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N EU R O A N E S T H E S I A
 NEUROANESTHESIA
A P R O B L E M- ​B A S E D L E A R N I N G A P P R O A C H

EDITED BY

David E. Traul, MD
SECTION HEAD OF NEUROANESTHESIA
DE PA RTM E N T OF A N E ST HE SI OLO GY
CLEVELAND CLINIC
CLEVELAND, OHIO

and
Irene Osborn, MD
CLINICAL PROFESSOR OF ANESTHESIOLOGY
DIRECTOR OF NEUROANESTHESIA DIVISION
ALBERT EINSTEIN COLLEGE OF MEDICINE
BRONX, NEW YORK

1
 1
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ISBN 978–​0–​19–​085003–​6
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice.
Treatment for the conditions described in this material is highly dependent on the individual circumstances.
And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written,
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1 3 5 7 9 8 6 4 2
Printed by Sheridan Books, Inc., United States of America
 For Christine, Andrew and Lauren
In loving memory of my father
DET
To my teachers, my trainees and my patients who have taught me so much
Irene Osborn
 D I G I TA L M E D I A AC C O M PA N Y I N G T H E B O O K

Individual purchasers of this book are entitled to free personal Please refer to the access token card for instructions on token
access to accompanying digital media in the online edition. redemption and access.

vi
 CONTENTS

Contributors ix 16. Pediatric Spine Surgery 131

SECTION 1 ONCOLOGIC PROCEDURES
1. Supratentorial Tumors
David E. Traul and Rachel Diehl
Abigail E. Meigh, Ingrid A. Fitz-James Antoine,
and Veronica Carullo
3 17. Myelomeningocele 139
Joanne Spaliaras

2. Anesthesia for Posterior Fossa Mass 9

Valerie L. Howell, Margaret M. Collins and S E C T I O N 5 F U N C T I O NA L P R O C E D U R E S
Lauryn R. Rochlen 18. The Patient for Epilepsy Surgery 147
Haitham Ibrahim and Irene Osborn
3. Awake Craniotomy 17
Shobana Rajan and Vibha Mahendra 19. Deep Brain Stimulation/​Stereotaxic Surgery 153
Sandra Machado
4. Transsphenoidal/​Pituitary Surgery 29
Vaia T. Abatzis and Edward C. Nemergut
S E C T I O N 6 OT H E R P R O C E D U R E S
S E C T I O N 2 VA S C U L A R P R O C E D U R E S 20. Traumatic Brain Injury and C-​Spine Management 161
Matthew Wecksell and Kenneth Fomberstein
5. Cerebral Aneurysm Clipping 41
Irene Osborn and Jocelin Jones Molina 21. Cerebrospinal Fluid Shunts 167
Jinu Kim and Aleka Scoco
6. Arteriovenous Malformation 49
Allison Spinelli and Liang Huang 22. Neurosurgery in Pregnancy 175
David Berman and Ben Touré
7. Carotid Endarterectomy/​Stenting 55
Hui Yang
S E C T I O N 7 N EU R O A N E S T H E S I A
8. Interventional Neuroradiology 65
C O M P L I C AT I O N S
Irene P. Osborn and Liang Huang
23. Elevated ICP 185
9. Endovascular Thrombectomy in Acute Ischemic Stroke 71
Sergey Pisklakov, Haitham Ibrahim,
A. Elisabeth Abramowicz
and Ingrid Fitz-James Antoine
10. Extracranial-​Intracranial Bypass 79
24. Subarachnoid Hemorrhage 191
Wael Saasouh and David E. Traul
K. H. Kevin Luk and Deepak Sharma
25. Venous Air Embolism 201
SECTION 3 SPINE PROCEDURES
Julia I. Metzner and Deepak Sharma
11. Anesthesia for Anterior/​Posterior Spine Surgery 87
26. Postoperative Visual Loss in Spine Surgery 209
Thomas N. Pajewski
David E. Traul
12. Unstable Cervical Spine and Airway Management 99
Michael R. Moore and Ehab Farag
S E C T I O N 8 N EU R O A N E S T H E S I A C O N C E P T S
13. Metastatic Spine Disease 105
27. Neurophysiology/​Neuroprotection 217
Juan P. Cata
Hossam El Beheiry
28. Neurophysiologic Monitoring 229
S E C T I O N 4 P E D I AT R I C P R O C E D U R E S
Antoun Koht and Tod B. Sloan
14. Chiari Malformations 113
29. Neuromuscular Disorders and Anesthesia 237
Marco Maurtua, Mathew Lyons, and Nicholas DaPrano
Mariel Manlapaz and Perin Kothari
15. Craniosynostosis and Anesthetic Management for
Cranial Vault Remodeling 121
Index 245
Hannah Hsieh, Lauren Thornton, and Glenn Mann

vii
 CONTRIBUTOR S

Vaia T. Abatzis, MD Ingrid A. Fitz-​James Antoine, MD

Assistant Professor of Anesthesiology Assistant Professor
University of Virginia School of Medicine Departments of Anesthesiology and Pediatrics
Charlottesville, Virginia Albert Einstein College of Medicine
Bronx, NY
A. Elisabeth Abramowicz, MD
Associate Professor of Anesthesiology Kenneth Fomberstein
New York Medical College Lennox Hill Hospital
Valhalla, New York New York, New York
Hossam El Beheiry, MBBCh, PhD, FRCPC Valerie L. Howell, DO
Trillium Health Partners, Mississauga Fellow in Neuroanesthesia
Associate Professor of Anesthesia University of Michigan Health System
University of Toronto Ann Arbor, MI
Toronto, Ontario, Canada
Liang Huang, MD
Frederic A. Berry, PhD Fellow in Neuroanesthesia
Professor of Anesthesiology Montefiore Medical Center
Professor of Neurosurgery Bronx, New York
University of Virginia Health System
Antoun Koht, MD
Charlottesville, Virginia
Professor of Anesthesiology, Neurological Surgery, and
Veronica Carullo, MD Neurology
Associate Professor Northwestern University Feinberg School of Medicine
Departments of Anesthesiology and Pediatrics Chicago, Illinois
Albert Einstein College of Medicine
Perin Kothari, DO
Bronx, NY
Anesthesiology Institute
Juan P. Cata, MD Cleveland Clinic
Department of Anesthesiology and Perioperative Medicine Cleveland, Ohio
MD Anderson Cancer Center
Mathew Lyons, MD
The University of Texas
Department of General Anesthesia
Houston, Texas
Cleveland Clinic
Nicholas DaPrano, MD Cleveland, Ohio
Department of General Anesthesia
Sandra Machado, MD
Cleveland Clinic
Department of General Anesthesia
Cleveland, Ohio
Cleveland Clinic
Rachel Diehl, MD Cleveland, OH
Department of General Anesthesia
Vibha Mahendra, MD
Cleveland Clinic
Baylor College of Medicine, Department of Anesthesiology
Cleveland, Ohio
Houston, Texas
Ehab Farag, MD, FRCA
Mariel Manlapaz, MD
Professor of Anesthesiology
Department of General Anesthesia
Cleveland Clinic Lerner College of Medicine
Cleveland Clinic Lerner College of Medicine
Cleveland, Ohio
Cleveland, OH

