Episodic High Irrigation Pressure During Surgical Neuroendoscopy May Cause Intermittent Intracranial Circulatory Insufficiency

Abstract

Intermittent high peak pressure values inside the endoscope during neuroendoscopic surgical procedures are associated with postoperative morbidity. Unexpected delay in awakening is the complication most frequently observed by the anesthesiologist as a result of high peak pressure values inside the endoscope. During eight neuroendoscopic procedures the authors continuously monitored cerebral hemodynamic function, using a transcranial doppler (TCD) probe fixed on patients' temporal window. We observed that episodes of high peak pressure values inside the endoscope during neuroendoscopic navigation rinsing periods resulted in changes in the TCD wave profile consistent with "near intracranial circulatory arrestlike" wave. No systemic hemodynamic warning signs accompanied these intermittent episodes of severe decrease in cerebral perfusion pressure. When the rinsing liquid was allowed to escape, the pressure inside the endoscope decreased and the TCD wave immediately returned to its previous value. Neuroendoscopic procedures, although classified as minimally invasive surgery, warrant special monitoring that could alert us to a decrease in cerebral perfusion pressure. Middle cerebral artery TCD recording is a reliable and accurate tool for this purpose.

Anestesia para neurocirugía mínimamente invasiva

“…Margetis y Souweidane 23 utilizaron corticoides endovenosos preoperatorios para reducir el posible riesgo de ventriculitis química subsiguiente a hidrocefalia, como consecuencia del derrame intraventricular de material coloide durante la resección endoscópica. La solución caliente de Ringer lactato es el líquido más comúnmente utilizado para irrigar [24][25][26][27] . Salvador et al 28 encontraron que el uso de solución salina producía cambios significativos en la composición del LCR.…”

“…Puede presentarse una baja PPC de manera precipitada, por la purga inadecuada de la solución de irrigación 24 . Sin embargo, mantener una señal confiable de DTC durante toda la cirugía es técnicamente difícil y algunas veces inalcanzable.…”

Anaesthetic Management of Patients Undergoing Intraventricular Neuro-Endoscopic Procedures

“…Most surgeons however do not use an extra sheath. Effusion capacity of the rinsing fluid is consequently largely restricted to the outflow channel of the endoscope, in which case substantial intracranial pressure can emerge, mandating adequate ICP monitoring (Fàbregas et al, 2001;Kalmar et al, 2005a). The manipulation of intraventricular fluid volume and pressure by controlling the rinsing inflow and outflow is sometimes advocated as a particular advantage.…”

“…In the literature describing the "Cushing reflex" during neuroendoscopy, the observation of hypertension is ubiquitous. However, several groups observed mostly hypertension and bradycardia as a predominant sign (El-Dawlatly 2008, Fàbregas 2001, while others (Van Aken 2003, Kalmar 2005a) systematically observed hypertension combined with an initial tachycardia, which only occasionally evolves into bradycardia. It is very conceivable that the differences in these observations are a result of variations in surgical practice.…”

Tension Pneumocephalus After a Neuroendoscopic Procedure-Case Report-

“…Severe complications of neuroendoscopy are rare, but hemorrhage, infection, fever, equipment failure, and convulsions have been described. [1][2][3][4][5][6][7][8][9][10][11][12][13] We report a rare case of tension pneumocephalus following neuroendoscopic tumor biopsy.…”