Brit. J. Anaesth.
(1965), 37, 268
GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
BY
MARIALUISA BOZZA MARRUBINI
Clinica Neurochirurgica della Universita di Milano
General anaesthesia for neurosurgery, and for
iintracranial surgery in particular, in the last
"twenty years has almost reached the status of a
-separate specialty. This is due to the existence of
three major problems, which are peculiar to intra-
cranial work, and which may be solved only on
the basis of a knowledge of the physiopathology
and pharmacology of central nervous regulation
systems, of cerebral circulation and metabolism,
and of cerebrospinal fluid circulation.
The three major problems of anaesthesia for
intracranial surgery are:
regulation of brain volume and tension;
control of haemorrhage;
protection of nervous tissue from ischaemic
and surgical injury.
Minor problems arise from other characteris-
tics of cranial surgery such as the inaccessibility
of the head of the patient after the operation has
started, the use of positions which tend to distort
and obstruct natural and artificial airways, the
relatively painless but greatly prolonged surgical
procedures, and the constant use of diathermy.
These minor problems are very relevant since
they condition important technical requirements.
Endotracheal airways must be used, and must
be unkinkable (steel or nylon wire annoured latex
tubes); metal connections and fixation of the tube
in the correct position require meticulous care,
since mistakes cannot be readily corrected sub-
sequently.
Anaesthetic agents should be of minimal toxi-
city, and cumulative effects avoided. Usually a
very light plane of anaesthesia is sufficient to
cover surgical stimuli but tolerance of the
tracheal tube may then be a problem.
Explosive and inflammable agents should not
be employed, or special precautions must be
taken in their use.
No method of anaesthesia available can auto-
matically assure the solution of all the major and
minor problems described. Therefore, a method
of anaesthesia is chosen which solves all the
minor problems and does not affect the major
ones. The solution of the major problems is then
obtained by the adoption of special techniques
which assure the best possible operating condi-
tions in the individual case.
GENERAL FEATURES OF ANAESTHETIC TECHNIQUES
Anaesthetic techniques at present used for in-
tracranial surgery may be divided into two main
groups depending on whether spontaneous or
controlled respiration is used.
During spontaneous ventilation the most im-
portant technical problem is to avoid respiratory
depression, a requirement which sets a number
of limits to the choice of both anaesthetic agents
and techniques. Unfavourable features include
any pharmacological or physical factor interfering
with normal gaseous exchange or free venous
return to the heart (e.g., opiates; high doses of
intravenous barbiturates; deep inhalation anaes-
thesia; anaesthetic circuits and systems with
large deadspaces and with valves, canisters or
multiple bends introducing respiratory resistance;
positions on the operating table interfering with
free thoracic or diaphragmatic movement, or
impeding venous return from the head, etc.).
Provided the above unfavourable influences are
avoided, and all the conditions mentioned in the
discussion of minor problems are fulfilled, almost
any method of anaesthesia may be adapted to
intracranial work. Most neurosurgical anaes-
thetists throughout the world, though not the
author, would, as far as their writings indicate,
favour a technique involving premedication with
atropine only, or atropine associated with a non-
depressant tranquillizer (hydroxyzine, promazine,
promethazine, pecazine) or with a short-acting
oral barbiturate; induction with a small dose of
intravenous thiopentone (250-300 mg); intuba-
tion with the aid of suxamethonium, and glottic
and tracheal spray with a surface anaesthetic
(lignocaine, cocaine); maintenance with 60-70
per cent nitrous oxide in oxygen, supplemented
GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
by volatile anaesthetic in low concentrations,
using a non-rebreathing system, a Magill attach-
ment, an Ayre T-piece, or a circle system with a
high flow of gases. The main variations in the
techniques adopted by different neurosurgical
anaesthetists consist in the choice of the volatile
anaesthetic: ethyl ether (Bielser, 1959; Carnegie,
1959; Cochs-Cristia, 1963), trichloroethylene
(McBurrows et al., 1956; Dodd et al., 1957;
Konig, 1958; Ballantine and Jackson, 1960; Da
Pian, 1960), halothane (Bozza, 1959; Hart, 1958;
Ballantine and Jackson, 1960, who recommended
it as an excellent alternative to trichloroethylene;
Stoffregen and Bushe, 1960; Alder, 1961; John-
stone, 1961; Schettini et al., 1961; Borroni, 1962;
Caballero, 1962; Schapira, 1964). Methoxyflurane
was suggested by Van Poznak et al. (1960) and
by Thomason et al. (1962), but rejected by
Fischer et al. (1962a). Others prefer intravenous
agents for the maintenance of anaesthesia, such as
hydroxydione (Deligne" and David, 1956), narco-
tics and/or phenothiazines (Lazorthes and Cam-
pan, 1952a; Hunter, 1958; David et al., 1961;
Burgos, 1962; Maus et al., 1963), procaine
(Cochs-Cristia, 1963) or a thiopentone-tubocura-
rine drip (Mollestad, 1962).
CONTROLLED RESPIRATION
Within the last decade the use of mechanical
ventilators has brought a great change in anaes-
thetic techniques for neurosurgery. If ventilation
is artificially controlled, a much wider choice of
methods and agents remains. Anaesthetic tech-
niques with controlled respiration differ mainly
in the use of muscle relaxants. Hunter (1960,
1963) believes that curarization may be a factor
of primary importance in improving venous
return from the head; Furness (1957), Hanquet
(1959) and Mortimer (1959) also state that the
patient should be curarized. Others (Dele"gue et
al., 1957; Klein et al., 1958; Gilbert et al., 1960;
Forlani and Decker, 1961; Borroni and Bozza
Marrubini, 1962; Hohmann, 1962; Bozza Marru-
bini et al., 1964a) have obtained full respiratory
control and good operative conditions without
muscle relaxants, especially when halothane has
been used.
Many anaesthetists believe that a negative
expiratory phase is necessary in order to avoid an
increase in venous, and consequently intracranial,
269
pressure due to impeded venous return to the
heart (Furness, 1957; Mortimer, 1957, 1959,
1960; Drube et al., 1958; Ressel, 1958; Carnegie,
1959; Galloon, 1959; Hanquet, 1959; Campan
and Deligne", 1960; Deligne" and David, 1960;
Grote and Wullenweber, 1960; Martin et al.,
1960; Wertheimer et al., 1960; Stern and
Bethune, 1961). Others think that good intra-
cranial operative conditions may be assured with-
out a negative phase (Brown, 1959; Hunter, 1960,
1963; Marshall, 1961; Schmidt, 1963a; Bozza
Marrubini et al., 1964a).
