Minim Invasive Neurosurg 2003; 46(4): 198-201
DOI: 10.1055/s-2003-42354
Original Article
© Georg Thieme Verlag Stuttgart · New York

Cardiovascular Changes During Endoscopic Third Ventriculostomy

J. van  Aken1 , M.  Struys1 , T.  Verplancke1 , L. de  Baerdemaeker1 , J.  Caemaert2 , E.  Mortier1
  • 1Department of Anesthesiology, University Hospital, University of Ghent, Belgium
  • 2Department of Neurosurgery, University Hospital, University of Ghent, Belgium
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
24. September 2003 (online)

Abstract

During an endoscopic third ventriculostomy (ETV) a sudden increase in intracranial pressure (ICP) may occur at any time. In the literature little attention has been paid to the early detection of such an increase. In particular the occurrence of a ‘Cushing reflex’ has not been discussed in this context. Therefore, we have now analysed retrospectively the anesthesia charts of 88 patients with obstructive hydrocephalus who had undergone ETV under general anesthesia. Monitoring included invasive blood pressure, electrocardiogram, end-expired carbon dioxide, pulse oximetry and heart rate. These variables were now evaluated before and after the introduction of the endoscope and during and after the occurrence of any change. In 67 patients the procedure had been uneventful. In 6 patients the occurrence of tachycardia and hypertension followed by bradycardia and hypertension was clearly the result of an increase in ICP, which we call a Cushing reflex. In his classical description of this pressure response Cushing reported the occurrence of hypertension, bradycardia and apnoea. However, many investigators have shown that beside systemic hypertension, both tachycardia and bradycardia are essential components of the Cushing reflex. Waiting for a persistent bradycardia to alert the surgeon during ETV can allow a fatal asystole.

References

  • 1 Murshid W R. Endoscopic third ventriculostomy: towards more indications for the treatment of non-communicating hydrocephalus.  Minim Invas Neurosurg. 2000;  43 75-82
  • 2 EI-Dawlatly A A, Murshid W R, Elshimy Magboul M A, Samarkandi A, Takrouri M S. The incidence of bradycardia during endoscopic third ventriculostomy.  Anesth Analg. 2000;  91 1142-1144
  • 3 EI-Dawlatly A A, Murshid W R, EI-Khwsky F. Endoscopic third ventriculostomy: a study of intracranial pressure versus haemodynamic changes.  Minim Invas Neurosurgery. 1999;  42 198-200
  • 4 Fàbregas N, López A, Valero R, Carrero E, Caral L, Ferrer E. Anaesthetic management of surgical endoscopies - usefulness of monitoring the pressure inside the neuroendoscope.  J Neurosurg Anesthesiol. 2000;  12 21-28
  • 5 Fàbregas N, Valero R, Carrero E, Tercero J, Caral L, Zevala E, Ferrer E. Episodic high irrigation pressure during surgical neuroendoscopy may cause intermittent intracranial circulatory insufficiency.  J Neurosurg Anesthesiol. 2001;  123 152-157
  • 6 Caemaert J, Abdullah J, Calliauw L, Carton D, Dhooge C, van Coster R. Endoscopic treatment of suprasellar arachnoid cysts.  Acta Neurochir (Wien). 1992;  119 68-73
  • 7 Webster D E, Lopez K. Neonatal and infant anatomy and physiology. In: Rasch DK, Webster DE (eds.). Clinical manual of paediatric anaesthesia. New York: McGraw-Hill, Inc 1994: 14-26
  • 8 Ingelfinger J R. Systemic hypertension. In: Adams FH, Emmanonilides GC, Riemenschneider TA (eds.). Moss' Heart disease in infants, children and adolescents. Baltimore USA: Williams & Wilkins 1989: 1016-1031
  • 9 Cushing H. Concerning a definite regulatory mechanism of the vaso-motor centre which controls blood pressure during cerebral compression.  Johns Hopkins Hosp Bull. 1901;  12 290-292
  • 10 Heymans C. The control of heart rate consequent to changes in the cephalic blood pressure and in the intracranial pressure.  Amer J Physiol. 1928;  85 498-505
  • 11 Graf C I, Rossi N P. Catecholamine response to intracranial hypertension.  J Neurosurg. 1978;  49 862-868
  • 12 Hunter A R. Neurosurgical anaesthesia. Oxford: Blackwell Scientific Publications 1964: 42-57
  • 13 Brown R S, Mohr P A, Carey J S, Shoemaker W C. Cardiovascular changes after cranial cerebral injury and increased intracranial pressure.  Surg Gynecol Obstet. 1967;  125 1205-1211
  • 14 Domino K B. Pathophysiology of head injury: secondary systemic effects. In: Lam AM (ed.). Anaesthetic management of acute head injury. New York: McGraw-Hill, Inc 1995: 25-58
  • 15 Lorenz R. The Cushing response. In: Beks JWF, Bosch DA, Brock M (ed.). Intracranial pressure III. Berlin, Heidelberg, New York: Springer Verlag 1976: 270-278
  • 16 Cushing H. The blood pressure reaction of acute cerebral compression, illustrated by cases of intracranial hemorrhage.  Am J Med Sci. 1903;  125 1017-1044
  • 17 Hall S RR, Wang L, Milne B, Ford S, Hong M. Intrathecal lidocaine presents cardiovascular collaps and neurogenic pulmonary edema in a rat model of acute intracranial hypertension.  Anesth Analg. 2002;  94 948-953
  • 18 Edwards N. Principles and Practice of Neuro-anaesthesia. London, New York: Chapman and Hall Medical 1991: 1-25
  • 19 Handler M M, Abbott R, Lee M. A near-fatal complication of endoscopic third ventriculostomy: case report.  Neurosurgery. 1994;  35 525-528
  • 20 Leusen I. Ions alcalino-terreux, liquide céphalo-rachidien et système nerveux central. In: Eichler O, Farah A (ed.). Handbuch der experimentellen Pharmakologie. Berlin, Göttingen, Heidelberg, New York: Springer Verlag 1964: 501-528
  • 21 Leusen I. Balancement entre les influences vasomotrices des concentrations intraventriculaires de calcium, potassium et magnésium.  J Physiol. 1950;  42 157-168
  • 22 Fàbregas N, Craen R A. Anaesthesia for minimal invasive neurosurgery. In: Van Aken H (ed.). Clinical Anaesthesiology.  Baillière Tindall and Elsevier Science Company. 2002;  16 81-93

Jozef van Aken

Department of Anesthesiology · University Hospital

De Pintelaan 185

9000 Gent

Belgium

Fax: +32-9-240-4987

eMail: Jozef.Vanaken@ugent.be