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ANESTHETIC MANAGEMENT OF
PATIENTS UNDERGOING
SURGERY FOR BRAIN TUMORS
David Ferson, MD, and Franco DeMonte, MD, FRCSC

The major goal of anesthesia for neurosurgical procedures is the mainte-

nance of neuronal homeostasis. Many additional surgical requirements must
also be considered, including the patient’s position, “brain relaxation,” and
special intraoperative monitoring. The neuroanesthesiologist must have a thor-
ough knowledge and understanding of several neuroanatomic, neurophysio-
logic, and pharmacologic principles and be able to integrate them into an
anesthetic plan to provide the best care to the patient and optimal operating
conditions for the neurosurgeon. If anesthetic drugs or techniques are used
improperly, they can worsen the existing intracranial pathology and lead to
additional damage.
The anesthetic management of patients undergoing surgical treatment for
tumors involving the central nervous system (CNS) does not begin in the
operating room, but rather at the time when the decision is made to perform
the surgery. Communication and collaboration between the neurosurgeon, neu-
roanesthesiologist, nurses, operating room personnel, and neurointensivists are
the most important features of a successful neuro-team during the preoperative
evaluation, intraoperative course, and postoperative care of the patient.

PREOPERATIVE EVALUATION

During the preoperative visit, the anesthesiologist should become familiar

with the results of the neuroimaging studies. In addition, the patient’s position
during the operation should be determined in consultation with the neurosur-
geon, as well as the need for special intraoperative neurologic monitoring,

From the Division of Anesthesiology and Critical Care (DF), and the Department of
Neurosurgery (FDM), The University of Texas, MD Anderson Cancer Center, How-
ton, Texas

ANESTHESOLOGY CLINICS OF NORTH AMERICA

VOLUME 16 NUMBER-.3 1998 663

664 FEFSON&DEMONTE

including awake craniotomy, during part or all of the surgery. All laboratory
data should be reviewed.

PREOPERATIVE SURGICAL EVALUATION

Precise tissue diagnosis of the pathologic processes involving the CNS is of

the utmost importance to the neurosurgeon in determining the natural history
of the tumor, deciding about different treatment options, and predicting the
patient’s outcome.

TUMOR TYPES COMMON TO THE CNS

The primary and metastatic tumors of the CNS can be compartmentalized

by their anatomic location; for example, supratentorial, infratentorial, extra-axial,
and intra-axial. Approximately 9% of all primary cancers develop in the CNS.
Of those, 85% are found in the brain?, 21
Of all supratentorial tumors, the primary brain tumors represent approxi-
mately 60% and consist of neuroepithelial tumors, meningiomas, and pituitary
adenomas. Glial tumors, which represent more than 90% of neuroepithelial
tumors, originate in the astrocytic lineage (astrocytoma, anaplastic astrocytoma,
glioblastoma multiforme), in oligodendrocytes (oligodendrogliomas),or in epen-
dymal cells (ependymoma).Meningiomas comprise the second largest group of
tumors, occurring intracranially and representing 15% to 20% of brain tumors.
Pituitary tumors, which are mainly adenomas, represent another 10% to 15% of
all intracranial tumors. Metastatic supratentorial tumors occur frequently and
affect approximately 130,000 patients in the United States each year. The vast
majority of metastatic brain tumors come from the lungs, breasts, and gastroin-
testinal and genitourinary tracts.
The infratentorial (posterior fossa) location is also a common site for both
benign and malignant tumors. The majority of tumors found in the posterior
fossa occur in children. In fact, the primary CNS tumors, such as medulloblasto-
mas, cerebellar astrocytomas, brain stem gliomas, and ependymomas, represent
the second most common cause of malignancy in children after leukemia.
Hemangioblastoma, the most common primary cerebellar tumor in adults,
is usually cystic and located in the cerebellar hemispheres, whereas epidermoids
and dermoids are usually found in the cerebellopontine angle and vermis,
respectively.
The posterior fossa also represents a frequent location for metastatic tumors.
Approximately two thirds of all cerebellar tumors in adults arise from distant
metastasis.