ix
Marco Maurtua, MD, CHSE Wael Saasouh, MD
Department of General Anesthesia Clinical Fellow in Neuroanesthesiology
Cleveland Clinic Cleveland Clinic
Cleveland, Ohio Cleveland, Ohio
Abigail E. Meigh, DO Aleka Scoco, MD
Anesthesiologist Department of Neurosurgery
St. Joseph’s Regional Medical Center Albert Einstein College of Medicine
Paterson, NJ Montefiore Medical Center
Bronx, NY
Margaret M. Mora, MD
Fellow in Neuroanesthesia Tod B. Sloan, MD, MBA, PhD
University of Michigan Health System Professor Emeritus
Ann Arbor, MI University of Colorado School of Medicine
Aurora, Colorado
Jocelin Jones Molina, MD
Resident in Anesthesiology Joanne Spaliaras, MD
Albert Einstein College of Medicine Assistant Professor of Anesthesiology
Montefiore Medical Center Albert Einstein College of Medicine
Bronx, New York Bronx, NY
Michael R. Moore, MD Allison Spinelli, DO
Department of General Anesthesia Assistant Professor of Anesthesiology
Cleveland Clinic Albert Einstein College of Medicine
Cleveland, Ohio Montefiore Medical Center
Bronx, NY
Edward C. Nemergut, MD
Professor of Anesthesiology and Neurological Surgery David E. Traul, MD, PhD
University of Virginia School of Medicine Department of General Anesthesia
Charlottesville, VA Section Head of Neuroanesthesia
Cleveland Clinic
Irene Osborn, MD
Cleveland, Ohio
Clinical Professor of Anesthesiology
Albert Einstein College of Medicine Hui Yang, MD, PhD
Director, Division of Neuroanesthesia General Anesthesiology
Montefiore Medical Center Cleveland Clinic
Bronx, New York Cleveland, Ohio
Thomas N. Pajewski, PhD, MD Matthew Wecksell, MD
Associate Professor of Anesthesiology and Neurological Chief, General Anesthesiology
Surgery Department of Anesthesiology
Director of Neuroanesthesiology Associate Professor of Anesthesiology and Neurosurgery
University of Virginia Health System Westchester Medical Center
Charlottesville, Virginia Advanced Physician Services Member of the Westchester
Medical Center Health Network
Shobana Rajan, MD
Valhalla, New York
Staff Anesthesiologist
Cleveland Clinic Lerner College of Medicine
Cleveland, Ohio
Lauryn R. Rochlen, MD
Staff Anesthesiologist
Neuroanesthesia Fellowship Director
University of Michigan Health System
Ann Arbor, MI

x • C ontrib u tors
 SECTION 1

ONCOLOGIC PROCEDURES
 1.
SUPRATENTORIAL TUMOR S
David E. Traul and Rachel Diehl

S T E M C A S E A N D K EY Q U E S T I O N S “tight” and asks if there is anything you can do to help relax

the brain.
A 69-​year-​old woman presents with a 1-​year history of memory
loss and apathy. Her husband states that he has noticed personality
WH AT A R E T H E M A I N C O NS T I T U E N TS
changes over this period of time. Her past medical history is signif-
O F T H E C R A N I U M , A N D H OW MU C H O F E AC H
icant for hypertension and dyslipidemia. She denies any history of
D O WE H AV E? H OW D O E S T H E B R A I N
headaches, numbness/​weakness, changes in vision, or trauma. She
C O M P E NS AT E F O R E L EVAT E D I C P ? WH AT A R E
has never smoked. She takes atorvastatin, and her blood pressure
S O M E WAYS T H AT T H E A N E S T H E S I O L O G I S T
(BP) is well-​controlled with losartan-​hydrochlorothiazide. Vitals
C A N D EC R E A S E I C P ? WH AT I S T H E E F F E C T
signs are BP 140/​80, pulse 72 bpm, and SaO2 99% on room air. On
O F P C O 2 , PAO 2 , C M RO 2 , A N D P O S IT I VE E N D -​
exam, she is alert and fully oriented.
E X P I R ATO RY P R E S S U R E ( P E E P) O N I C P ?
Labwork reveals normal complete metabolic panel and
D E S C R I B E T H E E FFEC T O F VO L AT I L E A N D
complete blood count. The patient undergoes a magnetic
I V A N E S T H ET I C S O N B L O O D FL OW A N D I C P.
resonance imaging (MRI) examination which reveals a large
WH AT I S C R I T I C A L B L O O D FL OW, A N D H OW
skull-​based supratentorial tumor (see Figure 1.1).
C A N YO U C H A N G E C R IT I C A L FL OW ? H OW
The patient is started on corticosteroids and scheduled to
C A N YO U C A L CU L AT E C E R E B R A L P E R F US I O N
undergo biopsy and surgical resection of the tumor through a
P R E S S U R E (C P P)?
bifrontal craniotomy.
The procedure has gone well, and the surgeon states that the
incision is now being closed.
WH AT A R E T H E M O S T C O M M O N
H I S TO L O G I C A L T Y P E S O F S U P R AT E N TO R I A L
T UMO R S I N A D U LTS ? WH AT P R E O P E R AT I V E WH AT I S YO U R P L A N F O R E M E RG E N C E
T E S T S WO U L D B E I M P O RTA N T TO YO U ? FRO M A N E S T H E S I A ?
The patient arrives in the OR and states she is very nervous. The patient is removed from the Mayfield pins and a head
She denies any complications with anesthesia in the past. She dressing is applied. After 15 minutes, the patient is still not
has an 18 g antecubital IV line. responsive, and the surgery team is getting concerned.

WH AT MO N I TO R S A R E A P P RO P R I AT E I N T H I S
PAT I E N T F O R H E R S U RG E RY ? S H O U L D
YO U P R E M E D I C AT E T H E PAT I E N T F O R H E R
N E RVO US N E S S ? WH AT A R E T H E G OA L S
F O R I N D U C T I O N A N D M A I N T E NA N C E
O F A N E S T H E S I A F O R C R A N I OTO M I E S ?
The patient is anesthetized and positioned for surgery. Her
head is placed in Mayfield pins and the incision is made. The
surgeon requests mannitol be administered.
WH E N I S T H E B E S T T I M E TO G I V E M A N N ITO L ,
A N D H OW D O E S I T L OWE R I N T R AC R A N I A L
P R E S S U R E ( I C P)? WH AT M A I N T E NA N C E FLU I D S
WO U L D YO U US E A N D WH Y ?
After the bifrontal craniotomy is performed and the or-
bital bar removed, the surgeon states that the brain is still
WH AT I S T H E D I FFE R E N T I A L
D I AG N O S I S F O R D E L AY E D E M E RG E N C E
FRO M C R A N I OTO MY ?
The patient is now fully awake and alert and is transferred to
the neurological intensive care unit for further monitoring.
DISCUSSION
I N C I D E N C E A N D P R E S E N TAT I O N
The Central Brain Tumor Registry of the United States
(CBTRUS) reported 379,848 cases of primary brain and other
central nervous system (CNS) tumors from 2010 to 2014.1 The
overall incidence rate for all primary brain and CNS tumors
was 22.64 per 100,000 population, with the highest incidence
rate (40.82) reported in persons older than 40 years of age.

