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PubMed1993

A prospective, comparative trial of three anesthetics for elective supratentorial craniotomy. Propofol/fentanyl, isoflurane/nitrous oxide, and fentanyl/nitrous oxide.

BACKGROUND: Different anesthetic agents have different effects on cerebrovascular physiology. However, the importance of these differences in neuroanesthetic practice are unclear. In an effort to determine whether important clinical differences are present, the authors compared three anesthetic techniques in 121 adults undergoing elective surgical removal of a supratentorial, intracranial mass lesion. METHODS: Patients were assigned randomly to one of three groups. In group 1 (n = 40), anesthesia was induced with propofol and maintained with fentanyl (approximately 10 micrograms/kg load, 2-3 micrograms.kg-1.h-1 infusion) and propofol (50-300 micrograms.kg-1.min-1). In group 2 (n = 40), anesthesia was induced with thiopental and maintained with isoflurane and nitrous oxide. Up to 2 micrograms/kg fentanyl was given after replacement of the bone flap. In group 3 (n = 41), anesthesia was induced with thiopental and maintained with fentanyl (approximately 10 micrograms/kg load, 2-3 micrograms.kg-1.h-1 infusion), nitrous oxide, and low-dose isoflurane, if required. Blood pressure, heart rate, expired gas concentrations, and ventilatory parameters were recorded automatically in all patients. Epidural intracranial pressure (ICP) was measured via the first burr hole, brain swelling was rated at the time of dural opening, and emergence was monitored closely. Preoperative computed tomography or magnetic resonance imaging scans were evaluated, and pre- and postoperative neurologic exams were performed by a neurosurgeon unaware of group assignments. Total hospital stay (days) and total hospital cost (exclusive of physician charges) also were reviewed. RESULTS: During induction, higher heart rates were seen in isoflurane/nitrous oxide patients, whereas mean arterial pressure was approximately 10 mmHg less during the maintenance phase (compared with both other groups). Otherwise, there were few intergroup hemodynamic differences. While there were no clinically important intergroup differences in mean ICP (+/- SD)-group 1, ICP = 12 +/- 7 mmHg; group 2, 15 +/- 12 mmHg; group 3, ICP = 11 +/- 8 mmHg-more isoflurane/nitrous oxide patients (nine, group 2) had an ICP > or = 24 mmHg than in the other groups (two each). Emergence was, overall, more rapid with fentanyl/nitrous oxide. For example, the median time until the patient could be awakened by quiet verbal command, e.g., "Open your eye," was 5 min, versus 10 min in the other groups. There were no relationships between ICP and any measurement of emergence (e.g., time to response to commands). Seven of 41 (17%) fentanyl/nitrous oxide patients vomited in the early postoperative period, compared with only 1 of 40 (2.5%) of those given propofol/fentanyl and 2 of 40 (5%) receiving isoflurane/nitrous oxide (P = 0.03). There were no differences in the incidence of new postoperative deficits, total hospital stay, or cost. CONCLUSIONS: Although there are modest differences among the three tested anesthetics, short-term outcome was not affected. These results indicate that, despite their respective cerebrovascular effects, all of the anesthetic regimens used were acceptable in these patients undergoing elective surgery.

Adult↗
PubMed1987

Use of SPECT to distinguish recurrent brain tumor from persistent activity at a craniotomy site.

A 50-year-old male underwent extensive left frontal lobe resection for a Grade II astrocytoma. Resection margins were free of tumor, and the patient suffered no significant postoperative neurologic deficits. One month later the patient was referred to radiation therapy for further evaluation and possible treatment. Unenhanced and enhanced transmission computed tomograms (CT) were interpreted as suspicious for recurrent tumor. However, using CT, which is essentially an anatomic technique, may not allow one to distinguish between surgical changes and the morbid anatomic findings of recurrent tumor. Because Tc-99m DTPA will cross the blood-brain barrier at sites of active intercranial disease, brain scintigraphy frequently is of value in distinguishing between recurrent tumor with an unstable blood-brain barrier and healed surgical changes with a stabilized blood-brain barrier. Therefore, clinicians requested that a Tc-99m DTPA brain scintigram be performed so as to distinguish between active disease and healed surgical changes.

Brain Neoplasms↗
PubMed1979

Scalp markers for precise craniotomy siting, using computed tomography.

A rapid, simple, and inexpensive computed tomographic technique has been developed for marking the scalp and lateral skull radiograph of patients with small cerebral convexity lesions. The more precise localization provided thereby facilitates planning and performance of surgery.

Craniotomy↗