Planning of anesthesia for craniotomy must emphasize hemodynamic stability, a sufficient cerebral perfusion pressure (CPP), and avoidance of agents or procedures that increase intracranial pressure (ICP), which results in swelling of cerebral tissue. An open-label study compared the effects of propofol, isoflurane, and sevoflurane on ICP and cerebral hemodynamics in patients undergoing elective craniotomy. Patients eligible for enrollment were 117 adults with supratentorial cerebral tumors and without clinical signs of arterial hypertension or chronic pulmonary insufficiency. The randomized groups received propofol-fentanyl, isofluranefentanyl, or sevoflurane-fentanyl anesthesia. Infusion rates of the agents were unchanged in each group during ICP measurements and during the neurosurgeon’s estimate of dural swelling (while blinded to choice of anesthesia and ICP value). When needed, mean arterial blood pressure was stabilized with IV ephedrine (2.5–5 mg). Patients were monitored for subdural ICP, mean arterial blood pressure (MAP), CPP, arteriovenous oxygen difference (AVDO2), and internal jugular vein oxygen saturation before and after a 10-min period of hyperventilation. Carbon dioxide reactivity was calculated as percent change of AVDO2/Ä PaCO2 (in mm Hg). The 3 groups were comparable in demographics, neuroradiologic examination, positioning of the head, and time to ICP measurement. Compared with the isoflurane and sevoflurane groups, the propofol group had markedly lower ICP and markedly higher MAP and CPP both before and during hyperventilation. The tension of the dura before and during hyperventilation was notably lower in the propofol group compared with the isoflurane group. Cerebral swelling after opening of the dura was lowest in the propofol group, and this group showed important differences in AVDO2 (higher) and in jugular vein saturation and carbon dioxide reactivity (both lower) when compared with isoflurane and sevoflurane groups. In these patients undergoing craniotomy for cerebral tumors, subdural ICP and the incidence of brain swelling after opening of the dura were both markedly lower during propofol-fentanyl anesthesia than during isoflurane-fentanyl and sevoflurane-fentanyl anesthesia. In this setting, operating conditions are better when propofol in used.

Background A critical point during craniotomy is opening of dura, where a high intracranial pressure (ICP) results in swelling of cerebral tissue. Controlled studies concerning ICP, degree of dural tension, and degree of cerebral swelling are therefore warranted. Methods In an open-label study, 117 patients with supratentorial cerebral tumors were randomized to propofol-fentanyl (group 1), isoflurane-fentanyl (group 2), or sevoflurane-fentanyl anesthesia (group 3). Normo- to moderate hypocapnia was applied, with a target level of arterial carbon dioxid tension of 30–40 mmHg. Mean arterial blood pressure was stabilized with intravenous ephedrine (2.5–5 mg) if necessary. Subdural ICP, mean arterial blood pressure, cerebral perfusion pressure (CPP), arteriovenous oxygen difference (AVDo2), internal jugular vein oxygen saturation were monitored before and after a 10-min period of hyperventilation, and the carbon dioxide reactivity was calculated. Furthermore, the tension of dura before and during hyperventilation and the degree of cerebral swelling during hyperventilation and after opening of the dura were estimated by the neurosurgeon. Results No differences were found between groups with regard to demographics, neuroradiologic examination, positioning of the head, and time to ICP measurement. Before and during hyperventilation, ICP was significantly lower and mean arterial blood pressure and CPP significantly higher in group 1 compared with groups 2 and 3 (P < 0.05). The tension of dura before and during hyperventilation was significantly lower in group 1 compared with group2 (P < 0.05), but not significantly different from group 3. In group 1, cerebral swelling after opening of dura was significantly lower compared with groups 2 and 3 (P < 0.05). Furthermore, AVDo2 was significantly higher and jugular vein oxygen saturation and carbon dioxide reactivity were significantly lower in group 1 compared with groups 2 and 3 (P < 0.05). No significant differences with regard to ICP, CPP, AVDo2, carbon dioxide reactivity, and jugular vein oxygen saturation were found between patients anesthetized with isoflurane and sevoflurane. Conclusions The study indicates that before as well as during hyperventilation, subdural ICP and AVDo2 are lower and CPP higher in propofol-anesthetized patients compared with patients anesthetized with isoflurane or sevoflurane. These findings were associated with less tendency for cerebral swelling after opening of dura in the propofol group. The carbon dioxide reactivity in patients anesthetized with isoflurane and sevoflurane was significantly higher than in the propofol group. The differences in subdural ICP between the groups are presumed to be caused by differences in the degree of vasoconstriction elicited by the anesthetic agents, but autoregulatory mechanisms caused by differences in CPP cannot be excluded.

