Neurosurgical
Anaesthesia for
neurosurgery
Rhys Davies
Mary McLoone
Abstract
Neuroanaesthesia provides its own set of unique challenges. Its aims
are to maintain cerebral perfusion and oxygenation, whilst providing
optimum operating conditions. Surgery is performed mainly for space-
occupying and vascular lesions. The pathology and any pre-existing
­neurological deficit should be carefully assessed because they influ-
ence the conduct of anaesthesia and postoperative care. A balanced
anaesthetic technique that maintains haemodynamic stability prevents
a harmful elevation in intracranial pressure (ICP) or decreases in cere­
bral perfusion pressure. To prevent raised ICP, maintenance of PaCO2
­between 4.0 and 4.5 kPa, prevention of hypertensive surges, and patient
positioning to allow good venous drainage from the head are important.
Adequate cerebral perfusion and oxygenation are achieved by prevent-
ing hypotension and maintaining PaO2 above 13 kPa. Intraoperative
fluid regimes should avoid dextrose-containing solutions, which may
exacerbate cerebral ischaemia and lead to cerebral oedema. The choice
of crystalloids is contentious, with advocates for both Ringer’s lactate
and ­ normal saline. There may be a need to acutely reduce ICP intra­
operatively; this can be achieved temporarily with mannitol, furosem-
ide or cautious hyperventilation. Anaesthetic techniques should allow
rapid emergence to allow postoperative neurological assessment. Some
patients will ­require close monitoring in a level 2 or 3 ICU. Pain relief
is best achieved with a multimodal approach, consisting of local an-
aesthetic infiltration, regular paracetamol, opioid analgesic agents, and
non-steroidal anti-­inflammatory agents if appropriate.
Keywords analgesia; cerebral perfusion; craniotomy; ICP; neuroprotection
The ultimate aim of anaesthesia for neurosurgery is to provide
the best possible operating conditions whilst avoiding cerebral
ischaemia by maintaining cerebral perfusion and oxygenation.
This aim is achieved by obtunding rises in intracranial pressure
(ICP) and ensuring haemodynamic stability and appropriate
­ventilation.
Rhys Davies, FRCA, is Specialist Anaesthetic Registrar on the North-west
Thames rotation and is and currently working at the National Hospital
for Neurology and Neurosurgery, Queen Square, London. He has a
special interest in neuroanaesthesia and intensive care.
Mary McLoone, FRCA, is locum Consultant Anaesthetist at the National
Hospital for Neurology and Neurosurgery, Queen Square, London. She
qualified from Charing Cross and Westminster Hospital, and trained
in anaesthesia in the North-west Thames region. Her interests include
neuroanaesthesia and chronic pain management.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:10
The range of elective neurosurgical procedures is large, but
most involve the removal of space-occupying lesions. Although
cranial and spinal vascular malformations are increasingly man-
aged by interventional radiological techniques, some require
open surgical operations. In contrast, emergency neurosurgery
is usually performed for traumatic or spontaneous intracranial
haemorrhage; however, it is sometimes indicated for the urgent
treatment of space-occupying lesions that result in dangerous
increases in ICP.
Pathology
Tumours: gliomas are the most common type (60%) of pri-
mary tumour found in the anterior cranial fossa, and most are
astrocytomas. These range from the relatively benign pilocytic
astrocytomas to the highly malignant glioblastoma multiformae.
Meningiomas are also common. Secondary tumours are less com-
mon, with the lung and breast being the most frequent primary
tumour sites.
Tumours found in the posterior fossa include meningiomas,
acoustic neuromas, haemangioblastomas, and arachnoid and
epidermoid cysts. Renal, lung, breast and skin malignancy may
metastasize to the cerebellum.
Vascular lesions: aneurysms arise more commonly in the an­­
terior circulation (90%) and are usually found in the anterior and
posterior communicating arteries. Rupture causes subarachnoid
haemorrhage, resulting in primary cerebral damage and the sub-
sequent risk of ischaemic damage due to vasospasm in 30–40%
of cases. In addition, hydrocephalus may occur if blood enters
the ventricular system and prevents cerebrospinal fluid (CSF)
from draining. Arteriovenous malformations are more common
in the supratentorial region (70–90%).