Some anaesthetists use controlled respiration
for every type of intracranial operation (Detegue
et al., 1957; Galloon, 1959; Urciuoli, 1961, 1963;
Gordon, 1963; Manzin and Carteri, 1963); others
believe that posterior fossa operations—especially
those requiring surgical manoeuvres in dose
proximity to the floor of the IV ventricle, medulla
and vermis (Mortimer, 1959) or to the brain stem
(acoustic neurinoma, meningioma of the cerebello-
pontine angle) in addition to operations for other
midline lesions—require continuous observation
of spontaneous respiration (Ballantine and Jack-
son, 1960; Lancet, 1960; Carnegie, 1959; Schet-
tini et al., 1961; Araujo, 1963). The solution of
this particular problem can be left to the personal
experience and preferences both of the surgeon
and of the anaesthetist.
SPECIAL TECHNIQUES
Since 1953, particular anaesthetic techniques have
been advocated as "ideal" or specifically indicated
for neurosurgery. Such are "potentiated anaes-
thesia" and "artificial hibernation" (Lazorthes and
Campan, 1952b); Woringer et al., 1952; Frowein
and Loew, 1954; David et al., 1961) and latterly
"neuroleptanalgesia" (De Castro and Mundeleer,
1962; Brown, 1962, 1964; Holdemess et al.,
1963; Brown et al., 1963; Carpino-Boeri, 1964;
Mazzarella and Memoli, 1964). Their use, how-
ever, remains limited to date to a few centres or
to occasional indications (induction of hypother-
mia, severe brain injuries, stereotactic operations,
neuroradiological diagnostic procedures).
Special techniques have been developed in
order to provide convenient solutions in situations
where the usual anaesthetic techniques cannot
provide sufficiently satisfactory conditions, be-
cause of the patient's disease or in relation to the
270
planned surgical programme. Usual anaesthetic
techniques may maintain brain tension, blood
pressure and brain metabolism at near normal
values (Alexander et al., 1963; Galindo and Bald-
win, 1963; McDowall et al., 1963, 1964), but
they may not provide the degree of brain softness
required, nor offer a bloodless surgical field for
lengthy operations, while at the same time pro-
tecting the nervous tissue from ischaemic damage.
Special techniques are grouped here according
to the specific problems concerned.
Reduction o] Brain Volume and Tension.
Intracranial contents consist of nervous (including
pathological) tissue, cerebrospinal fluid and blood.
All the special techniques adopted to reduce the
tension of intracranial contents operate by reduc-
ing the volume of one or more of these com-
ponents (Bozza et al., 1961a); compensatory
changes may occur so that the reduction in one
compartment is followed by an increase in one
of the others (Rosomoff, 1961, 1962, 1963a).
Methods acting on nervous and pathological
tissue volume include osmotic dehydration and
hypothermia (Rosomoff, 1961, 1962).
Osmotic dehydration.
With osmotic dehydration a reduction of brain
volume is obtained by shifting fluid from the
nervous system to the vascular stream through
an osmotic gradient at the blood/cerebrospinal
fluid (c.s.f.) barrier (Benson and Murphy, 1961);
therefore the effect of the different agents em-
ployed is related essentially to their ability to pass
the blood/c.s.f. barrier and to the rate of their
disappearance from the blood (Rosomoff, 1962;
Schmidt, 1963b; Ravin et al., 1964). Urea grad-
ients across glial cell membranes may be impor-
tant (Reed and Woodbury, 1962). The diuretic
effect seems to be of secondary importance (Javid
and Anderson, 1959).
Hypertonic saline (33 per cent) and glucose
(33-50 per cent) pass the blood/c.s.f. barrier
readily and are rapidly eliminated from the blood.
Levulose (50 per cent) passes the barrier more
slowly but is quickly destroyed in the liver. Sor-
bitol (50 prr cent) does not pass the blood/brain
barrier, and is slowly degraded to levulose. Urea
(30 per cent) diffuses slowly through the barrier
and is slowly eliminated by the kidney (Bounous
BRITISH JOURNAL OF ANAESTHESIA
et al., 1960; Benson and Murphy, 1961). Sucrose
(50 per cent) and mannitol (20-25 per cent) do
not pass the blood/c.s.f. barrier (Coleman and
Buckell, 1964) and are eliminated mostly un-
changed through the kidney, causing a marked
diuresis (Lilien et al., 1963). Dextran (10 per
cent), concentrated plasma and human albumin
(25 per cent) do not pass the blood/brain barrier,
and remain for a long time in the circulating
blood.
A secondary increase in intracranial pressure,
in some instances reaching values well above the
initial ones, is often observed after osmotic dehy-
dration with nearly all the agents described.
This "rebound" effect is marked a short time after
hypertonic saline and glucose, and 3-12 hours
after urea (Lundberg, 1960; Langfitt, 1961; Roso-
moff, 1961; Clark and Einspruch, 1962; Loehning
et al., 1962). It is alleged that this effect is mini-
mal or absent after mannitol (Wise and Chater,
1961a, b, 1962; Shenkin et al., 1962; Rossanda
et al., 1965) and sucrose (Masserman, 1935; Hahn
et al., 1937; Raison, 1957).
Osmotic dehydration increases cerebral blood-
flow and cerebral oxygen consumption (Schmidt,
1963b).
Intracranial hypertension due to tumour or
oedema is the main indication for osmotic dehy-
dration. At present urea and mannitol are the
agents most widely employed during intracranial
surgery (Javid, 1958, 1961; Stubbs and Penny-
backer, 1960; Jeppson and Jarpe, 1960; Bozza
et al., 1961a; Stern and Bethune, 1961; Caballero,
1962; Gordon, 1962, 1963; Gott et al., 1962;
Shenkin et al., 1962; Schmidt, 1963b'; Rossanda
et al., 1964; Schapira, 1964). Urea is probably
the agent of choice when maximal reduction of
the volume of the normal brain is needed, as in
surgery of the circle of Willis (Terry, 1961); the
best results are obtained if administration is
started early and is completed before the skull is
opened (Rosomoff, 1963b). When a rebound effect
is to be feared, as in surgery for malignant
growths, mannitol seems preferable. This agent
acts very quickly and its administration may be
postponed until the dura mater is exposed.
Concentrated plasma, albumin or dextran are
preferred when brain dehydration is required for
prolonged treatment (Maciver et al., 1958;
Matheson et al., 1959; Marshall, 1961; Bozza
GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
Marrubini, 1964). Mannitol too can be used in
these cases since it does not induce appreciable
changes in electrolyte balance (Wise, 1963) and
repeated administrations appear to be well toler-
ated (Rossanda et al., 1965).
