NEUROSURGICAL ANAESTHESIA

Anaesthesia for
neurosurgery

Learning objectives
After reading this article, you should understand:
C
the principles of anaesthesia for neurosurgery
C
the preoperative and perioperative requirements regarding
monitoring and positioning of the patient
C
the postoperative management of pain in neurosurgical
patients
C
the special requirements for pregnant patients and those
undergoing awake craniotomy and intraoperative MRI

Oliver Hambidge
Robert John

Abstract
Neuroanaesthesia is an expanding speciality that requires a good understanding of neurophysiology as well as the pathophysiology of
raised intracranial pressure. Neuroanaesthetists need to ensure neurosurgical patients maintain an adequate cerebral perfusion pressure
intraoperatively, while providing optimum operating conditions. To
achieve this, a balanced anaesthetic technique preventing hypertensive surges and optimizing cerebral venous drainage by careful patient
positioning is important. Knowledge of the therapeutic options available to the anaesthetist for decreasing ICP intraoperatively is essential.
As neurosurgery evolves, it provides neuroanaesthetists with new
challenges including awake craniotomies, stereotactic neurosurgery
and intraoperative MRI.

A full preoperative neurological examination should be carried out and documented, so a postoperative comparison can be
made. Neurological deficits following surgery may occur due to
oedema or intraoperative injury. Evidence of hearing difficulties,
receptive or expressive dysphasia should also be documented, as
communication problems will make the postoperative assessment more challenging.
Routine medications should be continued preoperatively,
especially anticonvulsants and corticosteroids. Neuroanaesthetists need to be alert to the pharmacokinetic and pharmacodynamic interactions between anticonvulsants and drugs
used in neuroanaesthesia. The most significant is the induction
and inhibition of the cytochrome p450 isoenzymes.
Hypertension is common in the neurosurgical population,
often as a consequence of the neurosurgical pathology (acromegaly, raised ICP) or its treatment (corticosteroid therapy). As
perioperative hypertension can contribute to intracranial
bleeding after a craniotomy, a well-controlled preoperative blood
pressure is important. Some units discontinue angiotensin converting enzyme (ACE) inhibitors and angiotensin II antagonists,
so as to avoid perioperative hypotension. Patients receiving
diuretic therapy may have disordered electrolytes, and those
receiving preoperative dexamethasone may be hyperglycaemic.
Sedative premedication is rarely required and should be
avoided in patients with raised ICP. Many patients will, however,
be very anxious and require reassurance prior to surgery.

Keywords Anaesthesia; awake craniotomy; intraoperative MRI;

monitoring; neurosurgery; postoperative analgesia
Royal College of Anaesthetists CPD Matrix: 1A02, 3F01

General principles
Preoperative assessment
A thorough preoperative assessment of the neurosurgical patient
is vital, and extends beyond the patients past medical history
and previous surgery. The anaesthetic technique and intraoperative positioning of the neurosurgical patient is influenced
by the site, size and vascularity of the intracranial lesion. As
such, preoperative CT scans and MRI scans are invaluable. Preoperative imaging can also inform the anaesthetist of any evidence of midline shift or hydrocephalus.
Supratentorial lesions commonly present with neurological
deficits, seizures, or symptoms consistent with raised intracranial pressure (ICP). Meningiomas account for around 15% of
central nervous system tumours, and are more likely to cause
significant blood loss owing to their increased vascularity. These
patients can have large tumours, yet may remain relatively
asymptomatic. In contrast, lesions in the posterior fossa
commonly present with lower cranial nerve symptoms, and poor
bulbar function. These patients may also have cardiorespiratory
dysfunction, which should be explored at the preoperative visit.

Induction
Induction of anaesthesia is normally performed using an intravenous agent such as propofol or thiopental. Short-acting opioids
such as fentanyl or alfentanil are used to attenuate the hypertensive response to laryngoscopy and intubation. Further boluses
can also obtund the haemodynamic response to Mayfield pins
insertion. Muscle relaxation is established with non-depolarizing
drugs such as rocuronium or atracurium. These have minimal
effects on intracerebral haemodynamics. It is important to allow
sufficient time to ensure complete paralysis before attempting
intubation, as coughing can raise ICP. If a rapid sequence is
required, suxamethonium should be used, as the importance of
securing a definitive airway promptly, outweighs any transient
rise in ICP seen with this agent.
To prevent kinking, reinforced endotracheal tubes are
commonly used for tracheal intubation. Adhesive tape should be
used to secure the airway as using ties can obstruct cerebral
venous drainage and result in a rise in ICP. If bulbar function is

Oliver Hambidge Bsc(hons) BM(hons) FANZCA is a Consultant

Anaesthetist and Clinical Fellow at the National Hospital for
Neurology and Neurosurgery, London, UK. Conict of interests: none
declared.
Robert John MBBS BSc (Hons) FRCA is a Consultant Neuroanaesthetist
at the National Hospital for Neurology and Neurosurgery, London,
UK. Conict of interests: none declared.