DIAGNOSTIC EVALUATION AND IMAGING TECHNIQUES

The evaluation of patients presenting with symptoms that are suggestive of

an intracranial tumor begins by obtaining a careful clinical history and per-
forming a thorough neurologic examination. Depending on the clinical history
and physical findings, further diagnostic workup will include appropriate neu-
roimaging tests.
Preoperative imaging studies of the brain are important for diagnosis and
localization of intracranial tumors. The decision about which diagnostic studies
 MANAGEMENT OF PATIENTS UNDERGOING SURGERY FOR BRAIN TUh4OFS 665

to select depends on the available imaging services, the level of urgency, and
the suspected intracranial pathology. Usually, more than one type of imaging
test may be required for accurate diagnosis. Computed axial tomography (CT),
which can be performed rapidly, usually is the first step in evaluating the brain
parenchyma. The CT technology uses radiographs for imaging, which permits
good visualization of bones and tissue (tumor) calcifications.
M R imaging provides a much better definition of soft-tissue anatomy than
does the CT scan. The signal detected during M R imaging is created by manipu-
lating the magnetic axis of the brain's water protons. The energy emitted by the
protons as each returns to its original axis is analyzed and translated into an
image of the brain that is superior to any other technique currently available. In
addition, the administration of paramagnetic contrast (e.g., gadolinium-DTPA)
during MR imaging helps to define the areas of abnormal blood-brain barrier,
which are frequently associated with intracranial pathology.2 If an intracranial
neoplasm is suspected, the use of contrast material is mandatory, as some tumors
may otherwise go undetected.
New techniques, such as M R spectroscopy and positron emission tomogra-
phy, may become important diagnostic tools, but they are currently in a rela-
tively early phase of development and are being used for research purposes
only. MR spectroscopy is used to quanhfy the concentration of certain products
of glucose metabolism at various sites in the brain. Position emission tomogra-
phy permits in vivo assessment of brain physiology and biochemistry.
Cerebral angiography is occasionally needed to better delineate the cerebral
vasculature in relation to the tumor. During angiography, embolization of highly
vascular brain tumors is sometimes used as means of decreasing intraoperative
bleeding associated with tumor removal. Surgical removal of skull-base tumors
frequently requires the manipulation or temporary or permanent occlusion of
major cerebral vessels. Temporary balloon occlusion testing, together with single
photon emission computed tomography (SPECT) cerebral blood flow studies,
allows for the preoperative assessment of the cerebrovascular reserve.
Stereotactically guided brain biopsies are occasionally necessary to obtain
tissue samples. This allows histologic evaluation of intracranial tumors and may
be important in developing a treatment plan.

DECIDING WHETHER TO OPERATE

Based on the patient's medical history, the neurologic examination, and

the results of diagnostic studies, the neurosurgeon decides whether surgical
intervention is warranted. This decision usually is complex, especially in patients
with a diagnosis of highly malignant intracranial tumors and poor prognosis. In
these patients the potential benefits of surgery must outweigh the risks. The
goals of surgery include maximum reduction of the tumor mass, adequate
tissue sampling for a definite histologic diagnosis, relief of increased intracranial
prrssure (ICP), increased survival time, and improved quality of life. Surgical
treatment of brain tumors usually is combined with other forms of treatment,
namely radiation therapy and chemotherapy. For example, the postoperative
survival of patients with glioblastoma multifonne treated with surgery alone is
only 4 munths; however, the addition of postoperative radiation can extend the
survival in this group to more than 9 months and significantly increases the
percentage of 2-year surviv0r~.*~ Chemotherapy and immunotherapy play in-
aea&gly p & r roles in patients with intracranid If surgeq is
666 FERSON & DEMONTE

indicated, a clear neurosurgical plan must be developed and communicated to

the patient and members of the neuro-team.

EVALUATION OF ORGAN DYSFUNCTION RESULTING FROM

PREVIOUS CHEMOTHERAPY

Patients presenting with primary intracranial tumors usually are healthy,

apart from symptoms associated with intracranial pathology, such as seizures,
headaches, nausea and vomiting, visual disturbances, and neurologic deficits.
In contrast, patients with metastatic CNS tumors frequently have undergone
chemotherapy with agents that may temporarily or permanently affect the
function of different organs. For instance, doxorubicin and daunorubicin can
cause cardiac dysrhythmias and congestive heart failure. Bleomycin and busul-
fan can cause significant pulmonary fibrosis, especially in the presence of high
oxygen concentrations. Carboplatin and cisplatinum can result in renal dysfunc-
tion or failure, whereas ifosfamide and cyclophosphamide may lead to the
development of hemorrhagic cystitis. Most chemotherapeutic agents cause tem-
porary liver dysfunction and thus may affect metabolism and the clearance of
several anesthetic agents. In addition, plasma cholinesterase activity can be
significantly inhibited after treatment with cycl~phosphamide.~ If warranted by
the patient's medical history or physical findings, special tests, such as Holter
monitoring, two-dimensional echocardiography, pulmonary and hepatic func-
tion tests, and creatinine clearance, may be indicated.

