied clinical physiology and pharmacology Anatomical considerations in neuroanaesthesia Nicole C Keong and Robert Macfarlane The cerebral circulation 17 Tonny Veenith and David K Menon Mechanisms of neuronal injury and cerebral protection 33 Kristin Engelhard and Christian Werner Section Neuroanaesthesia 11 General considerations in neuroanaesthesia 147 Armagan Dagal and Arthur M Lam 12 Anaesthesia for supratentorial surgery 162 Judith Dinsmore 13 Anaesthesia for intracranial vascular surgery and carotid disease 178 Jane Sturgess and Basil F Matta 14 Principles of paediatric neurosurgery 205 Craig D McClain and Sulpicio G Soriano 15 Anaesthesia for spinal surgery 222 Ian Calder Section Monitoring and imaging Intracranial pressure 45 Christian Zweifel, Peter Hutchinson and Marek Czosnyka Bedside measurements of cerebral blood flow 63 Amit Prakash and Basil F Matta Cerebral oxygenation 72 Ari Ercole and Arun K Gupta Brain tissue biochemistry 85 Arnab Ghosh and Martin Smith Neurophysiology 101 Dick Moberg and Sabrina G Galloway Multimodality monitoring 119 Nino Stocchetti and Luca Longhi 16 Anaesthetic management of posterior fossa surgery 237 Tonny Veenith and Antony R Absalom 17 Anaesthesia for neurosurgery without craniotomy 246 Rowan M Burnstein, Clara Poon and Andrea Lavinio Section Neurointensive care 18 Overview of neurointensive care 271 Martin Smith 10 Imaging 128 Jonathan P Coles and David K Menon 19 Systemic complications of neurological disease 281 Magnus Teig and Martin Smith 20 Post-operative care of neurosurgical patients 301 Christoph S Burkhart, Stephan P Strebel and Luzius A Steiner v http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 Contents 21 Traumatic brain injury 315 Ari Ercole and David K Menon 22 Management of aneurysmal subarachnoid haemorrhage in the neurointensive care unit 341 Frank Rasulo and Basil F Matta 28 Central nervous system infections and inflammation 430 Amanda Cox 29 Intensive care of cardiac arrest survivors 445 Andrea Lavinio and Basil F Matta 23 Intracerebral haemorrhage 359 Fred Rincon and Stephan A Mayer 30 Death and organ donation in neurocritical care 457 Paul G Murphy 24 Spinal cord injury 369 Rik Fox 31 Ethical and legal issues 475 Derek Duane 25 Occlusive cerebrovascular disease 385 Lorenz Breuer, Martin Köhrmann and Stefan Schwab 32 Assessment and management of coma 488 Nicholas Hirsch and Robin Howard 26 Neuromuscular disorders 397 Nicholas Hirsch and Robin Howard 27 Seizures 413 Brian P Lemkuil, Andrew W Michell and David K Menon Index 498 Colour plate section between pages 242 and 243 vi http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 Contributors Antony R Absalom University Department of Anaesthesia, Cambridge University Hospitals NHS Trust, Cambridge, UK Judith Dinsmore Consultant Neuroanaesthetist, Department of Anaesthesia, St George’s Hospital, London, UK Lorenz Breuer Department of Neurology, University Hospital Erlangen, Erlangen, Germany Derek Duane Consultant in Neuroanaesthesia and Neurointensive Care, Department of Neurosciences, Addenbrooke’s Hospital, Cambridge, UK Christoph S Burkhart Clinical Research Fellow, Department of Anesthesia, University Hospital Basel, Basel, Switzerland Rowan M Burnstein Neurosciences Critical Care Unit, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK Ian Calder Consultant Anaesthetist (retired), he National Hospital for Neurology and Neurosurgery and he Royal Free Hospital, London, UK Jonathan P Coles University Lecturer and Honorary Consultant, Department of Anaesthesia, Addenbrooke’s Hospital, Cambridge, UK Amanda Cox Consultant Neurologist, University of Cambridge, Cambridge, UK Marek Czosnyka Reader in Brain Physics, Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK Armagan Dagal Assistant Professor, Department of Anesthesiology and Pain Medicine Harborview Medical Center, University of Washington, Seattle, USA Kristin Engelhard Vice-Chair, Department of Anaesthesiology, Medical Center of the Johannes Gutenberg-University Mainz, Germany Ari Ercole Neurosciences Critical Care Unit, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK Rik Fox Consultant Anaesthetist, Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK Sabrina G Galloway Senior Vice President and Chief Operations Oicer, Sentient Medical, Baltimore, USA Arnab Ghosh Clinical Research Fellow, Neurocritical Care Unit, he National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK Arun K Gupta Consultant in Neuroanaesthesia and Intensive Care, Neurosciences Critical Care Unit, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK vii http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 List of contributors Nicholas Hirsch Consultant Neuroanaesthetist and Honorary Senior Lecturer, he National Hospital for Neurology and