3
 Normal Neuronal Function
>50ml/min/100g Normal EEG
Dysfunction of Neurons
<18ml/min/100g EEG slowing
Delayed Cell death
<10ml/min/100g Flat EEG
Rapid Cell Death
<6ml/min/100g Membrane Failure
Changes in cerebral blood flow (CBF) and corresponding
Figure 1.1.
electroencephalogram (EEG) findings. Normal CBF is >50 mL/​min per
100 g of tissue. EEG changes may be detected when CBF <18 mL/​min
per 100 g of tissue, with cell death occurring at a CBF rate <10mL/​min
per 100 g.
Most of these tumors were nonmalignant (68.5%), and the
median age at diagnosis was 59 years. Overall, meningioma
was the most common reported histology at 36.8%, followed
by pituitary (16.2%) and glioblastoma (14.9%). The majority
of all tumors (>70%) were supratentorial.
Although the exact incidence of brain metastases is un-
known, intracranial metastases from systemic malignancies
comprise the majority of brain tumors, with up to one-​third
of all cancer patients affected.2 The most common systemic
cancers with intracranial metastases are melanoma, lung
cancer, and renal cancer.3
Patients with supratentorial tumors may present with a
wide variety of signs and symptoms depending on the location
of the tumor and its histological type. Neurological symptoms
from high-​grade gliomas and brain metastases tend to man-
ifest over a shorter time course than symptoms from lower
grade tumors. Generalized symptoms may include headache,
nausea/​vomiting, and neurocognitive dysfunction, and the
patient may have signs of increased ICP. Focal deficits may
also be present, such as weakness, sensory loss, and aphasia.
Seizures, either focal or generalized, are often the presenting
symptom and are more common in low-​grade tumors.4
P R EO P E R AT I VE A N E S T H E S I A
C O N S I D E R AT I O N S
History and physical
Patients with supratentorial tumors quite often present for ur-
gent, if not emergent, surgical resection. Therefore, a complete
preoperative assessment is not always feasible. When possible,
the patient should be optimized as much as possible. History
and physical examination should include a full neurologic
evaluation that includes mental status, cranial nerve function,
motor and sensory testing, reflexes, and coordination testing
that is documented prior to surgery in order to properly as-
sess any postoperative deviations. Signs of increased ICP
including altered mental status, papilledema, and hyperten-
sive bradycardia should be assessed. If present, symptoms of
4 •
increased ICP may be temporarily alleviated by interventions
such as raising the patient’s head, administration of IV hyper-
tonic fluids, or placement of an intraventricular drain.
Any comorbidity such as cardiovascular disease, respira-
tory disease, or renal disease should be adequately evaluated
with further testing completed as warranted by the spe-
cific patient requirements. Previous surgeries and anesthetic
experiences are important data prior to proceeding with sur-
gery. Since the patient may develop significant bleeding during
the procedure, a complete blood count should be obtained.
Other labwork should include a basic chemistry panel and
coagulation studies. Patients with primary brain tumors or
metastatic disease are at a higher risk of thrombotic events,
and the use of anticoagulation therapy must be known prior
to surgery. Antiplatelet medications should be discontinued
7–​10 days prior to surgery. Warfarin should also be discon-
tinued prior to surgery, but anticoagulation may be bridged
with low-​molecular-​weight heparin. Neuroimaging with comp­
uterized tomography (CT) and MRI should be reviewed to
assist in developing a differential diagnosis and to formulate
the anesthetic plan.
Vascular access and monitoring
Adequate vascular access should be obtained with at least two
large-​bore peripheral IV lines. Central venous access may be
justified if there is a potential for significant blood loss, in
patients with extensive cardiac or pulmonary comorbidities,
when the risk of venous air embolism is high, or in patients
without satisfactory peripheral access. An arterial catheter
for continuous BP monitoring should be placed in addition
to standard monitors. Placement of the arterial catheter prior
to induction may be warranted in patients with large tumors
and in situations where there is a large mass effect or increased
ICP. A urinary catheter should also be placed.
Anxiolytics should be used with caution preopera-
tively in patients with supratentorial tumors. Sedation from
anxiolytics (such as midazolam) puts the patient at risk for
hypercapnia, hypoxemia, and airway obstruction that may
lead to increases in PaCO2, cerebral blood flow (CBF), and
ICP. However, patients presenting for tumor resection may
have very high anxiety levels and associated hypertension that
increases CBF and worsens an otherwise compensated ele-
vated ICP. Therefore, use of preoperative anxiolytics should
be used on a case-​by-​case basis and only in a monitored set-
ting. Preoperative corticosteroids used for mass effect and an-
ticonvulsant therapies should be continued the day of surgery,
P E R I O P E R AT I VE A N E S T H E S I A
C O NS I D E R AT I O NS
Induction of anesthesia
The goals of anesthesia induction for patients undergoing
resection of supratentorial tumors are to maintain adequate
ventilatory control (avoiding hypoxemia and hypercapnia),
suppress sympathetic output and hypertension, and minimize
cerebral venous outflow obstruction. This can be achieved by
O ncologic P rocedures
adequately pre-​oxygenating the patient followed by adminis-
tration of propofol (1–​2 mg/​kg) combined with fentanyl (1–​2
µg/​kg) or remifentanil (1 µg/​kg). Etomidate (0.2–​0.4 mg/​kg)
may be substituted for propofol in patients with co-​existing
cardiac dysfunction or hemodynamic instability.
Nondepolarizing muscle relaxants (NDMRs) have
minimal direct effect on cerebral metabolic rate, ICP, or
CBF. Typically, middle-​to short-​acting NMDRs such as
rocuronium, vecuronium, or cisatracurium are used for in-
duction and maintenance of muscle relaxation during intra-
cranial procedures. Pancuronium is usually avoided due to
its long-​term effect combined with its vagolytic activity that
may increase cardiac output, thereby increasing CBF and ICP.
Succinylcholine may be used in the setting of rapid intubations
or potential difficult airways, but has several disadvantages for
routine use. First, succinylcholine’s depolarization of acetyl-
choline receptors results in an efflux of potassium, which, in
the setting of profound muscle weakness or immobility, may
produce life-​threatening hyperkalemia. Additionally, succi-
nylcholine can cause transient increases in ICP; however if co-​
administered with an IV agent (i.e., propofol) this is usually
not clinically significant. Consideration should be given to
reports that the duration of N-​Methyl-​D-​aspartate (NMDA)
muscle blockade is shortened by long-​term use of anticonvul-
sant agents such as phenytoin and carbamazepine.5,6
Patient positioning should be evaluated prior to incision
to optimize jugular venous drainage and to avoid excessive
hyperflexion or extreme lateral extension of the head. Pinning
of the head in a holder device can produce a profound no-
ciceptive stimulus and should only be performed when the
patient has received adequate analgesia by local anesthetic in-
filtration or bolus administration of remifentanil or fentanyl.
If a sympathetic response does occur with head pinning, he-
modynamic control can be regained with IV bolus of propofol
or an antihypertensive agent such as esmolol.
Maintenance of anesthesia
The primary goals of anesthesia maintenance during resection
of supratentorial tumors are to control cerebral homeostasis
via control of CBF and cerebral metabolic rate (CMR) and to
provide a neuroprotective environment by decreasing cerebral
energy demands and minimizing areas of ischemia and edema.
The optimal anesthetic maintenance regimen required to
achieve these goals is a subject of much debate, with the greatest
controversy centered on the use of volatile agents versus IV
agents as maintenance anesthesia for intracranial procedures.
To date, there has been no prospective trial that definitively
favors the clinical outcomes of one technique over the other
in elective intracranial procedures.7–​12 The advantages of vo-
latile agents consist in their predictability, their titratability,
and their ability for rapid emergence. The drawback of using
volatile agents for intracranial procedures is their ability to in-
crease CBF and ICP13,14; however, this effect can be minimized
by using lower mean alveolar concentrations (MAC) and
mild hyperventilation.14–​16 IV anesthetics are an attractive op-
tion for intracranial surgery since they decrease in both CBF
and CMR, thereby lowering ICP without increasing the risk
1. S upratentorial  T umors  •
of cerebral ischemia.8,13 However, unlike volatile anesthetics,
awakening times with IV agents are often more difficult to
predict.
Opioid infusions (fentanyl, remifentanil, alfentanil) during
intracranial surgery are particularly useful as they decrease the
amount of volatile agent required to provide adequate anes-
thesia and therefore minimize the effects on CBF and ICP.
Opioids also help blunt the hemodynamic response to head
pinning. Remifentanil has become a very popular opioid to
use in intracranial surgery due to its short context-​sensitive
half-​life and minimal effects on CBF and ICP.17 Additionally,
the use of remifentanil is associated with a more rapid emer-
gence when compared to fentanyl.18,19
Typically, at our institution, patients undergoing elec-
tive intracranial procedures are maintained with 0.5 MAC
volatile anesthetics with an opioid infusion (remifentanil or
fentanyl) and muscle paralysis. Total IV anesthesia (TIVA)
with propofol/​ remifentanil infusions is considered when
difficulties with elevated ICP are anticipated.
Management of increased ICP
The cranial vault is a rigid, enclosed space with the volume of
the brain (85%), cerebrospinal fluid (10%), and blood (5%)
determining the ICP. Normally, the ICP is 8–​12 mm Hg.
Since CPP depends on ICP, increased ICP puts the cerebral
tissue at risk for ischemia. Increases in volume of any one of
the three components will result in increased ICP unless the
volume of another component is decreased. Therefore, normal
ICP can be maintained in the presence of a supratentorial
tumor via decreasing CSF volume (displacement or absorp-
tion) and/​or decreasing cerebral blood volume. However, at
some point, elastance (ΔP/​ΔV) in the system is maximized,
and further increases in the size of the tumor (or edema) will
cause the ICP to rise precipitously.
The anesthesiologist has several techniques at her disposal
to reduce ICP and promote adequate blood flow and surgical
conditions. When possible, avoidance of elevated ICP is best
done by raising the head of the bed and removing any com-
pression on the jugular veins. Administration of IV steroids
(dexamethasone 4 mg every 6 hours) can also help prevent
increased ICP by reducing tumor-​associated edema.20 Other
intraoperative interventions, such as avoiding high PEEP
(which may limit venous return) and ensuring adequate
muscle relaxation will also help prevent rises in ICP. When
increased ICP is already present, administration of osmotic
agents can reduce brain size by decreasing interstitial water.
Mannitol is an osmotic diuretic that reduces interstitial water
by increasing plasma oncotic pressure. Mannitol should be
given as a bolus (1 g/​kg body weight) around the time of in-
cision and can lower the ICP in 1–​5 minutes with peak effect
seen between 20 and 60 minutes.20 The effects of mannitol last
2–​3 hours, and repeat administration may actually worsen ce-
rebral edema in an increase in ICP.21 Hypertonic saline and
furosemide are also effective in reducing ICP and facilitating
surgical exposure.
The CMR is another important determination of CBF,
and therefore ICP. Due to flow–​ metabolism coupling,
5
Table 1.1. EFFECTS OF COMMON INHALATIONAL Blood flow and CPP
AGENT ON CEREBRAL BLOOD FLOW (CBF),
CEREBRAL METABOLIC RATE (CMR), AND Normal neuronal function in the healthy adult requires a
INTRACRANIAL PRESSURE (ICP) CBF of 50 mL/​min per 100 g of tissue (Figure 1.1). CBF is
regulated at the level of the cerebral arteriole and is dependent
VOLATILE AGENT CBF CMR ICP on forward pressure gradient and PaCO2. The pressure gra-
dient is the result of CPP, which is determined by the equation
Halothane ↑↑­ ↑→ ­↑→
CPP = MAP –​ICP. Cerebral autoregulation keeps CBF rela-
Isoflurane ­↑→ ↓ ­↑→ tively constant throughout a range of CPP of 50–​150 mm Hg
via alterations in vasomotor tone. When CPP is inadequate,
Sevoflurane ­↑→ ↓↓ → neuronal dysfunction occurs at CBF of less than 18 mL/​min
Desflurane ­↑→ ↓↓ ↓→ per 100 g of tissue and delayed cell death is seen when CBF is
less than 10 mL/​min per 100 g of tissue.
Nitrous oxide ­­↑↑ ↓→ ­­↑↑