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NEUROSURGICAL ANAESTHESIA

compromised, a nasogastric tube should be inserted. The eyes

need to be protected with a waterproof dressing and padded to
prevent any perioperative pressure damage.

Remifentanil
Remifentanil is a potent mu receptor agonist that is able to
achieve anaesthesia and profound analgesia. It is ultra-short
acting on account of its unique structure (2 ester links) allowing metabolism by non-specific plasma and tissue esterases;
having a context in-sensitive half time of 3 minutes following a
3 hours infusion. It is a potent respiratory depressant, which
avoids the need to repeatedly administer muscle relaxants intraoperatively. The use of remifentanil also facilitates a smooth,
haemodynamically stable extubation allowing rapid neurological
assessment. It can be used in conjunction with propofol or volatile agents for maintenance of anaesthesia.

Positioning
Patient positioning is largely determined by the location of the
patients intracranial lesion, so as to optimize surgical access.
Most neurosurgical procedures can be performed with the patient
in the supine position with the head rotated and fixed in Mayfield
pins. A sandbag is commonly placed under the ipsilateral
shoulder. A 15
reverse Trendelenburg tilt with appropriate head
rotation can improve cerebral venous drainage, lower ICP and
improve operating conditions. Excessive head rotation may,
however, cause stretching of the brachial plexus and jugular
veins.
The prone position may be used for access to midline structures in the posterior fossa. Placing the head in a Mayfield 3 point
fixator reduces the chance of injury to the face and eyes and
helps prevent facial and orbital oedema. The patient should be
placed in a specially designed mattress supporting the chest and
pelvis that allows for free abdominal movements and facilitates
effective ventilation. Bony prominences should be padded in all
prone patients.
The park bench position is a variation of the lateral position
and allows surgical access to the cerebellopontine angle. The
patient is placed on their side with anterior and posterior supports. The lower leg is flexed and the upper leg is straight with a
pillow between the knees. The lower arm is flexed while the
upper arm remains extended and taped along the body. The
axilla needs to be well padded so as to prevent brachial plexus
injuries.
The sitting position is achieved by placing the patient on a
conventional operating table and sitting them up at the waist
with their legs outstretched and slightly flexed. The advantages
of this position include excellent access to midline posterior
structures and good venous drainage, but there is an increased
risk of air embolism.

N2O
Nitrous oxide should be avoided in neuroanaesthesia as it causes
cerebral vasodilation with a resulting increase in cerebral blood
flow (CBF) and ICP. It also has a high blood:gas partition coefficient (0.47) so will worsen any pneumocephalus. It is also
associated with an increased risk of postoperative nausea and
vomiting (PONV).
Dexamethasone
Dexamethasone (4e8 mg on induction) has dual benefits in
neuroanaesthesia. It reduces the risk of PONV, as well as
reducing cerebral oedema associated with tumours. It is important to note however that even in non-diabetics this may result in
an appreciable increase in plasma glucose levels up to 12 hours
postoperatively. While this has not been demonstrated to increase the risk of wound infection it is prudent to exercise
caution in brittle diabetics.
Intravenous uids
The water flux across an intact blood brain barrier is determined by plasma osmolality. A 0.9% saline solution is a
hyperosmolar crystalloid and is the maintenance fluid of choice
in the neurosurgical patient, although large volume infusions
can cause a hyperchloraemic metabolic acidosis. Normovolaemia should be maintained and overhydration should be
avoided. Glucose containing solutions such as 5% dextrose
and 4% dextrose in 0.18% saline should not be used, as
their hypotonicity can raise ICP and may worsen cerebral
oedema. The intraoperative management of raised ICP is
summarized in Box 1.
Routine and specialized monitoring is essential during
neurosurgery (Box 2). Mild intraoperative hypothermia in elective neurosurgical patients has not been shown to confer any
benefit, therefore normothermia should be targeted using air and
fluid warming devices. Hyperthermia should be avoided.
All patients should be given an appropriate prophylactic
antibacterial agent. This may need to be repeated during long
procedures. Neurosurgical patients should all receive mechanical
deep vein thrombosis (DVT) prophylaxis intraoperatively (TEDS
and intermittent calf compression devices).

