Craniotomy for intracranial vascular malformations - Revision history

Chris.Rishel at 22:25, 12 December 2023

2023-12-12T22:25:05Z

Chris.Rishel at 01:45, 9 June 2023

2023-06-09T01:45:22Z

← Older revision		Revision as of 18:45, 8 June 2023
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	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|~~Commonly~~ associated with hypertension as well as other cardiac abnormalities including ischemia, arrhythmias, left ventricular dysfunction, and pulmonary edema.		\|If acutely ruptured, can be associated with hypertension as well as other cardiac abnormalities including ischemia, arrhythmias, left ventricular dysfunction, and pulmonary edema.
	\|-		\|-
	\|Pulmonary		\|Pulmonary

Chris.Rishel: Added risk stratification calculators

2022-07-17T11:38:09Z

Added risk stratification calculators

← Older revision		Revision as of 04:38, 17 July 2022
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	* The Spetzler-Martin AVM grading system estimates morbidity and mortality of surgery<ref>{{Cite journal\|last=Spetzler\|first=R. F.\|last2=Martin\|first2=N. A.\|date=1986-10\|title=A proposed grading system for arteriovenous malformations\|url=https://pubmed.ncbi.nlm.nih.gov/3760956\|journal=Journal of Neurosurgery\|volume=65\|issue=4\|pages=476–483\|doi=10.3171/jns.1986.65.4.0476\|issn=0022-3085\|pmid=3760956}}</ref>		* The Spetzler-Martin AVM grading system estimates morbidity and mortality of surgery<ref>{{Cite journal\|last=Spetzler\|first=R. F.\|last2=Martin\|first2=N. A.\|date=1986-10\|title=A proposed grading system for arteriovenous malformations\|url=https://pubmed.ncbi.nlm.nih.gov/3760956\|journal=Journal of Neurosurgery\|volume=65\|issue=4\|pages=476–483\|doi=10.3171/jns.1986.65.4.0476\|issn=0022-3085\|pmid=3760956}}</ref>
			<calculatormodule id="neuro" />
			<calculatoroptions patientInputInline="true" />
			<calculation id="avmSpetzlerMartinGradeRisk">Spetzler-Martin AVM grading scale</calculation>
			<calculation id="avmSupplementalGradeRisk">Supplemental AVM grading scale</calculation>

	=== Surgical procedure ===		=== Surgical procedure ===

Mitchel.DeVita at 04:32, 11 May 2022

2022-05-11T04:32:54Z

← Older revision		Revision as of 21:32, 10 May 2022
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	* Stable induction of general anesthesia and intubation with fentanyl, propofol, rocuronium, and +/- vasoactive agents to avoid hypo- and hypertension. Typically MAP >65 and SBP <140, however surgical team preferences can vary.		* Stable induction of general anesthesia and intubation with fentanyl, propofol, rocuronium, and +/- vasoactive agents to avoid hypo- and hypertension. Typically MAP >65 and SBP <140, however surgical team preferences can vary.
	* Moderate hyperventilation (PaCO2 30 mmHg)		* Moderate hyperventilation (PaCO2 30 mmHg)
	* Maintain euvolemia
	* Check that blood is available in the OR
	* For EEG burst suppression administer additional propofol boluses (50 mg) till burst suppression is achieved. Administer additional propofol boluses as needed to maintain burst suppression (communicate with neurophysiologists).
	* Typically postoperative hypertension is avoided to minimize bleeding from a coexisting aneurysm or residual AVM, as well as to avoid postoperative hyperemia. Consider prophylactic use of labetalol to attenuate emergence hypertension.

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

Mitchel.DeVita at 04:30, 11 May 2022

2022-05-11T04:30:34Z

← Older revision		Revision as of 21:30, 10 May 2022
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	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
			Goals are similar to other neurosurgical procedures, including a smooth emergence, avoiding hypertension, coughing, and straining. Intraoperative medications should be titrated down to allow for a rapid return to consciousness to permit neurologic examination prior to leaving the operating room. Alternatively, postoperative CT is sometimes utilized if a neurological exam can not be performed.

