RESUMEN
OBJECTIVE: We describe the development of an alternative approach to intraoperative magnetic resonance imaging (iMR)-guided neurosurgery and report our initial experience with 22 craniotomies and 16 brain biopsies. The advantages and disadvantages of each approach are examined. METHODS: An iMR suite houses a 0.2-T open configuration system (Siemens Medical Systems, Erlangen, Germany) and is equipped with anesthetic gases and a magnetic resonance imaging (MRI)-compatible anesthesia machine and monitor. Standard operating instruments and equipment were tested for safety and compatibility in the magnetic fringe fields surrounding the open MRI system. We then performed brain biopsies and craniotomies in the iMR suite. RESULTS: Standard operating equipment functioned properly in the 0.5- to 10-mT zone and was not affected by the magnet's attractive force. Twenty-two craniotomies and 16 brain biopsies were performed in the interventional suite, using serial intraoperative MRI guidance, without injury to patients or operating room staff. CONCLUSION: Full neurosurgical procedures may be performed in the weak fringe fields surrounding an MRI system, using standard operating room equipment. This approach to iMR-guided neurosurgery offers a significant cost advantage over retrofitting an entire operative suite with "MRI-compatible" surgical equipment. The surgeon's familiarity with standard equipment and the reliability of the equipment are additional advantages. Neurosurgery in the fringe fields allows the neurosurgeon to utilize serial MRI with a minimum of inconvenience, disruption, and change to the standard neurosurgical procedure. Serial intraoperative imaging to visualize the changes in the brain that are associated with neurosurgical intervention seems to enhance the ability to safely and effectively accomplish neurosurgical goals.
Asunto(s)
Imagen por Resonancia Magnética , Neurocirugia , Adolescente , Adulto , Anciano , Biopsia , Encéfalo/patología , Encéfalo/cirugía , Niño , Craneotomía , Femenino , Humanos , Magnetismo , Masculino , Persona de Mediana Edad , Quirófanos , Complicaciones Posoperatorias , Seguridad , Equipo QuirúrgicoRESUMEN
OBJECTIVE: We evaluated a combined technique designed for procedures requiring intraoperative language mapping. We planned to induce general anesthesia with endotracheal intubation and hyperventilation and then to awaken and extubate the patient for speech testing. After the latter, endotracheal reintubation and general anesthesia were planned. METHODS: With the patient under intravenously induced sedation, we topically anesthetized the airway with lidocaine that was delivered through a spraying catheter. Fiberoptic endotracheal intubation was then performed on the awake patient, using a modified endotracheal tube. General anesthesia with intravenous propofol or sodium thiopental was induced, the patient's head was attached to a Mayfield holder, and the pin and operative sites were infiltrated with 0.5% bupivacaine with epinephrine. In anticipation of speech mapping, general anesthesia was discontinued and lidocaine was injected into the catheter that was spirally attached to the endotracheal tube. After speech mapping, the awake patients were endotracheally intubated, guided with the fiberoptic laryngoscope or tube changer, and general anesthesia was induced and maintained until termination of the surgery. RESULTS: We did not observe any complications, such as coughing or head movements, during the preparation for general anesthesia, awakening and endotracheal extubation for speech mapping, and post-testing reintubation or induction of general anesthesia. CONCLUSION: The combined technique that we describe abolished the potential discomfort of surgical stimulation on a sedated patient, reduced the duration of wakefulness, and provided a secure airway and the means to hyperventilate our patients before dural opening.
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Anestesia General/métodos , Mapeo Encefálico , Lenguaje , Sueño/fisiología , Vigilia/fisiología , Adolescente , Adulto , Encéfalo/fisiopatología , Encéfalo/cirugía , Neoplasias Encefálicas/cirugía , Craneotomía , Diseño de Equipo , Femenino , Lóbulo Frontal/cirugía , Humanos , Periodo Intraoperatorio , Intubación Intratraqueal/instrumentación , Masculino , Ilustración Médica , Persona de Mediana Edad , Oligodendroglioma/cirugía , Convulsiones/fisiopatología , Convulsiones/cirugíaRESUMEN
Medical histories for 105 consecutive children who underwent selective posterior rhizotomy (SPR) were reviewed to determine the incidence and clinical significance of adverse events related to anaesthesia and surgery. No intraoperative or postoperative events with potential for lasting morbidity, nor life threatening events, were identified. Intraoperatively, the most common adverse events were moderate elevation of body temperature (13/105) and transient dysrhythmias (8/105). The most frequent postoperative complications were fever, marginal oxygen saturation in the absence of supplemental oxygen, and postcatheterization cystitis. Early surgical complications, such as wound infection, cerebrospinal fluid leak, haemorrhage, and bowel or bladder disturbance were absent in this series. Surgical technique and anaesthetic management are described.