Background A critical point during craniotomy is opening of dura, where a high intracranial pressure (ICP) results in swelling of cerebral tissue. Controlled studies concerning ICP, degree of dural tension, and degree of cerebral swelling are therefore warranted. Methods In an open-label study, 117 patients with supratentorial cerebral tumors were randomized to propofol-fentanyl (group 1), isoflurane-fentanyl (group 2), or sevoflurane-fentanyl anesthesia (group 3). Normo- to moderate hypocapnia was applied, with a target level of arterial carbon dioxid tension of 30-40 mmHg. Mean arterial blood pressure was stabilized with intravenous ephedrine (2.5-5 mg) if necessary. Subdural ICP, mean arterial blood pressure, cerebral perfusion pressure (CPP), arteriovenous oxygen difference (AVDo2), internal jugular vein oxygen saturation were monitored before and after a 10-min period of hyperventilation, and the carbon dioxide reactivity was calculated. Furthermore, the tension of dura before and during hyperventilation and the degree of cerebral swelling during hyperventilation and after opening of the dura were estimated by the neurosurgeon. Results No differences were found between groups with regard to demographics, neuroradiologic examination, positioning of the head, and time to ICP measurement. Before and during hyperventilation, ICP was significantly lower and mean arterial blood pressure and CPP significantly higher in group 1 compared with groups 2 and 3 (P < 0.05). The tension of dura before and during hyperventilation was significantly lower in group 1 compared with group2 (P < 0.05), but not significantly different from group 3. In group 1, cerebral swelling after opening of dura was significantly lower compared with groups 2 and 3 (P < 0.05). Furthermore, AVDo was significantly higher and jugular vein oxygen saturation and carbon dioxide reactivity were significantly lower in group 1 compared with groups 2 and 3 (P < 0.05). No significant differences with regard to ICP, CPP, AVDo, carbon dioxide reactivity, and jugular vein oxygen saturation were found between patients anesthetized with isoflurane and sevoflurane. Conclusions The study indicates that before as well as during hyperventilation, subdural ICP and AVDo2 are lower and CPP higher in propofol-anesthetized patients compared with patients anesthetized with isoflurane or sevoflurane. These findings were associated with less tendency for cerebral swelling after opening of dura in the propofol group. The carbon dioxide reactivity in patients anesthetized with isoflurane and sevoflurane was significantly higher than in the propofol group. The differences in subdural ICP between the groups are presumed to be caused by differences in the degree of vasoconstriction elicited by the anesthetic agents, but autoregulatory mechanisms caused by differences in CPP cannot be excluded.

Propofol is a cerebral vasoconstrictor while inhalation anaesthetics like isoflurane and sevoflurane act as cerebral vasodilators in both animal and human studies. This difference of action upon cerebral vessels might implicate a lower ICP during propofol anaesthesia. Cerebral metabolism is decreased by all three anaesthetics. In a prospective, randomised multicenter study ICP was compared during anaesthesia with propofol, isoflurane and sevoflurane.

We conducted a randomized, prospective, double-blind trial to compare the efficacy of subfascial (SF) versus subcutaneous (SC) lidocaine (10 mL 1%) given in the wound postoperatively through a catheter placed in the respective layer intraoperatively. The initial pain scores were similar in the two groups before injection of lidocaine. In the SC group, there was a reduction in pain scores during rest from 4 to 3 (P > 0.05), during cough from 6 to 5 (P > 0.05), and during mobilization from 7 to 5.5 (P > 0.05) at 15 min. In the SF group, the reductions in pain scores were from 4 to 2 (P < 0.05), from 6 to 3 (P < 0.05), and from 7 to 3 (P < 0.05), respectively. Supplemental analgesics after the lidocaine administration were needed earlier in the SC group than in the SF group (P < 0.01). We conclude that postoperative pain treatment with local lidocaine application after herniotomy has a better effect when applied in the SF, rather than the SC, layer.

A series of 53 patients was studied using a battery of tests and a neurobehavioral rating scale on average 4 months after closed-head injury (CHI). Social outcome was assessed 1 year after injury by interviewing a family member. The results supported the hypothesis that tests of flexibility and programming rather than tests of cognitive skills predict psychosocial recovery after CHI. Spatial Learning with Self-Set Goals and Sorting were measures of flexibility and programming. Contrary to expectation, word fluency performance was unrelated to these measures, but was associated with conventional intelligence tests, which did not predict psychosocial recovery. Cognition/Energy deficit on the Neurobehavioral Rating Scale and increased age were useful predictors of poor psychosocial outcome, whereas computed tomography findings or the Glasgow Coma Score were weakly related to the outcome indices. Evidently, cognitive flexibility and mental programming are very important psychological prerequisites of social recovery after CHI.