Possible dangers of osmotic dehydration are
intracranial haemorrhage with an increased gen-
eral tendency to bleeding, haemolysis, haemoglo-
binuria, venous thrombosis, and renal damage,
in addition to excessive electrolyte and water
losses (Raison, 1957; Stubbs and Pennybacker,
1960; Mason and Raaf, 1961; Watkins et al.,
1961; Gott et al., 1962; Wenker, 1962; Ravin
et al., 1964). Great caution should be exercised
in the use of hypertonic solutions after cranio-
cerebral trauma or in other acute conditions
whenever an intracranial haemorrhage may have
occurred. The retraction of the normal brain in
such cases would only have the effect of leaving
more space for the compressing haematoma and
of exaggerating the already dangerous distortion
of the brain stem.
The surgeon should always be informed when
osmotic dehydration has been produced, especially
during incomplete resection of malignant growths.
A "slack" brain, obtained through the temporary
effect of osmotic dehydration may mislead the
surgeon and could be the cause of insufficient
brain decompression.
Other methods.
Methods acting on cerebrospinal fluid volume
include ventricular tap and spinal drainage.
Ventricular tap is usually adopted as an emer-
gency measure during the first phases of anaes-
thesia and surgery in cases of severe intracranial
hypertension with hydrocephalus or after ventri-
culography (Campan and Deligne, 1960; Whitby,
1961). Spinal drainage can be used to obtain
retraction of the brain mass in cases of normal
intracranial pressure, in order to facilitate the
exposure of deep-seated structures and lesions
(operations on the hypophysis, on the circle of
Willis, on the brain peduncles, etc.; Vourc'h and
Rougerie, 1960; Vourc'h, 1963; Gordon, 1963).
Methods acting on brain blood volume com-
prise overventilation, controlled hypotension and
hypothermia.
Controlled hypotension and hypothermia are
complex and relatively dangerous procedures and
their effect on brain volume and tension is not
271
very marked (Lemmen and Davis, 1958; Ballan-
tine and Jackson, 1960; Campan and Delign6,
1960; Posnikoff et al., 1960; Nielson et al., 1962;
Lundberg, 1963). Their use, therefore, is not
recommended if a reduction of brain volume and
tension only is desired (Lemmen and Davis,
1958; Bozza Marrubini et al., 1961b; Marshall,
1961; Terry, 1961; Tappura et al., 1961; Gordon,
1963; Maspes et al., 1964).
PULMONARY OVERVENTILATION
Interest in overventilation as a means of reducing
intracranial pressure has been stimulated parti-
cularly by the publications of Lundberg (Lund-
berg et al., 1959; Lundberg, 1960). This tech-
nique has now reached wide popularity in neuro-
surgical anaesthesia, as it appears to be simple
and relatively harmless. Its potential dangers have
been carefully evaluated by many authors and the
majority agree now that that most feared, brain
ischaemia, is not a reality under clinical condi-
tions. The experimental studies of Adams and
Severinghaus (1962), Alexander et al. (1963),
Cohen et al. (1964), Hirsch (1964), Wassennan
and Patterson (1954), and of Wollman et al.
(1964), in addition to clinical observations of those
anaesthetists who employ overventilation widely
in neurosurgical anaesthesia, failed to confirm
the proposition of Clutton-Brock (1957), Allen
and Morris (1962), Bollen (1962) and of
Sugioka and Davis (1960), who all implied
that hypocapnia could produce cerebral hypoxia
through an uncontrolled constriction of the cere-
bral vessels. The cerebral and electroencephalo-
graphic effects of overventilation (Geddes and
Gray, 1959; McAleavy et al., 1961; Bollen, 1962;
Mangiavacchi and Boeri-Carpino, 1962) may be
due to the direct effect of Pco, and pH changes
on the brain (Robinson and Gray, 1961; Pierce
et al., 1962) rather than to ischaemia, or to acti-
vity transmitted to the brain by other structures
which are sensitive to carbon dioxide (Sakai et
al., 1962). Electrolyte shifts and acid-base changes
are well tolerated and quickly reversible if ex-
treme degrees of respiratory alkalosis are avoided
(Brown et al., 1949; Papadopoulos and Keats,
1959; Cutter and King, 1961; Okel and Hurst,
1961; Robinson, 1961; Andersen and Svane,
1962; Markello et al., 1963).
272
Recent experiences seem to cast doubt on the
effectiveness of overventilation in reducing brain
tension (Rosomoff, 1963a; Ueyama and Loehning,
1963); on clinical grounds, however, it appears
satisfactory in a number of cases (Furaess, 1957;
Bozza et al., 1961a; Marshall, 1961; Terry, 1961;
Slocum et al., 1961; Gordon, 1962, 1963; Hayes
and Slocum, 1962; Bozza Marrubini et al., 1964a).
Overventilation may be effected by manual con-
trol of respiration, but more consistently reliable
results are obtained when a mechanical respirator
is used. The importance of a negative phase has
probably been overstressed, since the cerebro-
spinal fluid pressure appears to be much more
closely correlated with the level of ventilation and
carbon dioxide tension than with the mean air-
way pressure (Bozza Marrubini et al., 1964a).
Overventilation may be safely combined with
any other method tending to reduce brain tension,
with the possible exception of extreme head-up
positions (Hunter, 1962). A summation of effects
is often obtained by associating overventilation
with osmotic dehydration or drainage of cerebro-
spinal fluid (Bozza et al., 1961a); Gordon, 1962,
1963; Bozza Marrubini et al., 1964a).
THE CONTROL OF HAEMORRHAGE
Apart from the carotid bodies, the brain has the
highest bloodflow of any organ and at the same
time is the most sensitive to anoxia. In intra-
cranial surgery highly vascularized lesions are
frequent; the operative field is often very small
and may be obscured by even limited oozing.
The control of haemorrhage, therefore, has often
been a serious problem for the neurosurgeon and
the anaesthetist. The technical solutions are pos-
tural drainage, the use of local vasoconstrictors,
controlled hypotension, and hypothermia widi
occlusion of arterial inflow. Hypothermia will be
dealt with in the next section.
Postural drainage.
Correct positioning of the patient, with free
venous drainage from the head, is always essen-
tial to reduce operative bleeding and to ensure
success for special techniques. A slight head-up
tilt is adopted for nearly all intracranial cases. A
steep reverse Trendelenburg position, or the sit-
ting position, is used in many centres for section
of the 5 th sensory root and for operations in the
BRITISH JOURNAL OF ANAESTHESIA
posterior fossa. The resulting advantage of
reduced arterial and venous pressures in the
cranial vessels (Enderby, 1954; Hunter, 1960,
1962), must be carefully weighed against the
dangers of cerebral ischaemia and air embolism
(Hamby and Terry, 1952; Keeri-Szanto and Rin-
fret, 1957; Vourc'h et al., 1960; Emery, 1962;
Hewer and Logue, 1962; Galindo and Savolainen,
1964), especially when controlled respiration is
used (Hunter, 1962), and when there is a large
loss of cerebrospinal fluid (Hoffman et al., 1954).