NEUROLOGIC EVALUATION

Evaluation and documentation of the patient's mental status and presence

of neurologic deficits is an important part of the preanesthetic visit. In patients
who are comatose or who may have increased ICE', no sedatives or narcotics
should be administered as premedication. Respiratory depression associated
with the administration of sedatives and opioids may lead to high levels of
PaCO, and further increase the ICP. Before the development of the CT scanner,
intracranial tumors often became large before they were discovered and a surgi-
cal procedure was performed. As a result, anesthesiologists were often faced
with a patient who had a very large brain mass, a considerably compromised
intracranial compliance, and a very high risk of brain herniation. Fortunately,
brain tumors can now be detected and visualized by neuroimaging technology
at a much earlier stage. Most of these tumors are 3 to 4 cm in diameter, and
patients rarely present with acutely elevated ICP. In addition, the preoperative
administration of steroids (dexamethasone) results in dramatic decreases of
peritumoral edema, thus further improving intracranial compliance; however,
the patient's near normal mental status should not fool the anesthesiologist into
believing that the patient is not at risk for penoperative intracranial hyperten-
sion. In general, it may be prudent to assume that any patient who is admitted
to the hospital with signs or symptoms of high ICP is still at risk for neurologic
damage from a sudden increase in ICP and should be managed caFefully, even
if the initial symptoms subside.
 MANAGEMENT OF PATIENTS UNDERGOING SURGERY FOR BRAIN TUMORS 667

EVALUATION OF CARDIAC STATUS

Patients with brain tumors often develop electrocardiographic (ECG)

changes as a result of increased sympathetic tone due to the elevated ICP.
Although in the past these changes were believed to be “benign brain ECG
abnormalities,” it is now well established that they represent a true cardiovascu-
lar response to elevated circulating catecholamines. If not treated appropriately,
this condition may lead to increased perioperative cardiac complications. The
most common ECG changes include sinus tachycardia, prolongation of the QT
interval, prominent U waves, and T- and ST-segment ischemic changes6

EVALUATION OF THE AIRWAY

Airway evaluation is an important part of the preanesthesia visit. Patients

with brain tumors and elevated ICP are at a much higher risk than patients
without intracranial pathology of serious neurologic complications if, after in-
duction of general anesthesia, problems with ventilation and oxygenation are
encountered.
Patients with acromegaly have changes in the upper airway due to overpro-
duction of the growth hormone by a pituitary adenoma. In these patients,
during the induction of general anesthesia, facemask ventilation may be difficult
because the distortion of facial features can result in a poor mask fit. In addition,
macroglossia and an enlarged epiglottis also predispose patients with acromeg-
aly to airway obstruction and cause difficulty in visualizing the vocal cords
during rigid laryngoscopy. The glottic opening may be narrowed due to vocal
cord hypertrophy. Subglottic stenosis due to soft-tissue enlargement can also be
encountered. Awake oral fiberoptic intubation in patients with acromegaly is the
usual choice for securing the airway before general anesthesia. The nasal route
for fiberoptic intubation in these patients should be avoided because the nasal
turbinates are frequently enlarged, thus increasing the risk of trauma and bleed-
ing.”
Patients with metastatic CNS tumors frequently have a history of multiple
neck surgeries, radiation therapy, and cervical spine surgery with fusion and
stabilization for metastasis. As a result, sigruficant difficulty in securing the
airway in these patients after induction of general anesthesia may be encoun-
tered.
The laryngeal mask airway (LMA) has several advantages in the airway
management of neurosurgical patients. Its insertion is associated with minimal
hemodynamic changes. In addition, in our experience at The University of
Texas M.D.Anderson Cancer Center, insertion of the LMA into patients with
intracranial hypertension does not cause any further increase in the ICP.5 Re-
cently, a new intubating form of the LMA (LMA-Fastrach, Gensia Automedics,
San Diego, CA) (Fig. 1)was developed by Dr.Archie Brain (inventor of the LMA)
to broaden the LMA’s role in airway management and to facilitate endotracheal
intubation via the LMA in patients with normal and difficult airways.
As with the standard LMA, the insertion of the inhibating LMA is associated
with minimal hemodynamic changes, and patients can be easily ventilated and
oxygenated during intubation attempts. The intubating LMA has the potential
to become the preferred instrument in the management of the difficult airway
in neurosurgical patients. The intubating LMA has several improved features
compared with the standard LMA that make intubation of the trachea much
easier. These features include (1) a short, anatomically curved, rigid stabless
668 FERSON & DEMONTE