Neurosurgery, London, UK Robert Macfarlane Consultant Neurosurgeon, Department of Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK Robin Howard Consultant Neurologist, he National Hospital for Neurology and Neurosurgery, London, UK Basil F Matta Divisional Director, Emergency and Perioperative Care, and Associate Medical Director, Cambridge University Foundation Trust Hospitals, Cambridge, UK Peter Hutchinson Senior Academy Fellow, Reader and Honorary Consultant Neurosurgeon, Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK Nicole C Keong Specialist Registrar in Neurosurgery, Department of Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK Martin Köhrmann Assistant Professor, Department of Neurology, University Hospital Erlangen, Erlangen, Germany Arthur M Lam Medical Director of Neuroanesthesia and Neurocritical Care, Swedish Neuroscience Institute, Swedish Medical Centre, and Clinical Professor of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA Andrea Lavinio Consultant in Anaesthesia and Critical Care, Neurosciences Critical Care Unit, Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Brian P Lemkuil Assistant Clinical Professor, Department of Anaesthesia, UCSD Medical Center, San Diego, USA Luca Longhi University of Milano, Neurosurgical Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, Italy Craig D McClain Assistant Professor of Anaesthesia, Harvard Medical School, and Associate in Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, USA Stephan A Mayer Professor and Director of Neurocritical Care, Department of Neurology, Columbia University Medical Center, Neurological Institute, New York, USA David K Menon Head of the Division of Anaesthesia, University of Cambridge, and Consultant, Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK Andrew W Michell Consultant in Clinical Neurophysiology, Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK Dick Moberg President, Moberg Research Inc., Ambler, PA, USA Paul G Murphy Consultant and Honorary Senior Lectures, Department of Anaesthesia, he General Inirmary at Leeds, Leeds, UK Clara Poon University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK Amit Prakash Consultant, Department of Anaesthesia, Addenbrooke’s Hospital, Cambridge, UK Frank Rasulo Institute of Anaesthesia and Intensive Care, Neurocritical Care Unit, Spedali Civili University Hospital, Brescia, Italy Fred Rincon Jeferson College of Medicine, Department of Neurological Surgery, Philadelphia, USA viii http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 List of contributors Stefan Schwab Chair and Professor, Department of Neurology, University Hospital Erlangen, Erlangen, Germany Martin Smith Consultant and Honorary Professor, Department of Neuroanaesthesia and Neurocritical Care, he National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK Sulpicio G Soriano Professor of Anesthesia, Harvard Medical School, Children’s Hospital, Boston, and CHB Endowed Chair in Pediatric Neuroanesthesia, Boston, USA Luzius A Steiner Médecin associé, Department of Anaesthesia, University Hospital Centre and University of Lausanne, Lausanne, Switzerland Nino Stocchetti Professor of Anaesthesia and Intensive Care, University of Milano, Neurosurgical Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, Italy Stephan P Strebel Head of Neuroanesthesia, Department of Anesthesia, University Hospital Basel, Basel, Switzerland Jane Sturgess Consultant in Neuroanaesthesia, Addenbrooke’s Hospital, Cambridge, UK Magnus Teig Specialist Trainee in Anaesthesia and Intensive Care Medicine, Neurocritical Care Unit, he National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK Tonny Veenith Honorary Specialist Registrar and NIAA Clinical Research Fellow, Division of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Christian Werner Chair, Department of Anesthesiology, Medical Center of the Johannes Gutenberg-University, Mainz, Germany Christian Zweifel Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK ix http://ebooks.cambridge.org/ebook.jsf?bid=CBO9780511977558 Cambridge Books Online © Cambridge University Press, 2012 Fig 8.7 EEG, compressed spectral array (CSA) and density spectral array (DSA) displays showing a seizure A segment of the raw EEG during the seizure shown at the top and the spectral edge frequency (described in Table 8.4) is plotted on top of the CSA At the bottom of the figure, a horizontal DSA display shows a seizure as the bright coloured area in the centre of the DSA Fig 8.9 Right brainstem auditory evoked response (BAER) recorded from ipsilateral A2–Cz and contralateral A1–Cz in a propofol-sedated patient Waves I, III and V from the ipsilateral (to the stimulus) side are shown Cambridge Books Online © Cambridge University Press, 2012 Fig 8.10 Right