For the prevention of air embolism, intermittent
compression of the jugular veins, a positive intra-
pulmonary pressure, and the use of antigravity
suits, have been advocated (Freuchen, 1959;
Hewer and Logue, 1962; Hunter, 1962).
Local vasoconstrictors.
Correct anaesthesia and good postural drainage
of the head may be insufficient to prevent brisk
arteriolar and capillary bleeding from the scalp
and other extracranial structures during the first
phases of surgery. Such bleeding may be reduced
by infiltration of the incision line with solutions
containing 1:200,000 to 1:500,000 adrenaline.
The safety of this practice has been questioned
especially when halothane or trichloroethylene is
used, since cardiac arrhythmias, sudden collapse
and cardiac arrest have been occasionally observed
(Brindle et al., 1957; Millar et al., 1958; Rosen
and Roe, 1963; Varejes, 1963). The author's
experience is in close agreement with the obser-
vations of Hunter (1964), who found no clinical
evidence of cardiac irregularities following the
use of adrenaline with halothane in a series of
spontaneously breathing neurosurgical cases, pro-
vided a total amount of 250-300 micrograms of
adrenaline was never exceeded. The importance
of the total dose of catecholamines injected by
subcutaneous infiltration has been pointed out
also by others (Johnstone and Nisbet, 1961; Katz
et al., 1962; De Lange, 1963) and has been sub-
stantiated by the experience of Andersen and
Johansen (1963). Concomitant respiratory depres-
sion is probably also of great importance in the
causation of cardiac irregularities in cases where
adrenaline infiltration has been used.
Troublesome venous bleeding from extracranial
structures, unrelated to anaesthetic errors or bad
position, is usually due to a raised intracranial
tension; this may be quickly corrected by ventri-
 GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
cular tap or by the intravenous infusion of 250-
500 ml of 20 per cent mannitol.
CONTROLLED HYPOTENSION
Induced hypotension* for neurosurgery has un-
dergone a remarkable evolution. It began with
complex techniques, such as total spinal block
(Swanson et al., 1951; Uihlein and Lundy, 1952;
Payne, 1953) and arteriotomy (Gardner, 1946;
Bilsland, 1951; Payne, 1953; Brown, 1954; Jack-
son, 1954; Hale, 1955). Then many different
ganglion-blocking agents including hexamethon-
ium, pendiomide, trimetaphan, pentolinium,
homatropinium and lastly Plegarol (Vogrin,
1963), were tried alone or in combination with
other drugs, to overcome "resistance" (see Little,
1956; Ballantine and Jackson, 1960). The intro-
duction of halothane and of mechanical ventila-
tors reduced the scope of ganglioplegia, and most
neurosurgical anaesthetists prefer now to obtain
a moderate and quickly reversible degree of arter-
ial hypotension with halothane, controlled respira-
tion, and a limited degree of postural assistance,
rather than to induce a possibly less reversible
circulatory imbalance through ganglioplegia and
a marked head-up tilt (Dam, 1960; Murtagh,
1960; Johnstone, 1961; Casaer, 1963; Rollason
and Latham, 1963). Controlled ventilation with
high positive pressure, used by some anaesthetists
along with ganglion-blocking drugs to facilitate
the control of arterial pressure (Armstrong-Davi-
son, 1962; Enderby, 1964), could also be neces-
sary during hypotension to correct the increase in
physiological deadspace resulting from the re-
duced pulmonary bloodflow (Eckenhoff et al.,
1963).
Some workers consider that the indications for
controlled hypotension in cranial surgery are now
rather limited. The surgical treatment of cerebral
aneurysms and other vascular malformations may
require a total cerebral ischaemia, which cannot
be obtained with arterial hypotension unless
safety limits are trespassed. Such cases now call
for hypothermia. In most of the other previously
accepted indications for hypotension, e.g. menin-
giomas or other highly vascularized tumours,
satisfactory operating conditions may be obtained
* A detailed discussion on this subject with a full
list of references can be found in the recent review
by Larson (1964).
273
by simpler and safer methods, such as the com-
bination of halothane, controlled respiration and
postural drainage, if necessary with the aid of
osmotic dehydration or cerebrospinal fluid drain-
age (Ditzler, 1964). At present the author be-
lieves that indications for controlled hypotension
are limited to large msningiomas, or similarly
vascularized tumours, in fit subjects, when it is
found that the operating field is unsatisfactory
even with the use of moderately hypotensive
halothane anaesthesia. In these cases it must be
remembered that halothane increases the subject's
sensitivity to ganglion-blocking drugs (Ballantine
and Jackson, 1960; Bozza, 1959). When the sur-
geon does not require interruption of the cerebral
blood supply, hypotension may be indicated dur-
ing the dissection and closure of arterial aneu-
rysms (Tappura et al., 1961).
Controlled hypotension may be a dangerous
procedure. Thus, "retractor ischaemia", diffuse
cerebral damage, renal insufficiency, retinal
ischaemia with irreversible amaurosis, and cardio-
respiratory failure during or after operation
have been described, even in cases in which more
than ordinary care in the anaesthetic management
had been exercised (Goldsmith and Hewer, 1952;
Bozza et al., 1953; Bromage, 1953; Gillan, 1953;
Hampton and Little, 1953; Nilsson, 1953; Fin-
nerty et al., 1954a, b; Goldblat, 1955; Stephen
et al., 1956; Berg et al., 1957; Enderby, 1961;
Brierley and Cooper, 1962; Gruvstad et al.,
1962).
Indeed, neither the calculations introduced by
Enderby (1954), by Woodhall et al. (1954), by
Stephen et al. (1956) or by Eckenhoff (1962) to
predict the intravascular pressure in the cerebral
arteries during hypotension, nor the special
measures adopted by Mannheimer and Keats
(1963), have a proved value in increasing the
safety of the method. The same applies to the
association of hypotension with hypothermia,
which has been advocated by many (Dundee et
al., 1954; Eccleston et al., 1956; McBurrows et
al., 1956; Campkin and Inglis, 1958; Rollason
and Latham, 1963) but which cannot give abso-
lute protection (Clinical Anaesthesia Conference,
1958).