Pilot Balloon

Metal Handle
Rigid Metal Shaft
(curved anatomically)

Cuff of the Laryngeal Mask

Epiglottic Elevating Bar (EEB)

Vshaped Guiding Ramp

B

Figure 1. A, and 6,The LMA-Fastrach. (Courtesyof Gensia Automedics, San Diego, CA.)

steel shaft that is configured to follow the oral, pharyngeal, and laryngeal axes
and allows the alignment of the mask with the glottic opening; (2) a metal
handle attached to the shaft near the connector end to aid the insertion and
manipulation of the device within the patient’s airway and to maintain the
intubating LMA in a steady position during endotrached tube (Em)insertion;
(3) a V-shaped guiding ramp located at the mask ape- that centralizes and
directs the ETT toward the glottis as the ETT emerges from the metal shaft; and
(4) a moveable epiglottic elevating bar (EEB) attached only to the upper rim of
the mask. The EEB replaces the mask aperture bars found on the standard LMA;
however, its function is different. As the ETT emerges from the mask aperture,
the tip of the ETT pushes the EEB outward. As a result, the EEB lifts the
 MANAGEMENT OF PATIENTS UNDERGOING SURGERY FOR BRAIN TUMORS 669

epiglottis, providing the ETT with an unobstructed path through the vocal cords
into the trachea.
During development of the intubating LMA, the inventor set the following
additional objectives: (1) to eliminate the need for head and neck manipulation
during insertion and intubation, thus making the device useful in patients
with cervical spine pathology; (2) to eliminate the need to distort the anterior
pharyngeal anatomy to visualize the laryngeal inlet, thus making the device
applicable to patients with a history of difficult intubation due to a "high or
"anterior" larynx; (3) to provide an intubation conduit that can be easily re-
moved once endotracheal intubation is completed; and (4) to eliminate place-
ment of the operator's fingers in the patient's mouth during insertion, thus
minimizing the risk of injury and transmission of infections as well as allowing
for the insertion of the device from almost any position.
The major difference between the intubating and the standard Lh4A lies in
the design and function of the shaft. In the standard Lh4A the primary function
of the shaft is to form a connection between the mask and the source of oxygen
or the ventilating apparatus. In the intubating LMA the shaft serves at least two
additional functions: (1)it acts as an insertion tool that assures the alignment of
the mask with the glottic opening and (2) it provides a conduit for a smooth
and atraumatic intubation with a larger ETT (up to 9 mm) when the mask's
aperture is in perfect alignment with the glottic opening.

PREMEDICATION

The administration of steroids and anticonvulsive medications is common

practice in the management of patients with brain tumors. These medications
should be continued during the perioperative period. Most modern neuroanesth-
esiologists tend to carefully titrate the intravenous sedatives and opioids to the
desired effect, and the administration of these agents begins only after the
patient is under direct observation and monitoring either in the holding area or
in the operating room. TypicaJly, midazolam is administered at a dose ranging
from 1 to 3 mg intravenously (IV). Fentanyl, 25 to 100 pg IV is usually adminis-
tered in combination with benzodiazepines.

PERIOPERATIVE ANESTHETIC MANAGEMENT

The main goals of anesthetic management in patients with intracranial

pathology are to (1) maintain stable cerebral perfusion pressure (CPP); (2) main-
tain neuronal homeostasis; (3) provide the neurosurgeon with the best operating
conditions by achieving optimal brain relaxation; and (4) provide a smooth
transition into the postoperative period with stable hemodynamics and optimal
neurologic status.