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Complicaciones Intraoperatorias , Complicaciones Posoperatorias , Rizotomía/efectos adversos , Adolescente , Anestesia por Inhalación/métodos , Niño , Preescolar , Humanos , Monitoreo Intraoperatorio , Espasticidad Muscular/etiología , Espasticidad Muscular/cirugía , Estudios RetrospectivosRESUMEN
Children frequently undergo muscle biopsy for the workup of hypotonia under general anaesthesia which poses unique risks in patients with undiagnosed muscle disease. Mitochondrial myopathies are a relatively newly recognized cause of myopathy and multisystem disease in both adults and children. The diagnosis is complex. In addition to causing myopathy, there are metabolic derangements present in some cases that may be life-threatening. We present three cases of children with hypotonia where the diagnosis was suspected in two patients, and confirmed in the third. The question of whether patients with mitochondrial myopathies are at increased risk for developing malignant hyperthermia is discussed.
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Hipertermia Maligna/etiología , Miopatías Mitocondriales/complicaciones , Hipotonía Muscular/etiología , Anestesia General/efectos adversos , Preescolar , Femenino , Humanos , Miopatías Mitocondriales/diagnóstico , Factores de RiesgoRESUMEN
We describe a case of propylene glycol toxicity due to intravenous administration of etomidate for cerebral protection. A continuous etomidate infusion was titrated to burst suppression of the electroencephalogram during surgical resection of a large intracranial arteriovenous malformation. The etomidate formulation used (Amidate, Abbot) contains etomidate 2 mg/ml in a 35% propylene glycol vehicle. A total of 5 g/kg of the solvent was given during 12 h. Adverse effects of propylene glycol were observed including hyperosmolality with an increased osmolal gap, hemolysis, hemoglobinuria, and metabolic acidosis. Normalization of these metabolic and ionic alterations occurred after 12 h of discontinuation of the infusion. The potential toxicity of the solvent should be considered during long-term administration of etomidate.
Asunto(s)
Anestésicos Intravenosos/efectos adversos , Etomidato/efectos adversos , Complicaciones Intraoperatorias/inducido químicamente , Glicoles de Propileno/efectos adversos , Acidosis/sangre , Anestésicos Intravenosos/administración & dosificación , Angiografía , Análisis de los Gases de la Sangre , Niño , Electroencefalografía/efectos de los fármacos , Etomidato/administración & dosificación , Hemodinámica/efectos de los fármacos , Hemoglobinuria/inducido químicamente , Humanos , Infusiones Intravenosas , Malformaciones Arteriovenosas Intracraneales/cirugía , Complicaciones Intraoperatorias/orina , Masculino , Solventes/efectos adversosRESUMEN
There is little information available concerning the alterations in skeletal muscle energy metabolism which occur in response to chronic arterial occlusive disease. In addition, the effect of arterial reconstruction on skeletal muscle energy metabolism in patients with peripheral vascular disease has not been defined. Needle biopsies were obtained from the quadriceps femoris muscle of 7 patients with aortoiliac disease and 15 patients with femoropopliteal disease and from the gastrocnemius muscle of 9 patients with femoropopliteal disease. Muscle samples were analyzed for ATP, ADP, AMP, phosphocreatine, creatine, and lactate. Eleven patients were rebiopsied after vascular reconstruction. Patients with rest pain had decreased total adenine nucleotides, energy charge potential, and ATP/ADP ratios as compared to those of controls. ATP levels were significantly decreased in muscle samples obtained distal to the arterial occlusion (i.e., quadriceps/aortoiliac, gastrocnemius/femoropopliteal) in patients with rest pain (compared with controls). ATP levels did not differ significantly from those of controls in muscle samples obtained from patients with claudication. However, energy charge potential was significantly decreased in all patients with claudication regardless of biopsy site and location of arterial occlusive disease. Normalization of muscle energy metabolism was not demonstrated following arterial reconstruction. We conclude that resting skeletal muscle energy metabolism is abnormal in patients with chronic arterial insufficiency and that progression of disease toward more severe ischemia is associated with more marked derangement. Whether the possible beneficial effects of revascularization on muscle energy metabolism are masked by the concurrent effect of injury in the early postoperative period remains to be clarified.