Therefore, besides all the cases of proved or
suspected derangement of cardiovascular, pul-
monary, renal and hepatic functions, contraindica-
274
tions may include severe intracranial hyperten-
sion; in these patients cerebral bloodflow is
already reduced by external compression of the
cerebral vessels (Kety et al., 1948) so that fatal
cerebral ischaemia could be precipitated by an
even mild degree of induced arterial hypotension
(Brown, 1954; Mortimer, 1959). If hypotension
is necessary, it seems advisable in these cases to
induce it only after the dura has been opened
and the high intracranial pressure has been
relieved (Bozza, 1955).
THE PROTECTION OF NERVOUS TISSUE FROM
ANOXIA OR SURGICAL DAMAGE
Neurosurgery is dominated by this problem. Even
very limited damage in some areas of the brain
(the brain stem, pons, diencephalo-pituitary
region, the floor of the IV ventricle, etc.) may
cause severe functional derangement or a fatal
outcome. Moreover, damage to nervous tissue is
constantly followed in a matter of minutes, hours
or days by a reaction in the form of localized or
diffuse oedema. The surgical approach and treat-
ment of such different lesions as tumours, aneu-
rysms, and hydrocephalus, entails a risk of tissue
damage through impaired blood supply, mechani-
cal injury, or thermocoagulation.
During surgery abnormal respiratory or cardio-
vascular patterns may reveal imminent danger to
important nervous centres. Typical patterns have
been described. Detailed discussions on changes,
their meaning, on the interrelation between res-
piratory and cardiovascular alterations, and on
the value of routine monitoring of vital functions,
will be found in papers by Howland and Papper
(1952), Bozza (1955), Bozza Marrubini et al
(1961b), Bergman (1957), Hunter (1962), and
Whitby (1963). It is worth emphasizing here that
any change in respiration or circulation which is
unrelated to variations of anaesthetic depth or to
changes in the circulating blood volume, may
indicate injury to nervous tissue. In many
instances timely action may avoid irreversible
damage; ventricular tap, removal of retracting
instruments, of cotton flaps or of other surgical
material, directly or indirectly compressing ner-
vous tissue, are all measures that the surgeon
may take if changes in vital signs are correctly
interpreted and reported by the anaesthetist.
BRITISH JOURNAL OF ANAESTHESIA
This part of the anaesthetist's duties requires
special knowledge and experience and is a unique
feature of neurosurgical anaesthesia. The neces-
sity of recognizing without delay even minor
changes in vital functions may explain why
anaesthetic techniques which upset autonomic
balance in an unpredictable way have been
rejected in many neurosurgical centres. This may
apply also to the invariable use of controlled
respiration.
Close supervision of the vital functions and
timely alarm are the best protection that the
anaesthetist may assure to the patient during
ordinary neurosurgical operations and to this end
various devices for monitoring have been sug-
gested.
MONITORING DURING NEUROSURGICAL OPERATIONS
Electrocardiography.
There are special indications for routine elec-
trocardiographic monitoring during anaesthesia
for neurosurgery, because of associated factors
such as the injection of adrenergic local vasocon-
strictors, the use of deliberate hypotension, occa-
sional sudden haemorrhage, and the possibility
that e.c.g. changes may reflect ischaemic trauma
to the brain stem or reveal air embolism;
ventricular extrasystoles usually point to inade-
quate pulmonary ventilation. When occupied, or
in difficulties, the sense of security given to the
neurosurgical anaesthetist by a glance at a normal
e.c.g. is scarcely rendered false by the very rare
(and possibly overdramatized) finding of a normal
trace in the absence of circulatory function. Cer-
tainly, caution is necessary in interpreting any
changes seen; only the ready availability or actual
use of all limb and chest leads can safeguard
against misinterpretation and possible abandon-
ment of surgery for the wrong reasons, e.g. abnor-
mal traces caused by rotation of the heart in
different body positions or by pulmonary over-
ventilation.
The electrocardiogram has gained a special
place in the surgical treatment of hydrocephalus,
by simplifying the insertion of ventriculojugular
drainage catheters incorporating one-way Pudenz
or Spitz-Holter valves. Two limb leads may be
used, one being left in situ, while the other makes
electrical contact with saline contained in a jugu-
lar catheter. In assessing the optimal site of place-
GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
ment of the catheter within the right atrium,
electrocardiographic signs should be at first con-
firmed by X-ray control; as experience is gained,
the use of the e.c.g. alone by the anaesthetist has
been found satisfactory in certain neurosurgical
units (Richards and Freeman, 1964).
Body temperature.
In air-conditioned operating theatres, body
temperature may fall as much as 1 degree per
hour. While this appears to have little adverse
effect in adult patients other than as a cause of
postanaesthesia shivering, periodic measurement
through an indwelling rectal or oesophageal elec-
trical thermometer may enable changes to be
forestalled, for example by the use of water-
warmed mattresses.
Ventilation volumes.
Ventilation volumes may be measured in adults,
probably with sufficient accuracy, with the Wright
respirometer (Nunn and Ezi-Ashi, 1962) or, if a
non-rebreathing system is used, with a simple dry
gas meter. If spontaneous ventilation is main-
tained, the gas meter may be inserted on the
expiratory side or may be placed in the path of
the inspiratory flow of a non-rebreathing system,
provided that a reservoir bag with a leak for
excess gases is connected to the system before
the patient and the meter. During controlled res-
piration the measuring device must be inserted in
the expiratory side of the system to avoid the
errors due to the leaks during the phase of
positive pressure. For T-piece techniques, when
small patients are covered by surgical sheets and
are remote from the anaesthetist, respiratory
movements may be observed semi-quantitatively
by means of a simple thermistor and bridge cir-
cuit (Millar and Marshall, 1963). If equipment
and technical assistance is available, measurement
of arterial pH, Pco3, and standard bicarbonate
(Siggaard Andersen et al., 1960) provides full
information about acid-base changes during
neurosurgical anaesthesia. Fine disposable needles
make single arterial puncture a rapid and trouble-
free procedure, and the use of such facilities is
fully justified in the most major cases, for
example where hypotension, hypothermia, and
overventilation are combined.
Rapid infra-red analyzers allow continuous
monitoring of expired carbon dioxide. This type
275
of measurement may offer useful information
during normo- and hypothermic anaesthesia pro-
vided its limitations and possible sources of error
are realized (Woolmer, 1959; Bozza Marrubini
et al., 1964b).
Arterial pressure.