upper-extremity somatosensory evoked potential (SSEP) recorded from Erb’s point, C5 cervical spine and the left somatosensory cortex in a propofol-sedated patient Note that the peripheral response (at the brachial plexus recorded at Erb’s point) is delayed to 12 ms instead of the normal ms This delay shifts the subsequent peaks out by ms and is most probably due to a peripheral neuropathy, but could also be due to a very long arm or a cold arm Cambridge Books Online © Cambridge University Press, 2012 Fig 8.11 Lower-extremity somatosensory evoked potential (SSEP), showing a peripheral response recorded from the popliteal fossa, a subcortical response recorded at the cervical spine and a cortical response recorded at the somatosensory cortex in a propofolsedated patient Cambridge Books Online © Cambridge University Press, 2012 Fig 8.12 Transcranial electrical motor evoked potentials (TceMEPs), recorded from left and right target muscles – the trapezius (TRAP) and abductor pollicis brevis (APB) in the upper extremities, tibialis anterior (TIB) in the lower extremities and abductor hallucis (AH) in the feet Cambridge Books Online © Cambridge University Press, 2012 Fig 9.1 Chart showing the changes in ICP, CPP, brain tissue oxygen tension (PbrO2) and brain temperature (measured in the vicinity of a hypodense lesion) during barbiturate induction for the treatment of raised ICP Thiopental effectively lowered ICP but induced a CPP reduction and an associated regional brain hypoxia that was corrected using norepinephrine In this patient, these data showed the CPP threshold required to ensure an adequate brain oxygenation in a vulnerable area of the brain TPS, thiopental; NE, norepinephrine Cambridge Books Online © Cambridge University Press, 2012 Fig 9.2 Chart showing the occurrence of an episode of transient regional brain hypoxia (brain tissue oxygen tension (PbrO2) measured in normal-appearing tissue) with no apparent cause and with spontaneous resolution Cerebral perfusion pressure was stable and remained above the threshold of 60 mmHg, arterial partial pressure of oxygen (PaO2)was adequate and PaCO2 was in the range of mild hyperventilation Jugular bulb oxygen saturation (SjO2) was normal The episode was followed by an increase in lactate/pyruvate (L/P) ratio measured in the corresponding area from 20 to 25 At follow-up CT scan, no ischaemic changes were observed in the monitored area These data highlight the complexity of understanding the pathophysiology of regional oxygenation and integrating it with other physiological variables FiO2, fraction of inspired oxygen Cambridge Books Online © Cambridge University Press, 2012 Fig 10.1 Bedside CT This patient sustained severe brain, chest and orthopaedic injuries following a road traffic accident Using the CereTom mobile CT scanner (NeuroLogica Corporation, Danvers, MA, USA), imaging was obtained at the bedside without the need to transfer the patient to the radiology suite Fig 10.11 CT and magnetic resonance angiography (MRA) The image in the left panel is from the same patient as shown in Fig 10.10 and demonstrates the arteriovenous malformation within the region of the right Sylvian fissure Further investigation using formal angiography was undertaken to delineate the arterial supply and venous drainage of the lesion The image in the right panel was obtained using MRA and demonstrates a normal-appearing cerebral circulation Cambridge Books Online © Cambridge University Press, 2012 Region of oligaemia Ischaemic penumbra Infarct core Fig 10.12 Schematic demonstrating the ischaemic penumbra: ischaemic core of infarcted tissue (black), penumbral region of ischaemic brain tissue at high risk of cerebral infarction (purple) and the surrounding region of oligaemia (pink) above the threshold for cerebral injury following an acute vascular occlusion 60 200 –2 CBF (ml (100g)– min–1) 60 –2 –2 CBV (ml (100 g)–1) MTT(s) Fig 10.13 Assessment of cerebral blood flow (CBF) using CT perfusion This patient suffered a subarachnoid haemorrhage secondary to an anterior communicating artery aneurysm The plain CT image on the left demonstrates hypodensity within the medial aspects of the frontal cortex in both hemispheres and also within the right occipital cortex These areas have very low CBF and cerebral blood volume (CBV) suggestive of established infarction In addition, there is a generalized reduction in CBF across the right hemisphere with an increase in CBV suggestive of cerebral ischaemia secondary to arterial vasospasm This reduction of perfusion is most noticeable on the mean transit time (MTT) image, which clearly shows the delay in perfusion across the whole right hemisphere Cambridge Books Online © Cambridge University Press, 2012 Fig 10.14 Positron emission tomography (PET) The