Changes in CBF (and therefore ICP) with isoflurane, sevoflurane, and desflurane Fluid therapy
depend on concentrations administered, with higher concentrations causing a
vasodilatory effect and therefore increasing CBF. Some of the vasodilatory effects Another area of debate in neurosurgery procedures is the
on ICP may be attenuated with hyperventilation.
choice fluid replacement therapy for intracranial surgery. As
the integrity of the blood–​brain barrier is often compromised
in patients undergoing surgical resection of supratentorial
reductions in CMR will cause a parallel reduction in CBF, tumors, administration of large volumes of IV fluids is thought
and this relationship can be of benefit to the anesthesiolo- to contribute to cerebral edema. However, maintaining
gist. Hypothermia, for instance, decreases CMR by approxi- normovolemia and avoiding hypotension are important
mately 6% for every 1°C decrease in temperature. However, goals for successful surgical outcome. Dextrose-​containing
due to the risks of even mild hypothermia in the surgical solutions are typically avoided in intracranial procedures as
setting (increased infection rate, coagulation disorders), hyperglycemia has been shown to worsen outcomes of cerebral
this technique is seldom used in intracranial surgery. Both ischemia.22–​24 Hypotonic solutions, such as lactated Ringer’s
inhalational and IV anesthetics can decrease CMR and (273 mOsm/​L), are often avoided since they are thought to
lower ICP (Table 1.1). Since all inhalational agents are exacerbate cerebral edema. Normal (0.9%) saline is slightly hy-
also vasodilators, the relationship between reduction in pertonic (308 mOsm/​L), which may improve cerebral edema
CMR and MAC concentrations is not linear. Reduction in and is typically the fluid of choice for intracranial procedures.
CBF by volatile agents is more pronounced at lower MAC Colloids are also suitable alternatives for fluid replacement
(<0.5) concentrations, where flow–​ metabolism coupling since their ability to increase plasma oncotic pressure could
predominates. At higher MAC concentrations, the vasodil- potentially decrease brain edema.
atory property of volatile agents predominates and balances
out the reduction in CBF. IV agents, on the other hand, re-
duce CMR and are vasoconstrictors (Table 1.2). The notable E M E RG E N C E FRO M A N E S T H E S I A
exception is ketamine, which increases CMR, CBF, and ICP. The anesthetic goals at the end of intracranial surgery are a rapid
emergence and extubation in the setting of controlled hemo-
dynamic and respiratory parameters. Prior to extubation, the
Table 1.2. EFFECTS OF COMMON INTRAVENOUS PaCO2 should be allowed to gradually rise to normal levels,
AGENTS ON CEREBRAL BLOOD FLOW (CBF), adequate reversal from neuromuscular blockade should be de-
CEREBRAL METABOLIC RATE (CMR), AND termined, and the patient should be normothermic. Coughing
INTRACRANIAL PRESSURE (ICP) or “bucking” on the endotracheal tube can elevate ICP and
may be prevented with the continuation of remifentanil in-
INTRAVENOUS AGENT CBF CMR ICP
fusion or with the administration of IV lidocaine (0.5–​1 mg/​
Propofol ↓↓ ↓↓ ↓↓ kg). Hypertension should be promptly treated with esmolol or
other IV agents, and persistent hypertension may necessitate
Barbiturates ↓↓ ↓↓ ↓↓ calcium channel blocker infusion (nicardipine). Postoperative
Etomidate ↓↓ ↓↓ ↓ pain may be significant, especially if remifentanil was utilized
during the procedure, and should be treated with short-​acting
Benzodiazepines ↓ ↓ ↓→ opioids or IV acetaminophen.
Opioids → ↓→ → In cases of delayed awakening following intracranial
procedures, the differential diagnosis includes three main
Ketamine ­­↑↑ ­↑ ­­↑↑ categories: (1) neurological causes such as ongoing seizure,
hemorrhage, or stroke; (2) physiological cause, such me-
Most intravenous agents cause a reduction in CBF and CMR, with the notable
exception of ketamine. Opioids produce very little effect on CBF and CMR tabolite or electrolyte disturbances, hypothermia, or hyper-
except with high doses. glycemia; and (3) pharmacological cause such as continued

