Neuro-Radiology, Interventional

Updated April 2, 2014   Author: X. Abess MD

Description: Management of cranial lesions in (interventional) Radiology

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Basic Information

  1. Location:
    • IR (formerly, and perhaps still referred to as, the Angiography Suite)
    • Phone # Angio Suite 662-4540
  2. Proceduralists: Robert Ecker, Chris Baker
  3. PreOp preparation:
    • Elective cases seen in PAT: NPO, etc
    • Urgent Cases may already be admitted / in SCU.
  4. Types of Cases, Usual Management:
    • Aneurysms: GA +/- arterial line
    • AVMalformations: MAC +/- arterial line (infusions likely necessary for sedation/stillness as well as BP management)
    • AV fistulas: MAC
    • Stroke: MAC vs. GA depending on clinical situation + arterial line
    • Carotid Stents: MAC + arterial line (vasopressors after stenting)
      • Dr. Baker has really only been using arterial lines with AVM embolizations
  5. Get controlled meds from Radiology Pyxis (ask Radiology Nurse)
  6. A second IV is helpful for vasoactive infusions; manifold if multiple drugs anticipated
  7. Have syringe pump or IV Infusion pump (Plum, Symbiq) available.
  8. Anesthesia Tech assistance: Phone 662-1761

Communication:

  1. Always speak with the proceduralist to get a good picture of the clinical situation and discuss any potential variations from the above preconceptions
  2. Always ask the proceduralist about desired goals for hemodynamics

Management:

  1. Be prepared for:
    • conversion to General Anesthesia
    • the need to increase monitoring (i.e. arterial line)
  2. Vasoactive Drugs (bolus and infusions) that you may need:
    • phenylephrine (80mcg/ml)
    • nitroglycerin 50mg-100mg / 250cc D5W (0.3-10 mcg/kg/min)
    • nicardipine can be an excellent choice for BP control (either as bolus or infusion -- and Dr. Ecker also likes it).
      • must be ordered from Pharmacy [20mg in 200cc, 0.1mg/cc]
      • usual starting dose 5mg/hr
      • titrate up or down (often in 2.5mg/hr increments)
    • nitroprusside 50mg / 250cc D5W (0.3-10 mcg/kg/min)
  3. Sedation:
    • Dexmedetomidine can also be considered for long MACs (or as an adjunct for BP control at emergence during GA).
      • Consider omitting the loading dose in order to avoid some of the hemodynamic issues (bradycardia, hypotension/hypertension).
      • Consider starting at a relatively low dose (0.1 or 0.2 mcg/kg/hr), but this can be increased depending on needs (can go as high as 0.7mcg/kg/hr) – exercise caution on escalating too rapidly.
  4. Complications:
    • Catastrophic Intra-op rupture/bleeding may occur.
      Anesthesiologist interventions are aimed at:
      • decreasing ICP, and
      • immediate reversal of heparinization.
      • Therapy can include hyperventilation, further decrease of BP, protamine, STP, mannitol, Dilantin, Decadron, etc.
    • Intra-op stroke/occlusion: you may be asked to elevate SBP 30-40% above baseline to augment perfusion distal to occlusion

Disposition:

  1. Always discuss post-anesthetic disposition
    • If GA, will the patient be extubated and awakened for a prompt neuro exam?
    • PACU or ICU?
    • Hemodynamic or positional concerns post-op?
  2. Dr. Ecker may ask for the “magic anti-nausea recipe”. It’s really just all of our anti-emetic tricks combined:
    • ondansetron 4mg
    • dexamethasone 4-10mg
    • haloperidol 0.5mg
    • low dose prop gtt (20-25mcg/kg/min)
    • metoclopramide 5mg

Stroke, Acute Ischemic: Additional Considerations

  1. In acute ischemic stroke cases, please be mindful of time and assist in enabling the procedure to begin expediently. “Time is brain”.
  2. Potential therapeutic interventions include:
    • chemical thrombolysis
    • mechanical thrombectomy/clot retrieval
    • stenting
    • combination of therapies
  3. Data shows improved outcomes if treatment occurs sooner (ideally within 3 hours of symptom onset)
  4. Other recommended guidelines during stroke cases include:
    • Avoid hypertension (<185/110) to decrease risk of hemorrhage with rTPA administration
    • Hypotension should also be avoided
    • Normoglycemia (80-140mg/dL)

References

  1. Anesthesia for Outpatient Diagnostic or Therapeutic Radiology
    Cutter, ASA Refresher Courses 2013 (pdf)