Preoperative assessment of the neurosurgical patient
The operation to be performed, the extent and nature of the
lesion to be operated on and its location can have an impact on
anaesthetic technique and predict postoperative problems.
Supratentorial lesions are more likely to present with epileptic
seizures, neurological deficits or raised ICP. These lesions may
be very large and exert a significant mass effect in a relatively
asymptomatic patient.
Posterior fossa lesions often present with lower cranial nerve
symptoms and signs, including poor bulbar function with as­­
piration of stomach contents, cardiorespiratory problems or a
decreased level of consciousness. Small lesions in this region
tend to have a devastating effect because of the limited compli-
ance of this space and the important structures lying within it.
It is important to assess and document any neurological deficit
preoperatively because there may be postoperative deterioration
due to oedema or intraoperative damage. Thus, the patient with
pre-existing swallowing or respiratory problems may be expected
to have a greater deficit in the immediate postoperative period,
with the possible need for mechanical ventilation. Plans should
be made for this eventuality.
After documenting any pre-existing gross neurological deficit
(including the Glasgow Coma Score), it is important to docu-
ment any expressive or receptive speech deficit. These forms of
speech are essential for an accurate postoperative assessment of
the patient in recovery.
427 © 2007 Published by Elsevier Ltd.
 Neurosurgical
Examination of radiological images to determine the size
and location of the lesion is important because it can provide
in­formation about the likelihood of raised ICP as well as the
­relationship of the lesion to other vital structures.
Preoperative medication may include anticonvulsant and
cortico­steroid therapy, and these must be continued periopera-
tively. A history of other medical conditions and functional status
is important. Cardiac and respiratory disease should be treated
preoperatively if possible as failure to do so may impact on the
ability to optimize cerebral oxygenation and perfusion. The
­preoperative aims for neurosurgery are summarized in Table 1.
Induction of anaesthesia
Induction of anaesthesia is performed using an intravenous
agent. In recent years propofol has become the most widely
used induction agent, with thiopental decreasing in popularity
despite having ideal cerebral pharmacodynamic characteristics.
A short-acting opioid (e.g. fentanyl or alfentanil) is used in most
cases, and these agents are titrated to maintain normotension
during induction. A short-to-medium acting, non-depolarizing
neuromuscular blocking agent (e.g. atracurium or vecuronium)
is used. It is essential that an appropriate time is allowed for
this agent to work so that coughing on laryngoscopy and trach­
eal intubation is prevented. When a rapid-sequence induction
is needed, suxamethonium should be used; the danger of the
transient rise in ICP caused by this agent is far outweighed by the
safe securing of the airway.
The hypertensive response to laryngoscopy, tracheal intuba-
tion and the application of head-holding pins must be blunted
by the appropriate use of opioids (or a bolus dose of induction
agent) before the intervention.
A reinforced, flexometallic tracheal tube is recommended, and
its position should be carefully checked to prevent endobronchial
intubation; this is vital as there is very restricted access to the
airway once surgery is under way.
Similarly, adequate securing of the tracheal tube is important,
and is usually achieved using adhesive tape; ties are avoided
as they can result in obstruction of cerebral venous drainage
by exerting pressure on the neck. A nasogastric tube should be
inserted, especially in patients undergoing posterior fossa surgery,
as ­ bulbar function may be compromised postoperatively. The
patient’s eyes should be protected with a waterproof dressing to
prevent surgical skin preparation entering them. Padding should
also be used to prevent pressure damage intraoperatively.
Monitoring of the neurosurgical patient
Intraoperative monitoring includes continuous ECG, pulse oxi­
metry and end-tidal capnography. Invasive blood pressure
Aims of preoperative period
• Assess and document any pre-existing neurological deficit
• Review available imaging for site and nature of lesion
• Optimize pre-existing medical conditions
• Continue anticonvulsant and corticosteroid medication
• Identify and correct fluid and electrolyte imbalances
Table 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:10
monitoring is indicated for most cases. This can be sited before
induction of anaesthesia, particularly if there are concerns over
pre-existing raised ICP. Urine output, temperature and central
venous pressure monitoring are also indicated in most cases.