6 • O ncologic P rocedures
neuromuscular block, opioid overdose, and persistent an-
esthesia. In such instance, an emergent head CT scan is
warranted.
R E VI EW Q U E S T I O N S
1. A patient is undergoing craniotomy for a frontal tumor
resection with general anesthesia using sevoflurane and
remifentanil as maintenance. The patient has the following
vital signs: BP 135/​85, pulse 60 bpm, ETCO2 38 mm Hg,
SpO2 99%. The surgeon asks you to facilitate more brain re-
laxation. What is the most appropriate intervention?
a) Increase PEEP
b) Lower the head of the bed
c) Increase sevoflurane
d) Increase minute ventilation
Correct Answer: d. Increasing the minute ventilation will
result in hypocapnia, which in turn produces cerebral vaso-
constriction. Assuming intact autoregulation, this will re-
sult in a reduction of brain volume and improve the surgical
conditions in this case.
2. What is the expected effect on cerebral metabolic rate of
oxygen consumption, CBF, and ICP when utilizing ketamine
for induction of general anesthesia in a patient with a known
supratentorial mass?
a) Decreased CBF, decreased CMR, decreased ICP
b) Increased CBF, increased CMR, increased ICP
c) Increased CBF, increased CMR, decreased ICP
d) Decreased CBF, increased CMR, decreased ICP
Correct Answer: b. Ketamine increases CBF, CMR, and ICP, al-
though the increase in CMR is minimal. This contrasts with vola-
tile anesthetics which decrease CBF, CMR, and ICP at 1 MAC.
3. Which of the following is the most appropriate choice for
maintenance IV fluids in an otherwise healthy adult patient
undergoing resection of a supratentorial mass?
a) D5 normal saline
b) 3% saline
c) 0.9% saline
d) Lactated Ringer’s
Correct Answer: c. Maintaining euvolemia is critical for suc-
cessful outcomes in neuroanesthesia. Normal saline is an ideal
choice since it is slightly hypertonic and may therefore im-
prove cerebral edema; 3% saline may be utilized to decrease
ICP. However, it would not be the first choice for mainte-
nance fluids. Fluids containing glucose should be avoided
as hyperglycemia has a negative impact on cerebral ischemia
outcomes. Hypotonic solutions, including lactated Ringer’s,
should also be avoided as they may increase cerebral edema.
4. All of the following are benefits of remifentanil except:
a) Improved postoperative pain control
b) Decreased requirement for volatile agents
c) Minimal effects on CBF and ICP
d) Rapid emergence compared to fentanyl
1. S upratentorial  T umors  •
Correct Answer: a. Remifentanil is frequently utilized in
neuroanesthesia to supplement volatile anesthetics, and its ef-
fect on CBF and ICP is minimal. Emergence from remifentanil
is reliable due to its short context-​sensitive half-​life. However,
remifentanil will not improve postoperative pain, so pain con-
trol may be necessary with a bolus of short-​acting opioids in-
cluding fentanyl on emergence.
5. All of the following are true regarding neuromuscular
blockade in a patient with supratentorial mass EXCEPT:
a) Succinylcholine may result in life-​ threatening
hyperkalemia.
b) Pancuronium is the preferred NDMR in cases of
increased ICP.
c) Nondepolarizing muscle relaxants have minimal effect
on ICP.
d) Depolarizing muscle relaxants may cause transient
increases in ICP
Correct Answer: b. Pancuronium is not an ideal muscle re-
laxant for most neuroanesthesia procedures due to its long
duration of action and its vagolytic effect, which may lead to
increased CBF and ICP.
6. Which of the following is an appropriate goal for emergence?
a) Normocapnia
b) Avoiding reversal of neuromuscular blockade
c) Hypothermia
d) Permissive hypertension
Correct Answer: a. The goals for emergence from intracranial
surgery include a normal physiologic PaCO2, normothermia,
and complete reversal of neuromuscular blockade. In addi-
tion, tight control of BP is necessary during emergence and
can be managed with esmolol.
7. Regarding CBF in an otherwise healthy adult, all of the fol-
lowing are true EXCEPT:
a) Normal CBF is 100 mL/​min per 100 g of tissue.
b) Cerebral autoregulation maintains CBF throughout a
CPP range of 50–​150 mm Hg.
c) Neuronal dysfunction occurs at CBF of less than 18
mL/​min per 100 g of tissue.
d) Delayed cell death is seen when CBF is less than 10
mL/​min per 100 g of tissue.
Correct Answer: a. CBF in a healthy adult is 50 mL/​min per
100 g of tissue.
8. Which of the following will produce the greatest decrease
in ICP:
a) Hyperventilation to decrease PaCO2 from 60 to 30.
b) Increase volatile anesthesia agent to 2 MAC
c) Increase PaO2 from 80 to 100
d) Increase temperature by 1°C
Correct Answer: a. There is a linear relationship between
CBF and PaCO2 for PaCO2 of 20–​70 mm Hg. Therefore, re-
duction in PaCO2 from 60 to 30 mm Hg will result in a sig-
nificant decrease in CBF and ICP. PaO2 of less than 50 mm
Hg can increase CBF and ICP. However, a change in PaO2
7
within physiologic range will not cause a significant change.
Hypothermia, not hyperthermia, will decrease CMR by ap-
proximately 6% for every 1°C decrease in temperature.
9. All of the following are true regarding the actions of man-
nitol EXCEPT:
a) Peak effect of mannitol is between 20–​60 minutes after
administration.
b) Repeated doses of mannitol may cause a paradoxical in-
crease in ICP.
c) Mannitol works as an osmotic diuretic by decreasing
plasma oncotic pressure.
d) Mannitol duration of action is 2–​3 hours.
Correct Answer: c. Mannitol is an osmotic diuretic that
decreases brain size by decreasing interstitial water via an in-
crease in plasma oncotic pressure.
10. Which of the following statements about propofol
is TRUE:
a) Increases CMR and decreases CBF
b) Increases CMR with induction doses only
c) Maintains cerebral autoregulation
d) Uncouples CBF and CMR
Correct Answer: c. Propofol, as well as opioids, barbiturates,
and sedative-​ hypnotics, does not cause uncoupling of
CBF and CMR. While most IV agents maintain cerebral
autoregulation, volatile agents at high MAC levels may impair
cerebral autoregulation.
QUESTIONS AND ANSWER S
This chapter has accompanying questions and answers
which are available to subscribers as part of the Oxford
eLearning platform. To access the questions, go to http://
oxfordmedicine.com/neuroanesthesiaPBL
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 2.
ANESTHESIA FOR POSTERIOR FOSSA MASS
Valerie L. Howell, Margaret M. Collins and Lauryn R. Rochlen
S T E M C A S E A N D K EY Q U E S T I O N S
A 56-​year-​old female patient with no known medical his-
tory presented to her primary care physician with a chief
complaint of bilateral headache, dizziness, and right-​sided
hearing loss that began 1 month ago. Physical exam re-
vealed end-​g aze nystagmus and ataxic gait. Initial workup
included retinal exam, which revealed no abnormalities
and no papilledema. Additional evaluation included a mag-
netic resonance imaging (MRI) scan of the brain which
revealed a lobulated, heterogeneously enhancing right
cerebellopontine angle cistern mass measuring 5.4 cm ×
5.4 cm × 5.0 cm posterior to the internal auditory canal
(Figure 2.1). Audiology report confirmed severe sensori-
neural hearing loss. Following interpretation of the MRI,
the patient is admitted to the hospital for observation of
neurologic status and initiated on acetazolamide and dex-
amethasone therapy. After further discussion with the neu-
rosurgical team, she consented to undergo a posterior fossa
craniotomy for resection of the tumor.
WH AT A R E T H E B O U N DA R I E S O F T H E
POSTERIOR FOSSA?
It is bounded anteriorly and medially by the dorsum sellae
of the sphenoid bone, anteriorly and laterally by the superior
border of the petrous part of the temporal bone, posteriorly
by the internal surface of the squamous part of the occipital
bone and superiorly bound by the tentorium cerebelli. The
floor of the posterior fossa is made up of the sphenoid, occip-
ital, temporal, and mastoid angles of the parietal bones. The
posterior and inferior limit is the foramen magnum.
WH AT A R E C O M M O N
P R E S E N T I N G C O M P L A I N TS
O F A PAT I E N T WI T H A P O S T E R I O R
FOSSA MASS?
Symptoms typical of posterior fossa masses include cere-
bellar dysfunction (ataxia, nystagmus, dysarthria), brainstem
compression (cranial nerve palsy, altered consciousness,
abnormal respiration), or elevated intracranial pressure
9
(ICP) due to obstructive hydrocephalus (headache, nausea,
papilledema).
WH AT A R E S P EC I FI C P R EO P E R AT I V E
C O NS I D E R AT I O NS F O R A PAT I E N T WIT H A
POSTERIOR FOSSA MASS?
The patient with mass lesion of the posterior fossa is at risk of
obstructive hydrocephalus due to obstruction of cerebrospinal
fluid (CSF) flow through the fourth ventricle or the cerebral
aqueduct of Sylvius. Such obstruction may be present even
with small lesions. Careful history and evaluation of available
imaging studies may be useful in determining the presence
of increased ICP. Medication review should focus on use of
corticosteroids, diuretics, and carbonic anhydrase inhibitors.
Corticosteroids should be administered up to and including
the day of surgery. Laboratory data should be evaluated
for corticosteroid-​induced hyperglycemia and electrolyte
disturbances due to diuretic use. Preoperative anxiolytics,
such as benzodiazepines and opioids, should be used with
caution in patients with posterior fossa lesions as their use
may lead to hypoventilation resulting in acute clinical decom-
pensation from increases in ICP. Use of anxiolytics should be
individualized to each patient and only administered when
uninterrupted care can be provided by a qualified anesthesia
professional.
WH AT P O S IT I O NS A R E C O M MO N LY U T I L I Z E D
F O R P O S T E R I O R F O S S A S U RG E RY ? WH AT A R E
T H E A D VA N TAG E S A N D D I S A DVA N TAG E S
O F E AC H P O S I T I O N ?
Resection of a posterior fossa mass may be approached from
a semi-​lateral, prone, supine with head turned, or sitting po-
sition. Selection of the patient position depends on location
of the tumor, patient risk factors, and surgeon preference.
Historically, the sitting position was favored by surgeons
since it improved surgical exposure, maintained anatom-
ical orientation, promoted venous drainage, improved he-
mostasis, and facilitated gravitational drainage of CSF and
blood from the field. Some anesthesiologists preferred the
position as it allowed improved access to the endotracheal
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as determined by the eye, check measurements are taken by rule,
trams and level and final adjustments made to bring the various
parts in final proper relation to one another. For instance, the rudder
post must be perfectly vertical, as determined by a plumb line, when
the engine bearers or the top longerons are level. The various fittings
such as those for horizontal and vertical stabilizers and the engine
sections and side panels must all conform accurately to one another
so that the airplane as a whole, when it is assembled, will not contain
any inherent defects such as tail planes with slightly distorted angles
of incidence, left main panels ahead of right or over or under right
main panels, fittings so located that an initial strain must be imposed
upon them by forcing them together, etc.
After the fuselage has been lined up in the factory as described
briefly above, it is permitted to set for a week or so and then it is
checked up again and such additional slight corrections made which
would be necessitated by the sets which had occurred. The
additional fittings required are then applied and the fuselage finally
covered and sent away to have the engine and instruments applied.
When checking and truing a fuselage on the flying field after the
airplane has been assembled and flown the process is not quite so
simple as when the fuselage is checked up and trued in the factory,
largely owing to the lack of ideal factory facilities and also because
so many fittings, coverings, etc., are in the way which one must
always be cautious about removing. In general, the method of
procedure may be outlined as follows, but it must be obvious that
one can not in a series of written notes touch upon all the possible
queries and combinations of fuselage distortions which may occur
and the ways for detecting and correcting them. A certain amount of
experience in the field accompanied with some fixed habits of
inspection, and everlasting curiosity about the perfections of your
machine, and a willingness and readiness always to pitch in and help
correct the defects found, will soon develop in you the ability to
diagnose easily and quickly and remedy intelligently whatever
trouble you may run across.
For satisfactory fuselage checking and truing let us say in the field
shop, a certain minimum equipment of tools is necessary. This
equipment is:

At least two sawhorses about 3 to 4 ft. high for mounting the fuselage in flying
position.
Several wooden wedges (show taper) for easy adjustment of fuselage for cross
and lengthwise level.
About 25 yd. of strong linen line for checking center lines.
2 carpenter levels about 2 to 3 ft. long.
4 perfectly formed steel cubes about 1¼ to 1½ in. in size.
1 plumb bob.
1 small screw jack.
1 pair of wood clamps.
1 straight edge about 12 ft. long.
Several small Crescent adjustable wrenches.
Several pliers with wire-cutting attachment.
Pins for manipulating turnbuckles.
1 steel tape.
1 foot rule, 6 ft. long.
1 small brass hammer.
A small work bench equipped with a 3-in. or 4-in. vise.

The fuselage which is to be trued is mounted on the horse with the

wedges between the top horse rails and the lower longerons. These
horses or trestles should be so arranged that about three-fourths of
the fuselage toward the tail sticks out unsupported. In this way it will
take, as near as possible, its normal flying position. It is always
desirable, in fact quite necessary, especially when checking a
fuselage for the first time, to have the airplane’s specifications as
well as a detailed drawing of the fuselage and an assembly of the
airplane as a whole available. The reason for this, of course, is quite
obvious.
 The engine bearers and the top longerons are the basic parts from
which the fuselage as a whole is lined up. Consequently the first
thing which is done, when inspecting the fuselage for alignment, is to
test the truth of these parts. This is done by sighting the top
longerons lengthwise to see if they are bowed downward, upward,
inward or outward. As near as possible the fuselage is made level on
the trestles. The steel blocks or cubes referred to in the tool list
above are placed on the longerons and the straight edge and level
placed on these, first crosswise and then lengthwise. A string is
stretched over the top of the fuselage touching the top cross braces
and brought as close as possible to the center of these pieces. This
string should stretch from the rudder post as far forward as possible.
Then the cross wires or diagonal brace wires are sighted to see how
close their intersections agree with this center-line string.
Furthermore, the level is placed on the engine bearers and they are
tested for cross level and longitudinal level. If the engine is mounted
in place, but one point on the bearers will be available for this
purpose, but the check should nevertheless be made. It may also be
found that the longitudinal level of the engine bearers can be tested
from underneath by placing the steel cubes mentioned above on the
top of the level and then holding the level up against the bottom of
the bearers. As a rule, if the fuselage is warped it should be possible
to detect this with the eye, but when engine bearers are out of line
this can only be detected with certainty by the use of the level.
Let it be assumed that the fuselage is out of true. The first parts to
tackle are, of course, the engine bearers. If they should not be in line
they must first be brought so, and afterward kept in this condition.
The diagonal wires at the front of the fuselage should be adjusted to
make this correction. If the bearers are badly out of line it will,
perhaps, be wisest to remove the engine, or at least loosen it up
from the bearers before doing any adjusting for the reason that it
may become strained by serious pulling on the bearers. After the
bearers are in place, it will be safe to bolt the engine fast again.
With the engine bearers temporarily disposed of, the fuselage
proper is tackled. Here the first thing to do is to get the top surfaces
of the longerons level crosswise. Use the spirit level and the two
steel cubes mentioned in the tool list for this purpose. Start at the
front of the fuselage in the cock pit. Adjust the internal diagonal wires
until the level bubble is in its proper place. Then measure these first
two sets of diagonal wires, getting them of equal length. Continue
this process throughout the length of the fuselage until the rear end
is reached, always working from the front.
Lastly, before proceeding to the next operation, try the engine
bearers for level again. If out, make the proper adjustments.
If the centers of the crosswise struts are not marked, this should
first be done before going further. Then stretch a string from No. 1
strut, or as far forward as possible to the center of the rudder post.
All center points on the cross struts, if the fuselage is true
lengthwise, should lie exactly on this string. If not, adjust the
horizontal diagonal wires, top and bottom, working from the front,
until the center-line points all agree. Always check by measuring
diagonal wires which are mates. These should be of equal length. If
not, some wire in the series may be overstressed. In order to pull the
center points on the cross struts over, always stop to analyze the
situation carefully, determining which are the long diagonals and
which the short ones from the way the fuselage is bowed. Then
shorten the long ones and ease off on the short ones, being careful
never to overstress any of the wires.
The last thing to do is to bring the longerons or the center line of
the fuselage into level lengthwise. For this purpose a long straight-
edge, the two cubes, and a spirit level are of advantage, although
simply stretching a string closely over the top of the longeron may
suffice. Then as in the case of removing a crosswise bow in the
fuselage, here too, we manipulate the outside up and down diagonal
wires in bringing the top longerons into their proper level position
lengthwise, always working from the front.
After all this is done it is well to make some overall checks with
steel tape or trams to see how various fittings located according to
the drawings, agree with one another. Since there is a right and a left
side, distance between fittings on these sides may be compared.
And, finally, the engine bearers should be tried again. In short no
opportunity should be neglected to prove the truth of the fuselage as
a whole and in detail.
It might be pointed out that an excellent time to check the fuselage
is when engine is being removed or changed. In fact this time in
general is a good one to give the airplane as a whole, a careful
inspection.
After all the necessary corrections have been made and all the
parts of the fuselage brought into correct relation with one another,
the turnbuckles are safety wired and then served with tape to act as
a final protection. The linen covering is reapplied if it had previously
to be removed and the level, empennage wires, panels etc., are
placed in position and aligned as pointed out in the notes on
assembly and alignment.
 CHAPTER X
HANDLING OF AIRPLANES IN THE FIELD
AND AT THE BASES PREVIOUS TO AND
AFTER FLIGHTS

No unimportant part of the operation and maintenance of airplanes

is their handling in the field, and at the various bases previous to,
between, and after flights. This phase of the entire subject
contemplates the transportation of airplanes in knockdown condition
either by railway or truck, their unloading and unpacking, to a certain
extent their assembly, their storage in hangars and sheds, their
storage and disposition in the open, their disassembling and packing
for transportation, etc.
The Unloading and Unpacking of Airplanes.—The personnel
required to unload an airplane properly boxed and crated from a
railway car, is 15 men and two non-commissioned officers. The tools
needed for this purpose are:

1 ax.
2 crowbars.
6 lengths of iron pipe about 2 in. in diameter, 3 ft. long.
6 lengths of iron pipe about 2 in. in diameter, 4 ft. long.
100 ft. manila rope, 1 in. in diameter.