use of positron-emitting isotopes, incorporated into biological tracers, has enabled in vivo studies of human physiology in health and disease These positronemitting isotopes decay by emitting a positron, which is the positively charged antiparticle of the electron The positron travels a short distance in tissue before it annihilates with an electron and causes the simultaneous release of two photons perpendicular to each other As the photons are emitted simultaneously, coincidence detection occurs for each event through a cylindrical array of detectors The large datasets acquired in PET require powerful computers to perform the data corrections and image reconstruction in a feasible timescale The emission frames from the PET scanner and the arterial blood radioactivity data can be used to calculate absolute physiological parameters using appropriate kinetic models Physiological map Computer processing Kinetic model Coincidence detection Timed arterial input data Positron annihilation Emission data frames 50 CBF (ml (100 ml)–1 min–1) 200 CMRO2 (µmol (100 ml)–1 min–1) 100 OEF (%) 45 CMRgluc (µmol (100 ml)–1 min–1) Fig 10.15 Positron emission tomography (PET) imaging of regional metabolism following head injury X-ray CT, PET cerebral blood flow (CBF), oxygen metabolism (CMRO2), oxygen extraction fraction (OEF) and glucose metabolism (CMRglu) images obtained following early head injury Note the right temporal haemorrhagic contusion with surrounding rim of hypodensity on the X-ray CT The lesion core reflects infarcted brain with no or very low CBF The pericontusional cerebral hemisphere displays variable pathophysiology Immediately adjacent to the lesion core (dotted arrow), CBF is increased, CMRO2 and OEF variable but glucose metabolism increased, while the right parietal occipital cortex (white arrow) demonstrates a decrease in CBF and CMRO2 with an increase in OEF and variable glucose metabolism suggestive of regional cerebral ischaemia The increase in CMRglu implies a switch to non-oxidative metabolism of glucose in order to meet underlying metabolic needs Cambridge Books Online © Cambridge University Press, 2012 PaCO2: 4.7kPa (35 mmHg) PaCO2: 3.5kPa (26 mmHg) CBF (ml (100 ml)–1 min–1) 30 OEF 75 % Fig 10.16 Assessment of the efficacy of acute hyperventilation using positron emission tomography (PET) imaging Structural CT following early head injury demonstrates a thin right subdural haematoma with underlying cerebral contusion, swollen hemisphere with effacement of the ipsilateral ventricle and midline shift Greyscale PET cerebral blood flow (CBF) images were obtained at relative normocapnia (left panel) and hypocapnia (right panel) Voxels with a CBF 55%) PaCO2 = 5.0 kPa Cambridge Books Online © Cambridge University Press, 2012 (b) Fig 22.1 (b) CT angiogram demonstrating a lobular aneurysm arising from the anterior communicating artery (arrow) Fig 22.2 Digital subtraction angiography showing an irregular and elongated (9 mm) aneurysm at the origin of the right posterior communicating artery The aneurysm is directed posterolaterally, with a small lobule directed medially Cambridge Books Online © Cambridge University Press, 2012 (a) (c) (b) L R (e) (d) R L 20 L R [ml/min/100g] CBF (f) 6.0 100 R [s] [ml/100ml] CBV L TTP Fig 22.3 Subarachnoid haemorrhage and ischaemic changes with time (a) Day of bleed CT angiogram demonstrating a lobular aneurysm arising from the anterior communicating artery (arrow) Both anterior cerebral arteries originate from the left side with hypoplasia of the right A1 (b, c) Day 10 post-bleed Plain CT head showing extensive infarction of the right anterior cerebral artery territory involving the genu of the corpus callosum (d–f) Day 11 post-bleed CT perfusion showing an established infarct in the right anterior cerebral artery territory (reduced cerebral blood flow (CBF) and cerebral blood volume (CBV), grossly delayed time to peak; red arrows) There is a large, hypoperfused salvageable area extending into the left anterior cerebral artery territory (reduced CBF with maintained CBV and moderately delayed time to peak; yellow arrows) Cambridge Books Online © Cambridge University Press, 2012 ... data Core topics in neuroanaesthesia and neurointensive care / [edited by] Basil F Matta, David K Menon, Martin Smith p ; cm Includes bibliographical references and index ISBN 97 8-0 -5 2 1-1 905 7-2 ... and α-amino-3-hydroxy-5-methyl4-isoxazolole propionate (AMPA) antagonism In healthy volunteers, xenon anaesthesia induces a uniform reduction in rCMRglu and a reduction in rCBF, but with an increase... anastomotic vein (draining upwards in the central sulcus to the superior sagittal sinus – the vein of Trolard), the Sylvian vein (draining downwards in the Sylvian issure to the sphenoparietal sinus)