Maintenance of anaesthesia
Propofol versus volatiles
There are no consensus recommendations regarding the type of
maintenance anaesthesia for neurosurgical procedures. Total
intravenous anaesthesia (TIVA) is, however, becoming a popular
anaesthetic technique for neurosurgery and there are some indications of its superiority over volatiles presented in a recent
meta-analysis.1 Compared to volatiles, propofol has been found to
be associated with a faster time to obey commands in the
post anaesthetic care unit (PACU), as well as a reduced risk of
postoperative nausea and vomiting. Other well-established benefits include suppression of the inflammatory response, less interference with motor evoked potentials (MEPs), anti-tumour
properties and the preservation of cerebral flow-metabolism
coupling and vascular reactivity to changes in CO2. While the
quality (and quantity) of studies seeking to establish any mediumto long-term outcome difference between propofol and volatile
maintenance in elective neuroanaesthesia remains low, volatiles
remain an acceptable alternative for maintenance of anaesthesia in
the elective neurosurgical patient.

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Emergence
To ensure early neurological assessment, emergence from
neurosurgery must be relatively rapid. Patients are usually
extubated at a deep plane of anaesthesia to prevent coughing.

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Postoperative management

Intraoperative management of raised intracranial

pressure
C

C
C
C
C
C
C

Patients undergoing intracranial surgery often experience moderate postoperative pain. This is usually superficial, involving the
scalp and pericranial muscles, but can also arise from dura mater
manipulation. Pain is typically worse in young, female patients,
and after posterior fossa surgery. Paracetamol, used in appropriate doses is a safe and well tolerated drug with proven
efficacy.
Non-steroidal anti-inflammatory drugs (NSAIDs) remain
controversial, given their antiplatelet effects. A recent editorial2
suggests NSAIDS should not be routinely administered but can
be considered after 24 hours, and only in the setting of inadequate analgesia.
Opioids are frequently used for short term postoperative
analgesia, typically in relatively small doses. Fentanyl,
morphine and oxycodone are all commonly used. Codeine is still
commonly used despite equivalent doses of morphine achieving
more predictable and sustained analgesia without an increase in
sedation scores. This is explained by the significant genetic
variations that exist with the handling of this pro-drug. Up to
28% of the population are known to be ultra-rapid metabolizers
(with a significant risk of morphine overdose), 11% intermediate metabolizers (with a risk of poor analgesia on account of
limited codeine metabolism) and 10% poor metabolizers (with
a risk of completely ineffective analgesia). There is therefore a
significant proportion of the population in whom codeine is
either potentially harmful or ineffective, and for this reason its
use should be discouraged.
Postoperative nausea and vomiting is common, especially
following posterior fossa surgery. Given the acute rise in ICP seen
with vomiting, it is important to administer prophylactic antiemetics in theatre.
Mechanical methods for preventing thromboembolic events
should be continued in the immediate postoperative period until
the patient is mobilizing or low molecular weight heparin can be
prescribed safely.

Check patient position and maintain reverse Trendelenburg

position
Avoid excessive head rotation
Tape tracheal tube rather than tie
Ensure CO2 4.5e5 kPa
Control blood pressure
Deepen anaesthesia using bolus of propofol or thiopental
Consider dexamethasone 8e12 mg for tumours if not previously
given
Mannitol 0.5 mg/kg is rarely used intraoperatively, but can be
used as a stalling strategy prior to surgery

Box 1

Monitoring in neuroanaesthesia
Routine
C
Continuous electrocardiography
C
Pulse oximetry
C
End tidal capnography
C
Invasive blood pressure
C
Temperature
C
Urine output
Specialized
C
Central venous pressure (for medical reasons, if large blood loss
is expected e.g. meningioma surgery or in sitting position risking
air embolism)
C
Somatosensory/motor evoked potentials (brainstem/spinal
surgery)
C
Facial nerve monitoring (acoustic neuroma surgery)
C
Electroencephalography monitoring (epilepsy surgery)