It was predicted that frontal lobe damaged patients are slower on word fluency tasks, especially on the generation of words beginning with a particular letter, and less flexible (“stuck-in-set”) on category alternation than patients with posterior lesions, whereas the latter commit a higher number of repetitions (“recurrent perseverations”) than the former. Twenty-nine anterior and 31 posterior brain damaged patients were requested to say as quickly as possible (1) 20 animal names, (2) 10 words beginning with the letter S, and (3) alternately animals and S-words, 10 from each category without repeating the words already used in these tasks. The results failed to confirm the predictions.

Computed tomography (CT) findings from early (less than 24 hours) and late scan (6 months) after closed-head injury (CHI) were compared to cognitive test scores obtained on an average of 4 months after injury in a consecutive series of 53 patients. The presence of parenchymal lesion was associated with poor test results, indicating cognitive inflexibility and disinhibition of routine response tendencies in novel tasks. These deficits have previously been found to be related in particular to frontal-lobe dysfunction, but the present study did not support the hypothesis that frontal lesion is the principal cause of this impairment in CHI. Parenchymal lesions in the right and left hemisphere were associated with spatial and verbal deficits, respectively. Ventricular enlargement in the late CT was related to cognitive inefficiency, both being strongly associated with age. The results suggest that parenchymal lesion in the early CT is an indicator of diffuse axonal injury, which results in cognitive inflexibility during recovery.

The aim of this study was to demonstrate that the inability to set adequate sub-goals in a cognitive task is a sensitive indicator of programming deficit after frontal lobe lesion. Sixty-one patients with focal cerebral lesions and 25 control subjects were studied with a modified Digit Symbol task, in which the score depended on the adequacy of the sub-goals set by the subject. This score was compared to that on the standard condition, in which the subject was requested to work as quickly as possible without self-selected goals. The results confirmed the prediction that patients with anterior lesions set less adequate sub-goals than patients with posterior lesions and, unlike the latter patients, have a more pronounced deficit on the performance with self-selected goals than on the standard condition. In particular patients with left frontal lobe lesions underestimated their capabilities in relation to task requirements.

A series of 83 patients was examined with a battery of cognitive tests, a clinical interview, and computed tomography 1 year after surgery for a ruptured intracranial aneurysm. Disability on the Glasgow Outcome Scale (33%), failure to return to work (25%), impaired social relations (25%), and subjective or clinical mental impairment (56%) were found to be related to each other and to poor performance on cognitive tests, especially to verbal impairments in patients with left lateral infarctions and to memory deficits and cognitive inflexibility in patients with frontal medial infarctions. Furthermore, cognitive deficits and poor outcome were associated with diffuse brain damage. Depression and anxiety were unrelated to test performances, but were frequently reported by patients with right lateral infarctions.

Seventy-seven brain damaged patients and 14 control subjects performed a visual memory test in which the subjects had to reproduce geometric figures from memory after studying the design for 10 seconds (standard condition) and after an observation period subjectively necessary and sufficient for accurate reproduction (self-timed condition). The brain damaged patients were less efficient than the control subjects on the self-timed acquisition even when the covariance on the standard condition was taken into account. The prediction that frontal lobe damaged patients are inferior to posterior brain damaged patients on the speed-accuracy optimization of acquisition was true only in the right hemisphere damaged patients on the simple trials, suggesting that right frontal lobe damage disturbs voluntary attention. Visuospatial errors were typical for right hemisphere damaged patients, perseverations for left frontal lobe damaged patients.

Patients with anterior or posterior brain damage and control subjects performed a spatial sequence learning task in which the score obtained depended on the subject's ability to set sub-goals appropriate for his learning capacity. The anterior group obtained lower scores and more frequently set inadequate sub-goals than the posterior group. No anterior vs posterior difference was found on a similar learning task in which another sequence was learnt by predetermined sub-goals. The result supported the hypothesis that frontal lobe lesions disturb programming or goal-based search for action structure on spatial learning.

A consecutive series of 118 patients operated on for ruptured intracranial arterial aneurysms was studied. Ninety-six of them could be adequately examined with a battery of psychological tests and computed tomographic scans 1 year after a subarachnoid hemorrhage. Seventeen orthopedic control patients with no history of brain damage were also tested. The pattern of cognitive deficits was strongly related to the findings on the computed tomographic scans. Patients with left lateral infarctions had deficits on performances requiring verbal efficiency, including memory and classification tasks, whereas patients who had right lateral infarctions were poor on a visuoconstructional task (the copying of Rey's Figure). These deficits were pronounced when lateral infarction was associated with diffuse brain damage. Patients with frontal medial infarctions had low scores on memory tests; the inefficiency in verbal fluency, categorical reasoning, and memory was related to diffuse brain damage. The patients who had no infarctions did not differ significantly from the control group. Cognitive impairments after left lateral and frontal medial infarctions, as well as diffuse brain damage, correlated with the Glasgow Outcome Scale.