The femoral vein is the favoured site for catheterization as it
provides easier intraoperative access, avoids the risk of carotid
artery puncture and does not require a head-down position for
insertion. Furthermore, this site avoids the risk of air entrain-
ment that can occur through an internal jugular catheter when
the patient is in the head-up position. Other specialized monitor-
ing techniques include somatosensory or motor evoked poten-
tials monitoring for brainstem and spinal surgery, facial nerve
monitoring for acoustic neuroma surgery, and electroencepha-
lography ­monitoring in epilepsy surgery.
Positioning of the neurosurgical patient
The area to be operated on determines the position of the patient;
the major positions are supine, prone, lateral and sitting.
The supine position is usually used for access to the anterior
cranial fossa. A reverse Trendelenburg tilt of 15% allows good
ce­rebral venous drainage, which helps reduce ICP and improves
the operating field. Excessive rotation of the head must be
avoided as it can occlude the internal jugular veins and cause
a rise in ICP. A support placed under the contralateral shoulder
allows appropriate lateral rotation of the head without compro-
mising venous drainage.
The prone position provides excellent access to the posterior
fossa, particularly for structures lying in the midline. The patient
is placed in head pins, which reduce the chance of injury to the
face and eyes. Head-up tilt improves venous drainage, although
the position increases the risk of venous air embolism. The
patient should be placed on a specially designed mattress (e.g.
the Montreal mattress), which allows for unimpeded abdominal
movement. Facial and airway oedema can result if venous and
lymphatic drainage are obstructed.
The lateral position allows surgical access to structures in the
temporal and posterior fossas (e.g. cerebellopontine angle lesions).
The park-bench position is the most frequently used. The patient
is placed on his or her side with the hips supported both anteri-
orly and posteriorly. The lower leg is flexed and a pillow placed
between the legs; the uppermost leg is kept straight to lock it at the
knee with the foot placed on a support to prevent the patient sliding
down the table. A brachial plexus roll is placed in the axilla of the
lowermost arm, which is flexed across the body. The uppermost
limb is taped along the line of the body. The head is fixed in head-
pins, avoiding excessive flexion of the neck to prevent occlusion of
venous drainage; this is encouraged by the use of a head-up tilt.
The sitting position: traditionally, this position was achieved by
placing the patient in a specially designed chair; more recently,
especially for adult neurosurgery, a conventional operating table
is used and the patient is placed in a sitting position, but with the
legs placed horizontally. The sitting position has distinct surgical
advantages as it provides clear access to midline posterior fossa
structures. The major complication of this position is venous air
embolism. The risk of this occurring can be reduced by ­ensuring
428 © 2007 Published by Elsevier Ltd.
 Neurosurgical
an adequate circulating blood volume, careful surgical tech-
nique and the application of a positive-end expiratory pressure.
An internal jugular venous catheter must be inserted in patients
undergoing surgery in this position as aspiration of air may be
necessary if a venous air embolism occurs. Other complications
of this position include cardiovascular instability and airway
(especially tongue) oedema.
Maintenance of anaesthesia
A balanced anaesthetic technique involving controlled ventila-
tion, opioids and either a propofol infusion or an inhalational
anaesthetic agent is favoured by most neuroanaesthetists.
Modern inhalational anaesthetic agents have less of a detri­
mental effect on cerebral physiology than their predecessors.
Sevoflurane has superseded isoflurane as the agent of choice. It
allows maintenance of cerebral autoregulation in concentrations
of up to a minimal alveolar concentration of 1.5 and reduces
cerebral oxygen requirements. In addition, reactivity of cereb­
ral blood vessels to arterial carbon dioxide tension (PaCO2) is
maintained. Its low blood:gas partition coefficient ensures rapid
recovery following discontinuation.
The use of nitrous oxide in neuroanaesthesia is waning. It
causes cerebral vasodilatation, increased cerebral blood ­volume
and raised ICP. It may also result in pneumocephalus post­
operatively, which occurs when an air-filled space remains after
closure of the dura. Nitrous oxide diffuses into the space more
quickly than nitrogen diffuses out. Pneumocephalus should be
considered when there is an unexpectedly delayed recovery fol-
lowing surgery. The problem can be circumvented by filling the
air-filled space with saline before dural closure. The introduction
of the opioid agent remifentanil has largely negated the necessity
of nitrous oxide as an anaesthetic adjunct.