Special circumstances
Pregnancy
The incidence of brain tumours and neurovascular lesions in
pregnancy does not differ from age matched controls, though
pregnancy may promote progression of vascular lesions
(increasing aneurysm size, aneurysm weakening/rupture) and
acceleration of tumour growth or oedema (meningiomas,
schwannomas and pituitary adenomas). VP shunts may become
less effective due to an increase in intra-abdominal pressure and/
or displacement. Trauma occurs in 6e7% of all pregnancies,
though only a minority of these will require neurosurgical
intervention. Any risk of preterm labour relates to the index
pathology, surgical stress response, nature of the surgery and
baseline maternal condition.
The physiological changes associated with pregnancy are well
understood. Specific points with relevance to neuroanaesthesia
are highlighted in Table 1.
Traditionally, surgery in the pregnant patient is delayed until
after delivery at full term if at all possible. However, there is
growing evidence suggesting that neuroanaesthesia in pregnancy
can be safe, and that delaying intervention often results in

Box 2

This technique requires a balance between an adequate anaesthetic depth, and a sufficient spontaneous minute ventilation to
avoid postoperative hypoxia and hypercarbia, both of which are
known to have deleterious effects on ICP. It is not uncommon
for neurosurgical patients to develop hypertension on emergence. This is partly mediated by raised plasma catecholamine
levels and nociceptive stimuli. Ensuring good analgesia and
using intravenous labetalol or hydralazine, can maintain haemodynamic stability in the immediate postoperative period.
Ventilation on the neurointensive care unit postoperatively
should be considered if the neurosurgical patient was severely
obtunded preoperatively or extensive intraoperative bleeding
occurred. Postoperative ventilation is also warranted if any
acute intraoperative brain swelling requires ICP monitoring
postoperatively.

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Neuroanaesthetic considerations in the pregnant patient

Airway

Breathing

Risk

Treatment notes

Aspiration risk from 14 weeks gestation to 72

hours post partum

Higher risk of difficult airway

More rapid desaturation on induction

C
C

Circulation

Other

Mechanical aorto-caval compression from

gravid uterus from approx 20 weeks gestation
Placental perfusion is pressure dependant

Hypercoagulable state (approx. 5 increase

risk of thromboembolic events)

Volatiles are associated with uterine smooth

muscle relaxation and increased risk of PPH
Mannitol may increase fetal lung fluid
production and plasma Na and cause
intravascular dehydration
Many anticonvulsants have teratogenic
properties

Ergometrine may be associated with severe

hypertensive responses

Rapid sequence induction and intubation

Pretreat with Ranitidine 150 mg bd for 24
hours prior to general anaesthesia, Na
citrate 30 minutes prior to induction
Meticulous planning for management of
difficult airway
Ramped position
Meticulous preoxygenation
Consider apnoeic oxygenation via high
flow nasal prongs and preoxygenation
with CPAP/PS
Use wedge under right hip/15 degrees
table tilt to left
Aggressive management of hypotension
with alpha agonist infusion
TEDS, calf compressors, early mobilization, prophylactic LMWH as soon as
possible following discussion with
neurosurgeons
TIVA if planned LSCS followed by neurosurgical intervention
Avoid mannitol if at all possible

Anticonvulsant management should be

undertaken by neurologists with expertise
in managing the parturient
Use with extreme caution in the neurosurgical patient

Table 1

maternal deterioration and more emergent delivery and neurosurgical intervention. The risk of subarachnoid aneurysm
rupture is 6% in the first trimester, increasing dramatically to
55% in the third trimester. This compares to a baseline average
yearly rupture rate of just under 1% for the general population.
The greatest threat of arteriovenous malformation (AVM)
rupture is in the second trimester when cardiovascular changes
are at their most pronounced.
The decision when and whether to intervene is complex and
all cases should be considered individually with extensive
collaboration between the multidisciplinary team caring for the
patient(s). The patient and family should be actively involved in
the decision making process. Any neurosurgical intervention
should occur in a setting where obstetric and neonatal support is
readily available.

and is associated with a shorter hospital stay, reduced cost and

reduced requirement for postoperative high dependency care.
Anaesthetic techniques include conscious sedation using
target-controlled infusions of propofol and remifentanil used
with large volumes of local anaesthetic infiltration to the scalp.
This technique allows the anaesthetist to rapidly adjust the level
of sedation and analgesia according to surgical events, and
makes a quick recovery possible. Obstructive apnoea leading
to hypoventilation is a risk, however, and anaesthetic management must include a plan for securing the airway rapidly if
necessary.
The use of an asleepeawakeeasleep technique with a laryngeal mask airway (LMA) is an alternative technique gaining in
popularity in many centres. The LMA is well suited to this
technique, as it is tolerated well by patients in light anaesthetic
planes and can be used for spontaneous as well as controlled
ventilation. The relative ease at which the LMA can be inserted
and removed further explains its widespread use in the awake
craniotomy setting.
Routine monitoring as for a craniotomy should be used. This
includes a urinary catheter if the procedure is expected to be
prolonged. It is also important to ensure the surgical drapes allow