INTRAOPERATIVE MONITORING

In addition to standard monitoring, the beat-to-beat arterial blood pressure,

u s d y via the radial artery, is fresuently monitored in neurosurgical patients.
The transducer &odd be placed and calibrated at the level of the Circle of
willis for a dose appmximation of the mean arterial pressure (MAP). when
670 FERSON & DEMONTE

MAP monitoring is used in combination with invasive ICP monitoring, the CPP
can be calculated:
CPP = MAP - ICP
Central venous pressure monitoring is frequently used during neurosurgical
procedures. In addition to measuring the fluid status of the patient, the central
venous cannula can also be used to diagnose and treat venous air embolism.
This complication is relatively rare during procedures performed in patients in
the supine position; however, when the patient’s head is elevated above heart
level to minimize venous and cerebrospinal fluid pressure during craniotomy or
when the superior saggital sinus is accidentally opened during the procedure, air
may be entrained into the venous system, causing air embolism. The incidence of
venous air embolism is much higher in patients undergoing posterior fossa
surgery in the sitting position. In these patients, air may enter the venous
system through noncollapsible venous structures in the skull. Precordial Doppler
monitoring is a reliable and simple noninvasive monitor that allows very early
detection of air bubbles in the venous circulation.
Pulmonary artery pressure monitoring should be used only if fine hemody-
namic monitoring is required by the patient‘s medical condition. The hemody-
namic parameters obtained with the aid of a pulmonary artery catheter are often
necessary to guide fluid management and the administration of inotropic and
vasoactive agents.
Hyperosmolar intravenous agents and diuretics are frequently used during
neurosurgical procedures to reduce brain edema. Urine output is therefore
routinely measured with the bladder catheter to assess the response to diuretics
and to guide the administration of intravenous fluids.
Neurologic monitoring using somatosensory-evoked potentials, brain stem
auditory-evoked responses, and cortical mapping is frequently used in the neu-
rosurgical suite. Occasionally the operation is performed with the patient awake
for a part or all of the procedure. Several anesthetic agents interfere with
neurophysiologic monitoring. A clear communication between the neurosur-
geon, neurologist, and neuroanesthesiologist must be maintained during the
procedure to distinguish the artifacts from monitor warnings of impending
neurologic damage.
Core temperature monitoring is now regarded as a standard of care during
general anesthesia; however, unlike during other types of surgery, body tempera-
ture in patients undergoing neurosurgical procedures is allowed to spontane-
ously decrease during anesthesia to approximately 34°C. The rationale for this
practice by modern neuroanesthesiologists is based on evidence that a modest
degree of hypothermia provides significant neuronal protection in case of focal
ischemia,’ whereas the cardiovascular risk is low.

INDUCTION OF ANESTHESIA

The induction of general anesthesia may be smoothly achieved with the IV

administration of a barbiturate (thiopental, 3 to 5 mg/kg) supplemented with
opioids (fentanyl, up to 10 Fg/kg) and IV lidocaine (1.5 mg/kg). IV induction
with propofol, a newer intravenous agent, at a dose of 2.5 mg/kg can signifi-
cantly decrease CPP by markedly decreasing systemic arterial pressure. This
agent probably offers no advantage to patients with brain tumors.”
After gentle hyperventilation has been established with 100% oxygen by
 MANAGEMENT OF PATIENTS UNDERGOING SURGERY FOR BRAIN TUMORS 671

facemask, endotracheal intubation usually is facilitated by administering a dose

of nondepolarizing muscle relaxant (usually vecuronium, 0.1 mg/kg). After 2 to
3 minutes, endotracheal intubation can be performed. Assuming the patient's
blood pressure and heart rate have been stable, anesthesia can deepened with
an additional 2 to 3 mg/kg of thiopental before endotracheal intubati~n.'~
The hemodynamic and ICP increases associated with rigid laryngoscopy and
endotracheal intubation can also be suppressed by administering a beta-blocker
such as esmolol (up to 100 mg) just before endotracheal intubation.

