ANAESTHESIA FOR INTRACRANIAL LESIONS

Intracranial lesions consist of tumors, abscesses, vascular and haematomas. In this

chapter, we will discuss about anaesthesia for intracranial tumor and abscess
resections.
Intracranial tumors can arise as primary or secondary lesion. Primary lesions are
predominantly supratentorial in nature (60%). Gliomas are the commonest primary
brain tumor followed by meningioma, which is more vascular. Secondary lesions
comprise about 40% of supratentorial tumors are usually metastasize from the lungs,
breasts and liver malignancies. Cerebral abscesses are common among patients with
ear abscess, intravenous drug abusers, immunocompromised and right to left cardiac
shunt (not filtered by pulmonary phagocytes and compensatory polycythemia causing
increased blood viscosity and focal ischemia on the brain).

[Insert Table on Classficiation of Brain tumors – adults and Paeds ]

Preoperative Management
- Obtain adequate history and physical examinations, focusing on Glasgow Coma
Scale (GCS), motor and sensory deficits and signs of raised ICP.
- Optimizing underlying co-morbidities such as hypertension and diabetes mellitus.
- Review all latest biochemical data and CT/ MRI brain, focusing on location and
size of tumor, together with mass effects (hydrocephalus, midline shift,
perilesional oedema). These will help in assessing intraoperative patient
positioning and bleeding.
- Anxiolysis with oral benzodiazepines can be given to anxious patients, provided
they do not have symptoms of raised ICP or features of difficult intubation.

Intraoperative Management
- The aims are to provide smooth induction of anaesthesia, ensure stable
hemodynamics, provide adequate cerebral relaxation for surgical excision, rapid
and smooth emergence from anaesthesia, provide brain protection and enable
postoperative neurological assessment.
- Induction of anaesthesia can be conducted using IV anaesthetic agents, opoids
and muscle relaxants. TIVA with proprofol and remifentanil ensure smooth
induction and intubation to avoid increases in BP that will cause vasogenic
cerebral oedema.
 - Laryngeal reflexes can be obtubded with beta blockers, short acting opioids
(fentanyl or remifentanil) or IV lignocaine prior to intubation.
- Large bore IV cannulas and CVL, ideally at right subclavian vein should be
instituted.
- BIS, cerebral entropy or cerebral state monitoring should be established if TIVA
is used as maintainance of anaesthesia.
- Insertion of skull pin mounts a painful stimuli, thus obtund it with short acting
opioids.
- Ensure unobstructed jugular venous outflow by ensuring proper head
positioning.
- Avoid hyperextension or hyperflexion of the head/ neck which may impair blood
flow to the brainstem and spinal cord with consequent macroglossia and raised
ICP due to impaired venous outflow from the head.
- If the head/neck is flexed, an oral pharyngeal airway/ bite block is placed to
ensure the patient does not bite the tongue or occlude the ETT. Also, ensure at
least two finger breaths of the thyromental distance to avoid airway obstruction
and increased peak inspiratory pressures.
- Ensure normocapnia (35-40mmHg), normotensive (MAP 80-90mmHg),
normothermia (34-36 °C), adequate oxygenation, normoglycemia, euvolemia and
normal electrolytes throughout the surgery.
- Avoid usage of hypotonic or dextrose containing solutions. Isotonic solutions
such as normal saline 0.9% or Sterofundin® are often used.
- Insertion of urinary catheter to monitor urine output of 1-2ml/kg/hour.
- IV Mannitol 20% (0.5- 1g/kg) can be administered 30-60 minutes prior to dura
opening. Ideally, serum osmolarity is maintained at 300-320mOsm/L.
- Transfuse blood products to achieve hemoglobin of ≥ 10g/dL.
- Should there be evidences of intraoperative cerebral oedema, hyperventilation to
PaCO2 of 28-30mmHg for 10-15 minutes is helpful.

Postoperative Management
- Patients with a good GCS should be extubated at the end of the surgery (if there
is no contraindications), while those with a poor GCS should remain ventilated
and sedated in the ICU postoperatively.
- Administer IV ondansetron 4mg and dexamethasone 8mg for PONV prophylaxis.
- Ensure smooth extubation with IV lignocaine 1.5mg/kg or esmolol 0.5mg/kg.
- Provide adequate analgesics post operatively with scalp block (unilateral or
bilateral), IV paracetamol or opioids.
- Examine postoperative GCS, basic cranial nerve functions (pupils size, gag reflex,
tongue functions), motor and sensory.