A regular flat-bed moving truck or ordinary truck with a flat-bed trailer

should be provided for handling the machine from the car to the field
erecting shop.
Airplanes are usually shipped in automobile cars with end doors or
gondola cars. After opening doors of cars, examine and inspect all
crates and boxes carefully to see that they are all there in
accordance with the bill of loading or shipping memorandum, as well
as to see that they are in good condition. If any boxes are found
damaged, they should not be removed from the car without first
reporting the fact to the receiving officer.
Next, all cleats and bracing should be removed. The crate
containing the fuselage and engine should, if possible, be unloaded
first. The heavy end where the engine is fixed should be lifted up,
have 2-in. pipe rollers put underneath and manipulated into the truck
which has been backed up against the car door so that this heavy
end, when finally placed, will rest on the body of the truck as far
forward as possible. Next lash the front end of the box securely to
the truck.
Should it happen that the fuselage crate is so located in the car
that the light end must of necessity emerge first through the door,
then this end may be run on to a truck and the crate removed from
the car with the heavy end adequately supported by sufficient help.
Another truck is then backed up against the rear of the first one
which has been moved into the clear, and the heavy end of the
fuselage crate brought to rest as far forward as possible in the
second truck. It is then secured and the first truck released.
After the box is properly lashed by means of the manila rope, a
man should be placed on each side of it to watch and see that the
lashings do not loosen and the box shift in transit. Trucks should be
driven slowly, especially over rough ground, tracks, etc. In addition to
the fuselage crate it may also be possible to load the panel crates on
this same truck, but as a rule it is better to load these on a second
truck. Common sense goes a long way in transporting aircrafts by
motor trucks.
Unloading of the crates is done with the use of skids applied to the
rear of the truck and secured so as to form a sort of an inclined plane
down which to slide the boxes on the pipe rollers to the ground.
These skids should be at least 4 in. by 4 in. by 6 ft. and made of
strong wood. The rear end of the crate may be brought to the
ground, rested there, and the truck moved forward slowly until the
entire length rests on the ground. Care must be used not to jolt or
drop this box at any stage whatsoever.
When uncrating the fuselage, remove the top and both ends of the
box. Fold both sides of box flat down on ground and use same for
assembling machine. The wing boxes should have the tops removed
and planes lifted out in that manner.
Next, the airplane is assembled in accordance with instructions
already given.
The Dismantling and Loading of Airplanes.—When airplanes
are to be prepared for shipment by motor truck or railway, they
should, of course, be taken down and crated similar to the way they
were shipped from the factory. The order in which this is done should
be as follows:

Remove propeller.
Unfasten control wires.
Unfasten main planes from fuselage and dismantle on ground.
Remove tail surfaces.
Unless machine is to be placed in box, landing gear and tail skid should remain
attached to fuselage.