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===

Mitchel.DeVita: added intra op, induction, etc

2022-05-11T04:26:54Z

added intra op, induction, etc

← Older revision		Revision as of 21:26, 10 May 2022
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	\|-		\|-
	\|Neurologic		\|Neurologic
	\|Neurologic symptoms and mental status		\|Neurologic symptoms and mental status, signs and symptoms of elevated ICP, seizures
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|Commonly associated with hypertension as well as other cardiac abnormalities including ischemia, arrhythmias, left ventricular dysfunction, and pulmonary edema.
	\|-		\|-
	\|Pulmonary		\|Pulmonary
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	\|-		\|-
	\|Hematologic		\|Hematologic
	\|		\|Anemia
	\|-		\|-
	\|Renal		\|Renal
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	* Inhalational and intravenous combination may optimize rapid emergence if needed.		* Inhalational and intravenous combination may optimize rapid emergence if needed.
	* One example could be propofol infusion (approximately 50mcg/kg/min), remifentanil infusion, vecuronium infusion, and sevoflurane		* One example could be propofol infusion (approximately 50mcg/kg/min), remifentanil infusion, vecuronium infusion, and sevoflurane
			*Hemodynamic "uppers and downers" should be available. For example: esmolol, labatelol, nitroglycerine, nicardipine infusion. Phenylephrine, norepinephrine drip. Adenosine can also be utilized for temporary cessation of cardiac output if surgical team requests.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

Mitchel.DeVita at 04:21, 11 May 2022

2022-05-11T04:21:11Z

← Older revision		Revision as of 21:21, 10 May 2022
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	*** Transitional malformations		*** Transitional malformations
	** Low-flow venous angiomas		** Low-flow venous angiomas
			*Patients may be symptomatic or asymptomatic
			*AVM may have be ruptured or unruptured and can be associated with vasospasm. Can also co exist with aneurysms. Most patients will have anesthesia for preoperative embolization of the AVM.

	=== Indications ===		=== Indications ===
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	\|-		\|-
	\|Neurologic		\|Neurologic
	\|		\|Neurologic symptoms and mental status
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
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	== Intraoperative management ==		== Intraoperative management ==

			=== Overall Goals ===
			Goals are to provide a stable hemodynamic anesthetic along with reducing/normalizing the ICP and maintaining adequate CPP (at least 70 mmHg) to prevent cerebral ischemia from brain retraction, brain swelling and vasospasm. Perioperative AVM rupture from hypertension is possible, but rare. However, in case of a coexisting aneurysm, hypertension must be avoided.

	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
			Standard ASA

			5-lead ECG

			Core temp

			UOP

			Arterial line

			2-3 large bore IVs

			Central line if poor peripherals access

			Neuromonitoring

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

	~~=== Positioning<!~~-- ~~Describe any unique positioning considerations~~, ~~including potential intraoperative position changes~~. ~~If none~~, ~~this section may be removed~~. ~~--> ===~~		* Stable induction of general anesthesia and intubation with fentanyl, propofol, rocuronium, and +/- vasoactive agents to avoid hypo- and hypertension. Typically MAP >65 and SBP <140, however surgical team preferences can vary.
			* Moderate hyperventilation (PaCO2 30 mmHg)
			* Maintain euvolemia
			* Check that blood is available in the OR
			* For EEG burst suppression administer additional propofol boluses (50 mg) till burst suppression is achieved. Administer additional propofol boluses as needed to maintain burst suppression (communicate with neurophysiologists).
			* Typically postoperative hypertension is avoided to minimize bleeding from a coexisting aneurysm or residual AVM, as well as to avoid postoperative hyperemia. Consider prophylactic use of labetalol to attenuate emergence hypertension.