Remifentanil is an ultra-short-acting opioid, with a context
sensitive half-life of 3 minutes. This allows rapid emergence
from anaesthesia even after long procedures. Furthermore, it
can be easily titrated to provide cardiovascular stability during
episodes of surgical stimulation and has favourable cerebral hae-
modynamic properties. In a balanced technique, remifentanil is
infused at a rate that allows the use of appropriate concentrations
of volatile anaesthetic agents.
Total intravenous anaesthesia using propofol and remifentanil
has also gained popularity, and allows rapid predictable emer-
gence at the end of surgery. Care must be taken to ensure that the
patient is receiving the appropriate doses of intravenous agents
so that awareness does not occur.
Modern anaesthesia dictates that mechanical ventilation is
used for most major neurosurgical procedures: the target level
for PaCO2 is 4.0–4.5 kPa. This practice follows a period when
more profound hyperventilation (to a PaCO2 of 2.5–3.0 kPa)
was widely used to produce a decrease in ICP to provide good
operating conditions. However, studies have shown that the
­latter strategy can result in brain ischaemia caused by excessive
­cerebral vasoconstriction.
A continuous infusion of a non-depolarizing muscle relaxant
is favoured by some anaesthetists, with a peripheral nerve stimu-
lator to guide infusion rate. However, the use of remifentanil
obviates this regimen.
Hypotensive anaesthetic techniques have fallen in popularity as
it has become increasingly recognized that an adequate ­ cereb­ral
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:10
perfusion pressure is necessary to avoid ischaemic damage.
Improved preoperative imaging and modern surgical techniques
allow most neurosurgical procedures to be carried out in normoten-
sive patients. If severe haemorrhage occurs during surgery, a brief
period of hypotension may be required to gain control of the bleed-
ing. However, this should be the exception rather than the rule.
In the past, thromboembolic events were common in the neu-
rosurgical patient largely due to the duration of surgery and their
subsequent, often prolonged immobility. The incidence of this
complication has declined markedly mainly because of the rou-
tine use of compression stockings and intraoperative intermittent
pneumatic calf compression.
Antibiotic prophylaxis usually consists of a single dose of a
second-generation cephalosporin before the start of surgery. The
intraoperative aims of neurosurgery are summarized in Table 2.
Fluid therapy
In previous practice intravenous fluids were administered very
sparingly, which resulted in dehydrated patients. Whilst this
practice decreased brain volume and ICP, allowing more favour-
able surgical conditions, it produced cardiovascular instability
and a decrease in cerebral perfusion pressure. Both of these
­factors increase the likelihood of cerebral ischaemic damage.
Although current fluid regimens are more liberal, the choice
of fluid remains controversial. Whilst there is general agree-
ment that a glucose-containing fluid should be avoided because
­hyperglycaemia exacerbates ischaemic damage, whether 0.9%
saline solution or Ringer’s lactate is the better fluid to use remains
­difficult to quantify. The former solution, when used in large
­volumes can lead to hypochloraemic acidosis. Metabolism of the
lactate in the latter can result in increased intracellular ­glucose
concentrations. However, both solutions have been widely used
without apparent detrimental effects. Colloid solutions are appro-
priate for volume replacement in acute blood loss or for volume
expansion in the dehydrated patient.
Acute reduction of ICP
Occasionally, it may be necessary to acutely reduce raised ICP
during surgery. The osmotic diuretic mannitol (0.5 g/kg) is the
most popular agent to achieve this because it produces a rapid
reduction in ICP. However, in damaged areas of brain tissue,
where the blood–brain barrier is disrupted, mannitol can pass
Aims of intraoperative management
• Prevention of raised ICP
PaCO2 controlled at 4.0–4.5 kPa
Prevent hypertensive surges
Position to allow good cerebral venous drainage
• Maintenance of cerebral perfusion
Prevention of hypotension
• Adequate oxygenation
Maintenance of PaO2 above 13 kPa
ICP, intracranial pressure; PaCO2, arterial carbon dioxide tension; PaO2,
arterial oxygen tension
Table 2
429 © 2007 Published by Elsevier Ltd.