MAINTENANCE OF ANESTHESIA

A longstanding debate exists regarding the optimal anesthetic maintenance

techniques for brain surgery. Those in favor of volatile anesthetic agents point
to their long record of safety and minimal effects on ICP in patients with brain
tumors, providing that hyperventilation is used. Those in favor of IV agents,
such as barbiturates, benzodiazepines, propofol, and opioids, support their view
by focusing on the ability of these agents to increase cerebrovascular resistance
and reduce the ICP.
All anesthetic agents influence different aspects of neuronal homeostasis.
Most, but not all, can be used safely in patients with cerebral tumors. The effects
of anesthetics on CPP, ICP, cerebral blood flow (CBF), and cerebral metabolic
rate for oxygen (CMRO?),as well as the potential for prolonged sedation, drug-
related protection against cerebral ischemia, and compatibility with neurophysio-
logic monitoring, are important factors to consider when selecting any particular
drug or a combination of anesthetic agents.
Different agents may have some specific effects that will require certain
ancillary techniques during their administration to achieve appropriate pharma-
cologic and physiologic responses. For instance, all volatile anesthetics will
increase the ICP during normocapnia; however, if they are used in combination
with moderate hyperventilation, little or no increase in ICP will be found. For
several years isoflurane has been the agent of choice in neurosurgery because it
produces a much smaller, if any, increase in CBF while at the same time
decreasing CMRO, to a much greater degree than either halothane or enflurane,
thus offering cerebral protective effects similar to thi0penta1.l~In addition,
isoflurane increases ICP only slightly in normal subjects as well as in those with
intracranial hypertension. Sevoflurane, a new volatile anesthetic agent, may offer
significant advantages when used in neurosurgical patients. Sevoflurane has a
low lipid solubility (blood/gas coefficient at 37°C is 0.63-0.69) and is thus
eliminated from the human body at a much faster rate than lipid-soluble agents
such as isoflurane, halothane, and enflurane, resulting in a much shorter recov-
ery from anesthesia. In addition, sevoflurane has effects similar to those of
isoflurane on cerebral hemodynamics, CMR02, and stability of ICP.l0 The disad-
vantages of sevoflurane are that the drug is biodegradable and the metabolites
in high concentrations may be nephrotoxic.8Although such toxicity has not yet
been reported in humans, despite several million anesthetics delivered safely
with this agent, this theoretical concern probably remains the main obstacle to
using sevoflurane more often in prolonged neurosurgical procedures.
In the modern neurosurgical suite, volatile and intravenous agents (usually
intravenous opioids) are frequently combined. This allows reduction of the total
dose of any individual drug, provides a stable intraoperative course, and allows
a smooth emergence with a safe transition to the postoperative period.
672 FERSON & DEMONTE

INTRAOPERATIVE FLUID MANAGEMENT OF

NEUROSURGICAL PATIENTS
Signhcant controversy seems to surround the fluid management of the
neurosurgical patient. In the past it was a common practice to limit fluid
administration in the neurosurgical patient to what was absolutely necessary to
maintain hemodynamic stability; however, in view of the current understanding
of the mechanisms responsible for water transfer across the intact or pathologi-
cally altered blood-brain barrier, fluid management in modern neuroanesthesia
practice in the operating room and neurointensive care unit is now very differ-
ent. Only iso-osmolar fluids are used to provide a hemodynamically stable
intraoperative course, maintain cerebral perfusion, and preserve neuronal ho-
meostasis.22Glucose-containing solutions and hyperglycemia are avoided be-
cause of their negative effect on neurologic outcome in ischemic injury.”lZ,l5This
new approach based on neurophysiologic principles helps maintain optimal
neuronal homeostasis at the conclusion of the surgery.
Intraoperative blood glucose levels should be monitored at regular time
intervals because general anesthesia in combination with dexamethasone pro-
motes gluconeogenesis.l*

INTRAOPERATIVE MANAGEMENT OF “TIGHT BRAIN”

The term tight brain can refer to a number of causes of cerebral swelling.
After bone flap removal, the neurosurgeon usually finds the dura to be bulging
and tense. Surgical exposure may be mildly to severely compromised. In addi-
tion, a dural incision in patients with intracranial hypertension will result in
brain extrusion with trapping of the brain parenchyma at the edges of dura and
little room to achieve optimal surgical exposure. Although brain edema may be
caused by a large tumor, it is important to first rule out correctable sources, such
as impaired venous return caused by extreme head position, increased PaC02,
head-down angle of the operating table, vasodilation with volatile agents, and
occult hematoma (usually bleeding into the tumor). Simple maneuvers, like
readjusting the operating table to elevate the head slightly or repositioning the
patient’s head and neck to allow venous drainage, can dramatically improve the
situation. Other therapeutic maneuvers that may need to be instituted include
moderate hyperventilation to lower the PaC02to 30 mm Hg, intravenous admin-
istration of osmotic diuretics (mannitol, 0.5 to 1 g/kg), and drainage of cerebro-
spinal fluid.