Awake craniotomy
Awake craniotomies are regularly used in neurosurgical centres
for epilepsy surgery and the excision of lesions adjacent to
eloquent brain areas. Continuous neurological assessment allows
maximal tumour resection with minimal neurological dysfunction.
It is used in conjunction with 3D navigation imaging techniques,

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NEUROSURGICAL ANAESTHESIA

constant access to the patients airway, and reduces the patients

feeling of claustrophobia.

Whilst the patient is being scanned, the anaesthetist does not

have direct access to the patient and they may be monitored from
a separate room. The distance between the anaesthetic machine
and patient is often greater than in standard operating theatres,
necessitating an extended anaesthetic breathing circuit for
ventilation. Capnography therefore requires a longer sampling
tube resulting in an increased response time. Total intravenous
anaesthesia and volatile anaesthesia have both been used with
success for iMRI surgery.
A

Stereotactic neurosurgery
Stereotactic neurosurgery allows a specific area of the brain to be
targeted with great accuracy while minimizing surgical exposure
and collateral injury to healthy brain tissue. It is widely used for
tumour biopsy/excision as well as functional neurosurgery for
movement disorders and dystonias. Surgery involving frames
may make access to the airway difficult if this is positioned prior
to surgery.

REFERENCES
1 Chui J, Mariappan R, Mehta J. Comparison of propofol and volatile
agents for maintenance of anesthesia during elective craniotomy
procedures: systematic review and meta-analysis. J Can Anaesth
2014; 61: 347e56.
2 Editorial. Controversy of NSAIDs and intracranial surgery, et ne nos
inducas in tentationem? Br J Anaesth 2011; 107: 302e5.

Surgery in intraoperative MRI (iMRI)

Intraoperative MRI is an exciting development which allows
neurosurgeons to perform MRI scans of patients at appropriate
intervals during surgical procedures. This offers valuable imaging guidance and has been successfully used for tumour surgery,
epilepsy surgery, awake craniotomies and deep brain stimulation
surgery.
iMRI is usually carried out in specially designed MRI suites
that are significantly larger than standard operating theatres and
divided into an inner 30 Gauss (G) area in which projectile
hazards exist, and an outer 5G area.
In the conventional MRI environment, anaesthetic considerations include restricted patient access, ferromagnetic projectile
risk and the use of appropriate MRI compatible monitoring. The
interference caused by MR on monitoring equipment, as well as
the high level of acoustic noise also needs to be considered.
Providing general anaesthesia for iMRI surgery brings additional challenges as the procedures are often very long, involve
repeated intraoperative scans and demand optimal operative
conditions for neurosurgery. Thermoregulation is difficult, and
meticulous attention needs to be paid to patient positioning to
prevent pressure areas developing. A urinary catheter should
always be sited and the airway needs to be well secured with the
pilot tube taped down and away from the area being scanned.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:12

FURTHER READING
Bergese SD, Puenta EG. Anaesthesia in the intraoperative MRI environment. Neurosurg Clin N Am 2009; 20: 155e62.
Bonhomme V, Franssen C, Hans P. Awake craniotomy. Eur J Anaesthesiol 2009; 906e12.
Dinsmore J. Anaesthesia for elective neurosurgery. Br J Anaesth 2007;
99: 68e74.
Flexman AM, Ng JL, Gelb AW. Acute and chronic pain following
craniotomy. Curr Opin Anaesthesiol 2010; 23: 551e7.
Lai LT, Ortiz-Cardona JR, Bendo AA. Perioperative pain management
in the neurosurgical patient. Anesthesiol Clin 2012; 30: 347e67.
Nossek E, Ekstein M, Rimon E. Neurosurgery and pregnancy. Acta
Neurochir (Wien) 2011; 153: 1727e35.
Reddy U, White M, Wilson R. Anaesthesia for magnetic resonance
imaging. Contin Educ Anaesth Critic Care Pain 2012; 12: 140e4.

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