 Neurosurgical
into cerebral cells and may cause a paradoxical increase in intra-
cellular water. This effect is increased when additional doses of
mannitol are given. Despite this disadvantage, the agent remains
useful when ICP is dangerously high. Furosemide (1 mg/kg) has
also been used but its action in reducing ICP may be delayed.
Bolus doses of thiopental may also be used to produce a tempor­
ary reduction of ICP.
Neuroprotective strategies
There are a number of strategies to reduce cerebral tissue isch-
aemia during neurosurgery. Barbiturates exhibit properties that
are desirable, including reduction of free radicals, inhibition of
­cellular calcium influx, and enhanced γ-aminobutyric acid activity.
However, when used by infusion, they are potent cardio­­vascular
depressants. In addition, their pharmacokinetic properties prolong
emergence from anaesthesia.
Hypothermia has been investigated as a possible neuro­
protective strategy, but although it leads to a decrease in cerebral
metabolism and ICP, recent multicentre trials have not shown
any outcome benefit following neurosurgery.
Emergence from anaesthesia
Emergence from anaesthesia should be relatively rapid to allow
early postoperative assessment, but coughing, straining and
hypertension must be avoided. Similarly, unless contraindicated,
extubation of the trachea should be performed at an appropriate
level of anaesthesia to prevent coughing.
Postoperative analgesia
Moderate-to-severe postoperative pain occurs in up to two-thirds
of patients undergoing craniotomy, and many patients remain
under-treated. Much of the pain is thought to arise from peri­
cranial muscle and soft tissue. Some types of surgery (e.g. poste-
rior fossa procedures) may be particularly painful.
Regular paracetamol (1 g orally every 6 hours) has been
shown to reduce opioid requirements, and an intravenous intra-
operative dose should be given. Local anaesthetic infiltration in
the scalp has also been shown to reduce postoperative pain. Tra-
ditional analgesic regimens favoured codeine phosphate because
of fears about respiratory depression with stronger opioid agents.
Studies have allayed these fears and it is now recognized that
morphine sulphate is a superior analgesic agent that can be
used safely. Oral, intravenous, and intramuscular routes with
this agent have been used, and patient-controlled analgesia with
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:10
Aims of postoperative period
• Rapid recovery from anaesthesia to allow neurological
assessment
• Smooth emergence from anaesthesia, avoiding coughing/
hypertension
• Adequate analgesia, including local anaesthetic agents,
paracetamol, opioid +/– NSAIDs
• Control of postoperative nausea and vomiting
• Prompt reassessment if any unexpected neurological deficit
occurs in recovery period
NSAIDs, non-steroidal anti-inflammatory drugs
Table 3
morphine is becoming more popular. The use of non-steroidal
anti-­inflammatory agents remains controversial. Although they
offer improved postoperative analgesia, they are a risk factor in
postoperative haematoma formation.
Prophylactic anti-emetics are used to avoid the rise in intracra-
nial pressure associated with vomiting; dexamethasone and sero-
tonin-receptor antagonists are the most widely used agents. The
postoperative aims of neurosurgery are summarized in Table 3. ◆
Further reading
Cowie DA. The role of hypothermia in neurosurgical patients. Curr Opin
Anaesthesiol 2005; 18: 496–500.
de Gray LC, Matta BF. Acute and chronic pain following craniotomy: a
review. Anaesthesia 2005; 60: 693–704.
Dinsmore J. Anaesthesia for elective neurosurgery. Br J Anaesth 2007;
99: 68–74.
Gupta AK, Summors A. Notes in neuroanaesthesia and critical care, 1st
edn. London: Greenwich Medical Media, 2001.
Hirsch NP. Advances in neuroanaesthesia (state of the art). Anaesthesia
2003; 58: 1162–5.
Mishra LD, Rajlumar N, Hancock SM. Current controversies in
neuroanaesthesia, head injury management and neurocritical care.
Contin Edu Anaesth Criti Care Pain 2006; 2: 79–82.
Porter JM, Pidgeon C, Cunningham AJ. The sitting position in
neurosurgery: a critical appraisal. Br J Anaesth 1999; 82: 117–28.
430 © 2007 Published by Elsevier Ltd.