Periodic indirect measurement of arterial pres-
sure is invariable during neurosurgical operations,
use frequently being made of the Scala Alternans
manometer (Von Recklinghausen). Direct intra-
arterial recording is unlikely to become routine
because of present limitations related to cost and
available expertise in the use of indwelling arterial
catheters. Meantime, where apparatus is available,
display of intra-arterial pressure (for example, on
a calibrated meter) can be a valuable contribution
to patient safety and technical success during in-
duced hypotension. Devices of simple construc-
tion have also been described for measuring pres-
sure through intra-arterial needles (Severinghaus,
1957; Fink, 1963).
Changes in venous pressure may be observed
with a graduated rule and a column manometer
adapted from an intravenous infusion set; these
and other factors related to blood volume changes
during surgery have been considered in a recent
Royal College of Surgeons symposium (1963).
Finally, steady-state conditions of halothane
anaesthesia might be attained consistently through
periodic measurement of end-expired anaesthetic
vapour concentration (Robinson, Demon, and
Summers, 1962).
HYPOTHERMIA
The expanding scope of neurosurgery now in-
cludes the direct treatment of vascular lesions,
radical dissection of cerebello-pontine angle
tumours and of craniopharyngiomas, and the
treatment of severe brain injuries. In the former
cases cerebral hypoxia and tissue injury in dose
proximity to the vital centres of the nervous sys-
tem are to some extent an accepted part of the
surgical plan; it is obvious, therefore, that the
simple passive attitude of vigilance previously
described becomes insufficient. Active steps must
be taken to protect the vital centres.
For this purpose hypothermia is indicated. This
is something quite different from "artificial hiber-
nation" (Lazorthes and Campan, 1952b; Lazor-
276
thes et al., 1952; Woringer et al., 1952; Campan
and Lazorthes, 1954; David et al., 1961) which
has no real protective effect against trauma or
hypoxia unless hypothermia is simultaneously
induced (Millar, 1954; Bozza, 1956; Pourpre et
al., 1958).
Moderate hypothermia was first used in neuro-
surgery for the direct treatment of cerebral aneu-
rysms in 1955 (Lougheed and Kahn, 1955;
Lougheed et al., 1955; Vandewater et al., 1955;
Botterell et al., 1956), and to date the reduction
of body and cerebral temperature is still the
only sure means available to protect nervous
tissue from oxygen lack and direct injury.*
Controlled hypothermia is now widely em-
ployed in neurosurgery. In most cases moderate
hypothermia only is induced (30-27°C). This
protects the brain from the effects of total oxygen
deprivation of 6-10 minutes duration. After a
suitable interval of re-oxygenation ischaemic
periods may be repeated if necessary. Partial
ischaemia and hypoxia consequent on induced
arterial hypotension or surgical manipulation are
said to be better tolerated during hypothermia;
however, as with total ischaemia, clear-cut limits
have not been defined.
Many techniques for the induction of moderate
hypothermia in neurosurgery have been described.
Essential features are: (a) the induction of an
adequate blockade of thermoregulatory reflexes
by the use of general anaesthesia and, if required,
of supplementary drugs such as phenothiazines
and muscle-relaxants; and (b) the use of a
physical surface cooling system; this may be
crushed ice, refrigerated mattresses and blankets,
cold water, alcohol, or cold air. As the surgical
field is limited to the head, neck and upper
thorax, heat exchange may be obtained on a
large body surface even during the operation,
so that, if a suitable method is adopted, cooling
and eventually rewarming can proceed during the
surgical manoeuvres. Additional anaesthesia time
may thus be reduced to a minimum (Bozza and
Rossanda, 1962).
* A full list of references on the general subject of
hypothermia will be found in the books and reviews
by Virtue (1955), Little (1959), Dundee and King
(1959), Cooper and Ross (I960), Boba (I960), and
Stephen (1964). For a detailed discussion and biblio-
graphy on the techniques and on the specific problems
of hypothermia in neurosurgery the reader is referred
elsewhere (Bozza Marrubini et al., 1964b).
BRITISH JOURNAL OF ANAESTHESIA
Exceptionally, an extracorporeal blood circuit
has been used for moderate hypothermia (Foltz
and Frederickson, 1960; Bozza Marrubini et al.,
1964b).
Extracorporeal circulation is required as a rule
when deep hypothermia (10-15°C) is used.
Deep hypothermia was introduced in heart
surgery by Drew (Drew and Anderson, 1959;
Drew et al., 1959). Both the original technique
(Daw et al., 1960; Guiot et al., 1960; Stoffregen
et al., 1962; Uihlein et al., 1962; Terry et al.,
1962) and closed-chest variations (Woodhall et
al., 1960; Patterson and Ray, 1962; Michen-
felder et al., 1963; Schapira, 1964) have been
adopted for the treatment of cerebral vascular
malformations requiring prolonged circulatory
arrest. The results seem to be good so far as
the tolerance of the heart and of the brain to
deep cooling are concerned. Also, acid-base regu-
lation is well maintained, provided long periods
of low-flow perfusion are avoided (Rehder et al.,
1962; Uihlein et al., 1963; Michenfelder et al.,
1964a). Surgical results and indications, however,
still appear debatable; in contrast with the pro-
mising results of the Mayo Clinic team (Michen-
felder et al., 1964b), Campkin and McNeil (1964)
have abandoned the technique after a discourag-
ing experience.
Selective brain cooling with an extracorporeal
circuit perfusing only the brain vessels (usually
one or both carotid arteries), although extensively
studied on animals and tried on man in different
centres both for heart and for brain surgery since
1956, has not yet passed beyond the experimen-
tal phase (Kimoto et al., 1956; Woodhall and
Reynolds, 1957; Adams and Pevehouse, 1958;
Lund et al., 1958; Woodhall et al., 1958, 1959;
Kristiansen et al., 1960; Louri et al., 1960; Wood-
hall, 1960; Pritchard, 1961; Wertheimer et al.,
1961; Boyd and Connolly, 1962; Donald and
White, 1962; Gott, 1963a, b; Kristiansen, 1964).
Moderate hypothermia obtained with surface
cooling remains, therefore, the method of wider
use in neurosurgery.
Its main dangers—cardiac irregularities leading
to ventricular fibrillation, and postoperative meta-
bolic acidosis—may be avoided by correct anaes-
thetic management and accurate maintenance of
circulatory and respiratory balance. Even cooling,
good control of the final temperature level, the
GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
prevention of shivering, the maintenance of ade-
quate blood pressure, even perhaps by the use of
vasopressors (Hewer, 1962), and maintaining of a
constant Pco, during the hypothermic phase
instead of a hypothennic alkalosis, as previously
recommended, are the salient points relevant to
the success and safety of the method (Albers,
1962; Wycoff, 1962; Bozza Marrubini et al.,
1964b; Burton, 1964). Even poor risk cases
tolerate the technique well.
