What are the essential steps and considerations in the management of a patient undergoing neurosurgery?

Management of Patients Undergoing Neurosurgery

Preoperative Management

All neurosurgical patients require multidisciplinary evaluation by a dedicated tumor board including neuroradiologists, neuropathologists, neurosurgeons, radiation oncologists, and neuro-oncologists before proceeding to surgery. 1

Preoperative Diagnostics and Imaging

• Brain MRI with T2-weighted, T2-FLAIR, and 3D T1-weighted sequences before and after gadolinium-based contrast is the diagnostic gold standard for detecting brain tumors and planning surgical approach 1
• Non-contrast CT of the brain and cervical spine should be obtained immediately in trauma cases to guide neurosurgical procedures and monitoring techniques 2, 3
• Perfusion MRI and amino acid PET can define metabolic hotspots for targeted tissue sampling, particularly useful when biopsy rather than open resection is planned 1
• Electroencephalography should be performed in patients with tumor-associated epilepsy or altered consciousness 1

Medical Optimization Before Surgery

• Corticosteroids should be administered to decrease symptomatic tumor-associated edema unless primary cerebral lymphoma or inflammatory lesions are suspected 1
• Patients with prior seizures must receive anticonvulsant drugs preoperatively, though primary prophylaxis does not reduce first seizure risk in seizure-naive patients 1
• Osmotic agents are rarely necessary for preoperative management 1

Intraoperative Management

Airway and Ventilation

• Establish airway control as absolute priority through tracheal intubation and mechanical ventilation, beginning in the pre-hospital period for severe TBI 2
• Confirm correct endotracheal tube placement through end-tidal CO2 monitoring 2
• Maintain PaCO2 between 35-40 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• Maintain PaO2 between 60-100 mmHg during all neurosurgical procedures 1

Hemodynamic Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 2
• Lower blood pressure values may be tolerated for the shortest possible time only in cases of difficult intraoperative bleeding control 1

Hematologic Parameters

• Maintain hemoglobin >7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery, with higher thresholds for elderly patients or those with limited cardiovascular reserve 1
• Maintain platelet count >50,000/mm³ for life-threatening systemic hemorrhage; higher values (>100,000/mm³) are advisable for emergency neurosurgery including ICP probe insertion 1
• Maintain prothrombin time/activated partial thromboplastin time <1.5 times normal control during all neurosurgical interventions 1
• In massive transfusion scenarios, initiate RBC/plasma/platelet transfusion at 1:1:1 ratio, then modify based on laboratory values 1, 2

Anesthetic Considerations

• Two approaches exist for AVM embolization: general anesthesia for improved visualization without patient movement, or deep intravenous sedation to allow neurological testing 1
• Neither general endotracheal anesthesia nor intravenous sedation demonstrates lower complication rates based on available evidence 1
• Direct arterial pressure transduction is indicated for intracranial embolization procedures, especially with systemic pressure manipulation 1

Surgical Technique and Technology

• Surgical management should occur in high-volume specialist centers with dedicated neurosurgeons 1
• Frame-based or frameless stereotactic biopsy should be performed when microsurgical resection is not safely feasible, with serial samples acquired along the biopsy trajectory to avoid sampling bias 1
• Intraoperative MRI systems (ranging from 0.12-3.0T) allow adjustment for brain shift after craniotomy and provide real-time visualization to maximize tumor resection while avoiding critical structures 4
• High-field (1.5T) intraoperative MRI systems enable MR spectroscopy, MR venography, MR angiography, brain activation studies, and diffusion-weighted imaging 4

Postoperative Management

Immediate Postoperative Care

• Neurological intensive care monitoring is required for at least 24 hours postoperatively 1
• Blood pressure should be monitored with arterial catheter and urine output with indwelling catheter 1
• Typically maintain normotensive and euvolemic conditions, though tight blood pressure control with agents that do not act centrally may be appropriate for selected patients 1

Intracranial Pressure Management

• Implement ICP monitoring in patients at risk for intracranial hypertension (comatose patients with radiological signs of IH) regardless of need for emergency extra-cranial surgery 1
• Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring becomes available, adjusting based on neuromonitoring data and individual cerebral autoregulation status 1, 2
• Use a stepwise approach for elevated ICP, reserving more aggressive interventions with greater risks for situations when no response is observed 1
• In cases of cerebral herniation awaiting or during emergency neurosurgery, use osmotherapy and/or temporary hypocapnia 1

Temperature Management

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death 2

Corticosteroid Use for Cerebral Edema

• Dexamethasone sodium phosphate is administered initially at 10 mg intravenously followed by 4 mg every six hours intramuscularly until symptoms of cerebral edema subside 5
• Response is usually noted within 12-24 hours, and dosage may be reduced after 2-4 days and gradually discontinued over 5-7 days 5
• For palliative management of recurrent or inoperable brain tumors, maintenance therapy with 2 mg two or three times daily may be effective 5

Postoperative Imaging

• Angiogram should be performed during the immediate postoperative period to confirm complete resection of AVMs 1
• New neurological deficit after surgery should be investigated with CT scan to rule out hemorrhage or hydrocephalus 1
• MRI with diffusion-weighted imaging may be appropriate if infarction is suspected 1

Specific Surgical Indications

Emergency Neurosurgical Intervention

• After control of life-threatening hemorrhage, all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention 1
• Urgent neurological evaluation (pupils + Glasgow Coma Scale motor score if feasible, and brain CT scan) is required to determine severity of brain damage 1

Traumatic Brain Injury

• Surgical evacuation is indicated for: symptomatic extradural hematoma, acute subdural hematoma with thickness >5 mm and midline shift >5 mm, brain contusions with mass effect, acute hydrocephalus requiring drainage, and open or closed displaced skull fractures with brain compression 2, 3

Infective Endocarditis with Embolic Stroke

• For patients with severe cardiac decompensation and severe mechanical cardiac lesions, operate emergently or urgently unless neurological status (coma, large intracranial hemorrhage) precludes heparinization or neurological recovery to reasonable quality of life is very unlikely 1
• For patients with IE and ischemic stroke without severe neurological impairment, proceed with surgery without delay 1
• For patients with IE and parenchymal hemorrhage, proceed for small lesions or delay surgery 0-4 weeks depending on size and urgency, with vascular imaging performed 1

Critical Pitfalls to Avoid

• Never delay transfer to specialized neurosurgical center for "stabilization" at non-neurosurgical facility 2
• Never use bolus sedation rather than continuous infusions, which causes hemodynamic instability 2
• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors 2
• Avoid hypocapnia as it induces cerebral vasoconstriction and increases risk of brain ischemia 6
• Do not perform definitive histological diagnosis avoidance unless biopsy risk is too high or prognosis is very unfavorable 1

Special Considerations for COVID-19 Era

• Only surgical on-call teams should be present within hospital settings 1
• Maximal PPE is required for all persons under investigation and COVID-positive patients 1
• Consider designating specific ORs as COVID ORs divided by surgical type 1
• Anteroom should be used for donning/doffing and intubating/extubating patients 1
• Minimize personnel for intubations and extubations 1