Anesthesia for Functional Neurosurgery

Abstract

The use of functional stereotactic neurosurgery is increasing for treatment of patients with movement disorders and other chronic illnesses. The anesthetic considerations include the influence of the anesthetic agents on the microelectrode recordings and stimulation testing of an awake patient. The purpose of this study was to review the anesthetic management and incidences of intraoperative complications during functional neurosurgery in our institution. One hundred seventy-eight patients underwent an ablative procedure (n = 6) or the insertion of deep brain stimulator (n = 172) under monitored anesthesia care for movement disorders (n = 124), chronic pain (n = 20), and other procedures (n = 34). Local anesthetic was used for head frame pin sites and burr holes. No sedation/analgesia was administered to 57 (32%) patients. One patient required conscious sedation and another general anesthesia for the entire procedure. The remainder received small increments (mean +/- SD) of propofol (113 +/- 73 mg), midazolam (1.6 +/- 0.8 mg), and/or fentanyl (93 +/- 55 mug). Intraoperative complications that occurred in 16% of the patients included seizures (n = 8), change in neurologic status (n = 5), airway obstruction (n = 2), and hypertension (n = 7). Functional neurosurgery can be performed with minimal anesthesia in many patients. Awareness and vigilance can improve the identification and early treatment of intraoperative complications such as seizures, loss of airway, and changes in the neurologic status.

Anesthetic Considerations for Deep Brain Stimulation

“…The process of electrodes' placement is guided by MERs and concomitant macrostimulation, which consists of intraoperative physical stimulus or mental tasks to assess the responses of patients to DBS [7]. Anesthetic drugs have an important impact at this stage of the surgery [7,8].…”

“…Currently, limited data has been published with regards to the anesthetic management of DBS with no strict guidelines to follow by healthcare providers [8]. Nevertheless, there are some common concerns for DBS surgery, including patient comfort, Airway and blood pressure management , neuromonitoring, and anesthetic drugs interference with MERs.…”

Neuroradiology, Anesthesia, Bioengineering, and Hardware Programming in the Clinical Applications of Deep Brain Stimulation

“…Though no clear data exists in regards to suggestions that 'awake' technique versus general anesthesia provides better MER signaling, studies have suggested that total intravenous techniques using combination of propofol and remifentanil may in fact lead to suppression of parkinsonian tremors. In addition, other options may include using 'twilight' or monitored anesthesia care with and without sedation, analgesia, or both [58][59][60][61].…”

“…This seems to be a relatively common occurrence when using propofol infusion for DBS procedures. Sneezing can cause patient discomfort, interfere with surgical mapping, and cause sudden rises in intracranial pressure putting patients at higher risks of intracranial hemorrhages, making it important to avoid intraoperatively [61][62][63][64][65][66].…”

Preservation of microelectrode recordings with non–GABAergic drugs during deep brain stimulator placement in children

“…16 Because the brain is free from pain fibers, the electrode insertion part of the procedure is performed with the patient awake while receiving monitored anesthesia care or an asleep-awake-asleep technique. 3,[10][11][12]14,21,22 However, young children with severe dystonia, developmental delay, and other associated cardiorespiratory conditions are not good candidates for awake procedures because their restlessness and anxiety can interfere with the operation. The unsedated patient may also have a higher risk of intracerebral bleeding from intraoperative hypertension.…”