The indications, after a decline of initial enthu-
siasm, are now regarded more critically. The only
indications accepted by the majority are opera-
tions for vascular malformations, especially when
partial or total temporary arrest of the cerebral
circulation exceeding 2-3 minutes is planned
(Botterell et al., 1958; Vandewater et al., 1958;
Vourc'h et al., 1958; Hjorth et al., 1962; Maspes
et al., 1964). Large cerebral tumours and angio-
mas whether requiring arterial hypotension or
not, craniopharyngiomas, and other tumours
located in close proximity to vital centres (III and
IV ventricle, brain stem) are considered by many
neurosurgical teams to be indications for hypo-
thermia (Inglis and Turner, 1957; Sedzimir and
Dundee, 1958; Lundberg, 1963) but this is far
from being universally accepted (Ballantine and
Jackson, 1960; Maspes et al., 1964).
SPECIAL PROBLEMS
Many intracranial operations constitute a special
problem for the anaesthetist but, if the features of
the patient's pathology and the surgical plan are
clearly settled and discussed beforehand, the
correct anaesthetic management can be adopted
on the basis of the general principles outlined
in the preceding paragraphs.
Certain special cases, however, require further
detailed discussion.
CHILDREN
Neurosurgical diseases in the first years of life
include traumatic conditions (especially birth
injuries), congenital defects (encephalo- and
meningocoele), hydrocephalus, tumours, hydatid
cysts, vascular lesions, and degenerative diseases
requiring hemispherectomy or similar operations.
Surgery is performed on children of all ages but
more frequently on infants under 1 year of age.
277
In neonates the technical problems differ some-
what from those of adult neurosurgery; for in-
stance, brain tension is seldom a problem and
special treatment to reduce it is almost never
required. On the other hand, haemorrhage is
always a matter of concern, since apparendy
minor blood losses may be dangerous because of
the small blood volume of the newborn baby.
Troublesome venous bleeding is in most cases
the consequence of an inadequate airway, of a
large external deadspace and rebreatbing, or of
excessive resistance to breathing either in the
anaesthetic system or as a result of incorrect
positioning.
The importance of tracheal intubation with un-
kinkable tubes of the widest possible bore, of the
use of non-rebreathing or open anaesthesia sys-
tems (Stephen-Slater valve or Ayre T-piece), with
minimal deadspace and resistance, and of arrange-
ments leaving the abdomen free (for instance, if
the prone position is required, the use of the so-
called Mohammedan-praying position (Bozza,
1955)), cannot therefore be overstressed.
The management of haemorrhage should rely
on blood replacement only, as special techniques
for reducing bleeding are usually inapplicable and
dangerous in these cases; adrenaline infiltration
should be undertaken with caution as local skin
ischaemia may be so widespread and prolonged
as to compromise good healing of surgical wounds.
Transfusion should exactly compensate blood
loss; in the author's experience of paediatric
neurosurgery, however, the dangers of excess
replacement are far less than those of insufficient
transfusion, which may result not only in shock,
but in delayed recovery from the anaesthetic,
slow resumption of feeding, and metabolic
acidosis.
In infants, vital functions often follow irregular
patterns which are devoid of pathologic signi-
ficance; progressive changes may be the conse-
quence of errors in the anaesthetic management,
such as excessive anaesthetic depth, resistance
to breathing, excessive deadspace, and uncom-
pensated blood loss. At all ages serious alterations
such as hypotension, bradycardia, extreme tachy-
cardia and/or tachypnoea and respiratory insuffi-
ciency may be related to sudden changes in
intracranial pressure (evacuation of large clots,
loss of large volumes of cerebrospinal fluid) or
278 BRITISH JOURNAL OF ANAESTHESIA

to surgical manipulation near the brain stem as patient from the occurrence of a generalized
during dissection of craniopharyngiomas or of epileptic fit during the operation, of assuring to
tumours related to the floor of the IV ventricle. the surgeon a perfectly quiet and favourable
In temperate climates, heat loss with hypother- surgical field, and of avoiding the stress for the
mia during prolonged general anaesthesia is much patient of prolonged and sometimes painful sur-
more frequent than hyperthermia (Stephen et al., gical manoeuvres (Spear and Gaard, 1953; Pas-
1960). Hypothermia in the baby may lead to quet, 1954; Bozza et al., 1959; Hall et al., 1959;
delayed recovery and a complicated postoperative Ingvar et al., 1959; Gordon and Widto, 1962;
course (France, 1957; Hackett and Crosby, 1960; Vourc'h et al., 1963; Backman et al., 1964).
Harrison et al., 1960; Calvert, 1962; Farman, If electrocorticography only is planned, with-
1962; Nesling, 1963; Smith, 1963). Body tem- out cortical mapping and stimulation, satisfactory
perature changes should therefore be prevented electrical patterns may be observed with the fol-
by the use of a warm water blanket or a similar lowing types of anaesthesia: tranquillizer-anal-
electrical device (Stephen et al., 1960; Calvert, gesic-belladonna drug premedication; nitrous
1962). oxide-oxygen and trichloroethylene or halothane
Anaesthetic techniques usually rely on inhala- induction; tracheal intubation with the aid of
tion anaesthetics only: after atropine premedica- suxamethonium and topical anaesthesia; main-
tion anaesthesia is induced with nitrous oxide- tenance either with trichloroethylene or halo-
oxygen or cyclopropane (Voorhoeve, 1960) and thane, if necessary supplemented by an intra-
maintained with nitrous oxide-oxygen and tri- venous narcotic such as pethidine, or with full
chloroethylene, ethyl ether or halothane (Ballan- curarization and controlled respiration plus mini-
tine and Jackson, 1960; Deacon, 1960; Schmalz mal trichloroethylene (or halothane) or pethidine.
and Grabow, 1962). Methoxyflurane has also The best results are probably obtained if the
been found satisfactory (Richards and Bachman, volatile anaesthetic is discontinued at least 20
1964); ether is now seldom used. Spontaneous minutes before the electrical recording and if
respiration is usually maintained throughout the nitrous oxide proportion never exceeds 60
operation, unless the respiratory exchange be- per cent. In any case barbiturates and ethyl ether
comes insufficient. In the author's experience, should be avoided (Bozza et al., 1959).