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
			Patients typically receive Cefazolin, 10 mg of decadron and 1 gm/kg of mannitol on skin incision (verify all with surgeon). Keppra 1g may also be utilized

			Anesthesia can be maintained safely with many different medications, and can be guided primarily by other coexisting conditions.

			* An isoflurane/N2O technique offers hemodynamic stability and quick wake up test if needed. This benefit is offset by increased risk of PONV and possibility for N2O closed space expansion.
			* TIVA is a reasonable option however it may not allow for a rapid wake up test if needed
			* Inhalational and intravenous combination may optimize rapid emergence if needed.
			* One example could be propofol infusion (approximately 50mcg/kg/min), remifentanil infusion, vecuronium infusion, and sevoflurane

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

			=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
			Perioperative bleeding from AVM, cerebral ischemia from brain swelling, retractor pressure, inadequate CPP (increased ICP, vasospasm), postoperative intracranial hemorrhage, postoperative brain edema.

	== Postoperative management ==		== Postoperative management ==

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
			Neuro Critical Care Unit
	~~=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===~~

	~~=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===~~

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:39:53Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:39, 5 April 2022
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	\| airway = ETT		\| airway = ETT
	\| lines_access = Large bore IV x2		\| lines_access = Large bore IV x2
	~~Art~~ line		Arterial line
	± Central line (if arterial nidus)		± Central line (if arterial nidus)
	\| monitors = Standard		\| monitors = Standard

Chris.Rishel at 07:20, 5 April 2022

2022-04-05T07:20:42Z

← Older revision		Revision as of 00:20, 5 April 2022
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	\| lines_access = Large bore IV x2		\| lines_access = Large bore IV x2
	Art line		Art line
	~~±Central~~ line (if arterial nidus)		± Central line (if arterial nidus)
	\| monitors = Standard		\| monitors = Standard
	5-lead ECG		5-lead ECG
Line 10:		Line 10:
	UOP		UOP
	ABG		ABG
	~~±CVP~~ (if arterial nidus)		± CVP (if arterial nidus)
	Neuromonitoring		Neuromonitoring
	\| considerations_preoperative = Characterize neurologic deficits		\| considerations_preoperative = Characterize neurologic deficits

Chris.Rishel at 07:20, 5 April 2022

2022-04-05T07:20:15Z

← Older revision		Revision as of 00:20, 5 April 2022
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	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ETT		\| airway = ETT
	\| lines_access = Large bore IV x2~~<br />~~		\| lines_access = Large bore IV x2
	Art line~~<br />~~		Art line
	±Central line (if arterial nidus)		±Central line (if arterial nidus)
	\| monitors = Standard~~<br />~~		\| monitors = Standard
	5-lead ECG~~<br />~~		5-lead ECG
	Core temp~~<br />~~		Core temp
	UOP~~<br />~~		UOP
	ABG~~<br />~~		ABG
	±CVP (if arterial nidus)~~<br />~~		±CVP (if arterial nidus)
	Neuromonitoring~~<br />~~		Neuromonitoring
	\| considerations_preoperative = Characterize neurologic deficits		\| considerations_preoperative = Characterize neurologic deficits
	\| considerations_intraoperative = Smooth induction~~<br />~~		\| considerations_intraoperative = Smooth induction
	Hemodynamic goals vary~~<br />~~		Hemodynamic goals vary
	Hypotension ↑ risk of steal~~<br />~~		Hypotension ↑ risk of steal
	If arterial nidus:		If arterial nidus:
	*Hypertension ↑ risk of rupture		*Hypertension ↑ risk of rupture
	*Have adenosine available		*Have adenosine available
	*Decrease CRMO2		*Decrease CRMO2
	\| considerations_postoperative = Avoid hypertension (risk of hyperemia)		\| considerations_postoperative = Avoid hypertension after excision (risk of hyperemia)
	}}		}}