EMERGENCE FROM ANESTHESIA

Smooth emergence from anesthesia after brain surgery is probably one of
the most important and challenging goals in neuroanesthetic practice. Hyperten-
sion, bucking, and couglung on the endotracheal tube can threaten the delicate
hemostasis achieved in the operative bed at the conclusion of the surgery,
resulting in hemorrhaging, neurologic damage, and the need to reoperate. A
smooth emergence is especially important because some neurosurgical patients
may develop thrombocytopenia, and disseminated intravascular coagulopathy
predisposes to bleeding, even if only a moderate elevation in systemic blood
pressure occurs.’6 Intravenous lidocaine and small doses of barbiturates or pro-
pofol are useful adjuncts to help with a smooth emergence. H e m d m c
stability can be achieved with minimal effect on cembral circulation by the
 MANAGEMENT OF PATIENTS UNDERGOING SURGERY FOR BRAIN TUMORS 673

judicious use of beta-blockers or calcium channel blockers. In addition, initiating

the LMA use at the conclusion of the surgery is associated with sigruficantly
less hemodynamic stimulation, excellent tolerance by the patient, and smooth
emergence without coughing or bucking?

POSTOPERATIVE MANAGEMENT

After the patient is transferred from the operating room to the neurointen-
sive care unit, it is important to communicate to the neurointensivists any
intraoperative events that may alter postoperative care. For example, involve-
ment of the lower cranial nerves during surgery may interfere with pharyngeal
and laryngeal reflexes, and these patients should remain intubated to prevent
aspiration until postoperative brain swelling subsides.
Most neurosurgical patients are extubated in the operating room. During
the initial postoperative period, the head of the bed should be elevated to at
least 30 degrees to facilitate venous return and reduce cerebral swelling.
The administration of sedatives and opioids should be kept to an absolute
minimum in the immediate postoperative period to differentiate between the
effect of medications on the patient’s neurologic status and possible postopera-
tive complications.If neurologic examination reveals a worsening in the patient’s
condition, a CT scan should be performed to look for the presence of increasing
postoperative cerebral edema, a hematoma, or hydrocephalus.

CONCLUSION

The anesthetic management of patients undergoing surgical treatment for

tumors involving the CNS represents a unique challenge. The anesthetic plan
needs to be individualized based on the patient’s underlying pathology. Neuro-
anatomic and neurophysiologic principles guide the neuroanesthesiologist in
planning the anesthetic management to provide the best care to the patient and
optimal operating conditions for the neurosurgeon.
Careful preoperative evaluation with a thorough airway and neurologic
examination, review of the neuroimaging studies and pertinent laboratory data,
and consultation with the neurosurgeon regarding special monitoring and posi-
tioning are of the utmost importance in assuring a safe, smooth, and efficient
intraoperative course. Perioperative maintenance of neuronal homeostasis is the
major goal and responsibility of the neuroanesthesiologist and can have a sig-
nificant impact on the neurologic outcome of the patient that is distinct from
surgical prognosis. If anesthetic drugs or techniques are used improperly, they
can worsen the existing intracranial pathology and lead to additional damage.
Airway management, optimal oxygenation, ICP control, hernodynamic
monitoring, and fluidand electrolytemanagement, cornbind with careful neum
physiologic monitoring, are only a few duties of the modem neuroanesthesiolo-
gist. Communication and collaboration between the neurosurgeon, neuroanesth-
esiologist, nurses, operating mom personnel, and neurointensivists are the most
important features of a successful neuroteam during the preoperative evaluation,
intraoperative course, and postoperative care of the patimt. A cohesive team
approach is the hallmark of a successful surgical outcome of these patients.
674 FERSON & DEMONTE

ACKNOWLEDGMENT
The authors would like to extend special thanks to Nancy Arora from the Department
of Scientific Publications at the University of Texas M. D. Anderson Cancer Center in
Houston for her most valuable comments and help in the preparation of this manuscript.

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