basal narcosis with rectal tribromoethanol or Motor responses to cortical stimulation may
thiopentone offers no advantage over simpler tech- be observed even during general anaesthesia
niques, and entails the risks of depression of (obviously without curarization), but if psychic,
vital functions during operation and slow recovery sensory, and verbal responses are also to be
from anaesthesia (Schmalz and Grabow, 1962). studied it is necessary to have the patient fully
After 4-5 years of age all the anaesthetic and awake (and extubated) during stimulation. In this
special techniques used in the adult may be em- case, general anaesthesia is induced and main-
ployed if indicated. tained as described, but heavy premedication,
intravenous narcotics and long-acting muscle
OPERATIONS WITH ELECTROCORTICOGRAPHY relaxants are omitted; 30 minutes before cortico-
Until recently this type of surgery was generally graphy and stimulation all the anaesthetics are
performed under regional analgesia. Neurosur- discontinued and an intravenous drip with 1-2
geons believed that only with this technique was per cent lignocaine is started; this maintains some
it possible to ensure an intact electrocortical wave degree of analgesia and of depression of the
pattern, and the direct control of the patient's tracheal reflexes and facilitates, therefore, a quiet
psychic, verbal, sensory and motor answers to awakening and extubation. As soon as the patient
cortical stimulation (Penfield, 1954; Carnegie, reacts to external stimuli the endotracheal tube
1959). With the development of neurosurgical is removed; usually full co-operation is obtained
anaesthesia many came to believe that similarly in a matter of minutes. If necessary light general
favourable conditions could also be obtained with anaesthesia is induced again for closure. It must
the use of special types of general anaesthesia, be pointed out here that during neuroleptanal-
with the added advantages of protecting the gesia a typical waking e.e.g. pattern, with alpha
GENERAL ANAESTHESIA FOR INTRACRANIAL SURGERY
activity, has been recorded (Ingvar and Nilsson,
1961); this technique might therefore be indicated
for operations with corticography.
STEREOTACTIC OPERATIONS
Patients requiring stereotactic surgery for Parkin-
son's disease, intractable pain or dyskinetic con-
ditions are very often in poor general condition.
Most surgical techniques require ventricular or
lumbar puncture with the injection of contrast
media, the adoption of the sitting position for at
least part of the procedure, and die patient's
co-operation.
In some centres these complex requirements
have been met by the use of general anaesthesia
for the whole or for the first half of the procedure
(Hurter, 1960; Adams et al., 1964); halothane is
the agent of choice for Hurter (1960), Fischer et
al. (1962b) and for Bianchetti and Urciuoli
(1963), while lytic cocktails, neuroleptanalgesia
and similar techniques are preferred by Carnegie
(1959), Deligne et al. (1960), and by Brown
(1964). Coleman and De Vflliers (1964) use a
methohexital intermittent drip without intubation,
but their technique has been criticized by Adams
et al. (1964) and by Brown (1964). Vourc'h et
al. (1963) have chosen hydroxydione as the only
general anaesthetic available which leaves un-
altered synaptic activity and evoked responses
in thalamic nuclei, allowing therefore exact
stereotactic localization.
In the author's experience general anaesthesia
is limited to children, to very anxious subjects
and to those with severe dyskinetic syndromes.
Local analgesia without any form of sedation is
preferred in all other cases. After a six-year exper-
ience it has been concluded that even minimal
sedation may greatly reduce or abolish tremor,
rigidity, involuntary movements and the patient's
self-control, especially towards the end of the
operation when these symptoms are of impor-
tance as a guide to surgical manipulation.
NEUROSURGICAi EMERGENCIES
These include acute brain injury, acute intra-
cranial hypertension, subarachnoid haemorrhage.
In all these cases irreversible anoxic damage
to nervous tissue is always an impending danger.
This may be due to rapidly increasing intracranial
pressure, to cerebral compression (tumours,
279
abscesses, haematomata, oedema, hydrocephalus,
etc.) with temporal or occipital coning, or to
persistent spasm of cerebral arteries. Respiratory
and circulatory insufficiency due to coma or extra-
cranial injuries may further aggravate the tissue
damage.
In neurosurgical emergencies, therefore, gen-
eral anaesthesia must always be preceded by
appropriate resuscitation treatment (Hawkes and
Hawkes, 1962). It must be remembered here
that both induction of anaesthesia and tracheal
intubation are often accompanied by an increase
in intracranial pressure, which may be very
marked and persistent in cases of severe pre-
operative intracranial hypertension (Schmidt,
1963a). This obvious danger cannot always be
avoided by preinduction ventricular tap or by
the infusion of osmotic dehydrating agents. Care-
ful observation of the patient is of paramount
importance; apnoea, hypotension with dispropor-
tionate tachycardia and bilateral mydriasis with
areflexia to light, are all alarm signs marking the
end-point of the brain's tolerance to decompen-
sated intracranial hypertension with anoxia of
the vital centres (Dodd et al., 1957; Thompson
and Malina, 1959; Ballantine and Jackson, 1960;
Taverner, 1960; Wertheimer and Mounier-Kuhn,
1960; Ingvar and Lundberg 1961; Hunter, 1962;
Le Beau, 1962.
These ominous signs should be immediately
pointed out to the surgeon, since it is well known
that only very few minutes may elapse between
their appearance and irreversible brain damage.
If it is possible in these cases surgical cerebral
decompression should be effected as quickly as
possible.
Anaesthetic techniques must stricdy adhere to
the general principles already described; in the
author's opinion general anaesthesia should be
avoided whenever possible, especially in cases of
deep coma. In these last it is preferred to proceed
first of all to tracheal intubation, or to tracheos-
tomy, under topical or local analgesia; if neces-
sary, the patient is then sedated with a tran-
quillizer (hydroxyzine, phenothiazine derivates,
chlordiazepoxide or diazepam) carefully injected
intravenously; the operation is then performed
under local analgesia. With diis technique it is
always possible, should the necessity arise in the
course of the operation, to induce light general
280
anaesthesia and/or to proceed to artificial ventila-
tion. Only if the patient is fully conscious or very
agitated, is general anaesthesia induced from the
beginning, after a standard premedication.
In severe brain injuries and in cases of ruptured
cerebral aneurysms with deep coma and decere-
brate rigidity, hypothermia has been indicated
both as an adjuvant to anaesthesia for the emer-
gency surgical treatment and as a long-term
therapeutic procedure (Rowbotham, 1957; Bot-
terell et al., 1958; Lazorthes and Campan, 1958,
1964; Hendrick, 1959; Sedzimir, 1959; Le Beau,
1962). This type of treatment is supported by
sound experimental evidence (Rosomoff, 1959;
Shulman and Rosomoff, 1959) and good clinical
results have been claimed; its clinical application,
however, is still under discussion (Ballantine and
Jackson, 1960; Maspes, 1962, 1964; Bozza Mar-
rubini, 1964).
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