If the machine is crated it should be handled when shipped the

same as described above. If, however, it is to be loaded without
being crated, then the following procedure should be observed.
Using two planks, 2 in. by 12 in. by 18 ft. long for runway from
ground into car, load machine into car, engine first. Block wheels to
prevent machine shifting. Secure fuselage, tail end, to the floor of the
car by means of ropes passed over the fuselage and fastened to the
floor with cleats. The wings should be crated against the sides of car
and secured by wires, ropes or canvas strips. All boxes should be
marked with name of organization, destination, weight, cubic
contents, hoisting centers, number of box, “This Side Up,” etc. A
shipping memorandum should always be made out and mailed to
destination when shipment goes forth.
Storing of Airplanes and Parts at Bases and in Fields.—
Airplanes when not in active flying duty are stored in hangars or
sheds especially adapted to house them. Under certain conditions it
is necessary to store them in the open. In each case particular
precautions should be observed in order not to subject the machines
to unnecessary wear and tear.
Since moisture is one of the airplanes’ worst enemies in that it
deteriorates the weatherproofing and the fabric, distorts and
otherwise injures the wooden parts of the machines and worst of all,
rusts the metal parts, the first consideration for proper storage
facilities should be the absence of moisture. Next, extreme heat and
cold are a menace to airplanes. The temperature of the air
surrounding them while in storage should be regulated as much as
possible. Under shelter, especially when the machine is to be out of
active service for 48 hr. or more, the entire machine should be raised
off the ground a few inches so that the wheels are free and the
flexible connections released. This is done by the points where the
undercarriage struts meet the skids. Furthermore, the wings might
well be supported and the weight thus taken off the landing wires,
and hinge connections by placing padded trestles underneath the
wing skids. Care should be exercised that dirt, grease, water, etc.,
does not accumulate in any part of the airplane.
Furthermore, all water should be drained from the radiator and
gasoline from the gasoline tank. The propeller should be placed in a
vertical position and covered with a weatherproof cloth. The engine
cockpit and instruments should all be covered and the magneto
should be enclosed in a thick layer of felt or cotton waste. If any fluid
is apt to freeze, and oil will freeze in temperatures low enough, it
should be carefully drained.
When spare parts such as wings, struts, fuselages, etc., are
stored, the same general precautions outlined above should be
observed. Spare planes particularly should be placed in such a
manner that their weight is evenly supported. Never should planes of
any kind be laid flat on the ground. They should always stand
edgewise, with the leading edge down, supported several inches off
the ground on blocks or boards evenly spaced. One plane must not
be allowed to lean against another. In fact, the best way is to
suspend planes by means of canvas slings hung from overhead.
Within the loop of the slings there must be a batten about 2½ in.
wide.
All parts of an airplane subject to attack by rust should be kept well
coated with grease or oil. Periodically the entire machine should be
wiped by means of clean, dry cheese cloth or selected cotton waste.
Engines which are in stored planes or which have been set aside for
future use should be turned over by hand daily.
It will sometimes be impossible for airplane sheds or hangars to be
brought up to the front on service, hence, airplanes must be
prepared to remain in the open. When this is the case they should be
placed to the leeward of the highest hedge available, a clump of
trees, a building, a bank, a knoll, or hill, etc. They should be sunk as
low as possible by digging a trench for the wheels and
undercarriage. The nose of the plane should, of course, first be run
into the wind, and then the wings and the tail pegged down with
ropes, particularly if there is any chance of a wind starting up. The
engine, propeller, instruments, and cockpit should be covered over
with a waterproof cloth and great care taken to protect the propeller
from the sun, for it will surely warp if not cared for properly. At night
in cold or wet weather the magneto should be packed round with
waste and water in the radiator drained. While machines are stored
in the open, the necessity of wiping them to keep them moisture and
dirt free is all the more urgent and should be pursued with doubled
energy.
 CHAPTER XI
INSPECTION OF AIRPLANES
Mechanics in charge of airplanes, who are primarily responsible
for their safety while in their care, should constantly think of new
methods for insuring greater safety and reliability. They should
invariably bring any fresh points they think of to the attention of their
Flight Commander, in order that the rest of the Corps may benefit by
them. They should always try to find out the cause of anything
wrong, and inform the officer in charge of the machine of their
opinion. They should bear in mind any particular incidents which may
have happened to their machine while under their charge during
each flight, and be on the lookout for signs of stresses that may have
occurred to the machine in consequence of these incidents. For
example, a steep spiral may cause side strains on the engine
bearers; a flight in bad weather may cause bending stresses on the
longitudinal members of the body, besides stretching the landing and
flying wires. No part of a machine can be safely overlooked, and
good mechanics will always be seeking for the possible cause of
accidents and bringing them to the notice of the officer in charge of
the machines.
During all inspections the following matters of detail deserve
particular attention:
Look out for dirt, dust, rust, mud, oil on fabric. Cleanliness is the
very first consideration.
Give the control cables particular attention. These should not be
too tight, otherwise they will rub stiffly in the guides. The hand should
be passed over them to detect kinks and broken strands. They
should be especially well examined where they run over pulley. Don’t
forget the aileron balance wire on the top plane.
See that all wires are well greased and oiled, and that they are all
in the same tension. When examining wires, be sure to have
machine on level ground as otherwise it may get twisted, throwing
some wires into undue tension and slackening others. The best way,
if time is available, is to jack the airplane up into “flying position.” If a
slack wire is found, do not jump to the conclusion that it must be
tensioned. Perhaps its opposite wire is too tight, in which case it
should be slackened.
Carefully examine all wires and their connections near the
propeller, and be sure that they are snaked around with safety wire,
so that the latter may keep them out of the way of the propeller if
they come adrift.
Carefully examine all surfaces, including the controlling surfaces,
to see whether any distortions have occurred. If distortions can be
corrected by adjustment of wires, well and good, but if not, matter
should be reported.
Verify the angles of incidence, the dihedral angle, the stagger, and
the overall measurements as often as possible (at least once a
week) and correct as outlined in notes on assembly and adjustment
of airplanes.
Constantly examine the alignment and fittings of the
undercarriage, the condition of tires, shock absorbers and the skids.
Verify the rigging position of the ailerons and elevators.
Constantly inspect the locking arrangements of the turnbuckles,
bolts, etc.
Learn to become an expert at vetting, which means the ability to
judge the alignment of the airplane and its parts by eye. Whenever
you have the opportunity practice sighting one strut against another
to see that they are parallel. Standing in front of the machine, which
in such a case should be on level ground, sight the center section
plane against the tail plane and see that the latter is in line. Sight the
leading edge against the main spars, the rear spars, and the trailing
edges, taking into consideration the “washin” and “washout.” You will
be able to see the shadow of the spars through the fabric. By
practising this sort of thing you will, after a time, become quite
expert, and will be able to diagnose by eye faults in efficiency,
stability and control.
The following order should be observed in the daily and weekly
inspections:
Daily Inspection.—All struts and their sockets, longerons, skids,
etc.
All outside wires and their attachments.
All control levers or wheels, control wires and cable and their
attachments.
All splices for any signs of their drawing.
Lift and landing gear cables or wires for any signs of stretching.
All fabrics, whether on wings or other parts of the machine, for
holes, cuts, weak or badly doped places, or signs of being soaked
with gasoline, and to see if properly fastened to wings, etc.
All outside turnbuckles, to see that they have sufficient threads
engaged, and that they are properly locked.
Axles, wheels, shock absorbers, and tires, pumping the latter up to
the correct pressure.
The seats, both for passenger and pilot, seeing that they are
fastened correctly.
Safety belts and their fastenings.
This examination should be carried out systematically in the
following order:
(a) Lower wings, landing gear complete, tail planes with all wires
attached to these tail skids and all attachments and rudder.
(b) Nacelle or fuselage, bolts of lower plane, all control levers and
wires.
(c) Top wings, wing flaps or ailerons and wires.
Inspection after Each Flight.—The landing gear, tail skid and
attachments and lift and drag wires for tautness.
 The wheels, after a rough landing, for bent spokes, uncovering
them if necessary.
After flying is finished for the day, wipe all oil off the planes as far
as possible with a cloth or cotton waste.
Weekly Inspection.—Check over all dimensions, span, chord, gap,
stagger of wings, angles of incidence or set angle of wings and tail,
dihedral angle, alignment of fuselage, rudder, elevators, and the
general truth of the machine.
Examine the points of crossing of all wires to see that there are no
signs of wear, and that each wire is properly bound with insulating
tape to prevent rubbing.
Examine all places where wires cross the strut to see if the plates
require renewal.
Examine any control wires which are bound together, and see that
they are correct. (Insulating tape should be used for this in
preference to wires which are bound to slip and cause slack.)
Examine the wheels for bent or loose spokes, uncovering if
necessary.
Examine all nuts and bolts of cotter-pin applications, lock washers,
etc.
The following directions for inspection are given to the U. S.
Inspectors of Airplanes:
Inspection of Cables.
Are there any kinks in the cable?
Are loops properly made?
Are thimbles used in eyes?
Are ends wrapped properly (when wrapped splice is used, wrap
must be at least fifteen times the diameter of wire).
No splicing of the cable itself is permitted.
Has acid struck cable during soldering?
 Are any of the strands broken?
Are unwrapped ends stream-lined and show the result of skilled
workmanship?
For Roebling Hard Wire.
Are there any file cuts or flaws to weaken it?
Is loop well made?
Is ferrule put on correctly?
Are there any sharp bends or kinks?
Are wires too loose or tight in machine?
Fittings.
Is workmanship good?
Is material good?
Are holes drilled correctly to develop proper strength?
Are there any deep file cuts or flaws to weaken it?
Is rivet or fastening wire put in properly?
Are thimbles of large enough diameter?
Turnbuckles.
Any file cuts, tool marks, or flaws in shank or barrel?
Are there too many threads exposed?
Is turnbuckle of right strength and size to develop full strength of
wire?
Are shanks bent?
Are threads on shank or in barrel well made?
Is barrel cracked?
Is turnbuckle properly wired?
Inspection of Linen.
 All linen used in airplane construction should be of the following
specifications:
Free from all knots or kinks.
Without sizing or filling.
As near white as possible.
Weight, between 3.5 and 4.5 oz. per square yard.
Strength as per Government Specifications.
Inspection of Wood.
All wood should be inspected before varnish is applied.
Is grain satisfactory?
Are there any sap or worm holes?
Are there any knots that look as if they would weaken the
member?
Any brashiness?
Any holes drilled for bolts or screws that would weaken the
member?
Any splits or checks?
Are laminations glued properly?
Are there any plugged holes?
Any signs of dry rot?
Inspection of Metal Fittings.
When fittings are copper plated and japanned the inspection
should take place after the copper plating.
Have fittings been bent in assembling?
Does fitting show any defects that lessen its strength?
Are holes drilled properly. Do fittings fit?
 Sheet aluminum should be inspected for defects such as cracks,
bad dents, etc. Where openings occur in sheet aluminum the corners
should be rounded, allowing a good-sized radius.
Directions for Work.
Before you start work on rigging you are advised as follows:
1. Do not hurry about the work. No rush jobs can be done in
airplane rigging.
2. You are cautioned against leaving tools of any kind in any part
of the airplane.
3. The bolts and their threads must not be burred in any way; for
this reason, the use of pliers or pipe wrenches on bolts is very bad
form.
4. Start all turnbuckles from both ends every time they are
connected up.
5. Full threads must be had in every case to develop the full
strength of a bolt and nut, with turnbuckles at least turn on for a
distance equal to three times the thickness of the shank.
6. Lock with safety wires all turnbuckles and pins, and cotter-pin
every nut.
7. Watch for kinking of wires and their rubbing around controls and
wherever they may vibrate against one another.
8. All bolts and pins must have an easy tapping fit only; do not
pound them into position.
 Transcriber’s Notes
pg 22 Changed: funished with dual control
to: furnished with dual control
pg 83 Changed: rather than flying off in a straight ine
to: rather than flying off in a straight line
pg 86 Changed: to get out of an immanent pancake
to: to get out of an imminent pancake
*** END OF THE PROJECT GUTENBERG EBOOK LEARNING TO
FLY IN THE U.S. ARMY ***

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