UPDATED REVIEW IN NEUROSURGICAL ANESTHESIOLOGY AND NEURO-CRITICAL CARE

1. 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

2. NEUROANATOMY AND NEURORADIOLOGY RVIEW FOR THE ANESTHESIOLOGIST RAMSIS F. GHALY, MD, FACS

3. HEAD, BRAIN AND CRANIAL NERVES

4. 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

5. 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

6. 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

7. 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

8. Cerebrum – Lobes of brain Temporal • Emotion • Processing smell, hearing, tastes • Sensory speech Occipital • Processing visual input

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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 Cerebral Circulation

16. 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

17. CTSCAN: BRAIN TUMOR

18. AP C-SPINE X-RAY

19. 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

20. 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)

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. THE END THANK YOU ?QUESTIONS