Lehecka|Laakso|HernesniemiHelsinkiMicroneurosurgery|BasicsandTricksDepartment of NeurosurgeryEst. 1932University of HelsinkiFinlandDepartment of NeurosurgeryEst. 1932University of HelsinkiFinlandHelsinki MicroneurosurgeryBasics and TricksMartin Lehecka, Aki Laaksoand Juha HernesniemiForeword by Robert F. SpetzlerDepartment of NeurosurgeryEst. 1932University of HelsinkiFinlandDepartment of NeurosurgeryEst. 1932University of HelsinkiFinlandDepartment of Neurosurgery at Helsinki University, Finland, led by its chairman JuhaHernesniemi, has become one of the most frequently visited neurosurgical units in theworld. Every year hundreds of neurosurgeons come to Helsinki to observe and learnmicroneurosuergery from Professor Juha Hernesniemi and his team.In this book we want to share the Helsinki experience on conceptual thinking behindwhat we consider modern microneurosurgery. We want to present an up-to-datemanual of basic microneurosurgical principles and techniques in a cook book fashion.It is our experience that usually the small details determine whether a particularsurgery is going to be successful or not. To operate in a simple, clean, and fast waywhile preserving normal anatomy has become our principle in Helsinki.
Helsinki MicroneurosurgeryBasics and TricksBy Martin Lehecka, Aki Laakso and Juha HernesniemiDepartment of NeurosurgeryEst. 1932University of HelsinkiFinlandDepartment NeurosurgeryEst. 1932HelsinkiUniversity Central HospitalFinlandCollaborators:Özgür ÇelikReza DashtiMansoor ForoughiKeisuke IshiiAyse KaratasJohan MarjamaaOndrej NavratilMika NiemeläTomi NiemiJouke S. van PoptaTarja RandellRossana RomaniRitva SalmenperäRod SamuelsonFelix ScholtesPäivi TanskanenPhotographs:Jan BodnárMansoor ForoughiAntti HuotarinenAki LaaksoVideo editing:Jouke S. van PoptaDrawings:Hu ShenHelsinki, Finland 2011
Every man owes it as a debt to his profession to put on record whateverhe has done that might be of use for others.Francis Bacon (1561-1626)Simple, clean, while preserving normal anatomy. Clean is fast andeffective. Surgery is art - you should be one of the artists.Juha Hernesniemi
AcknowledgementsThe authors would like to thank Aesculap, a B. Braun company, for kindly supporting printing ofthis book, with special thanks to Ingo vom Berg, Bianca Bauhammer and Outi Voipio-Airaksinen.In addition, the authors want to express their gratitude to the administration of Helsinki Univer-sity Central Hospital for their support over the past years.
FOREWORDby Robert F. SpetzlerFortunate are the neurosurgeons who have theopportunity to visit the Department of Neu-rosurgery at the Helsinki University CentralHospital and receive this delightful volume asa souvenir for it is likely to be one of the mostcharming books they will ever read about neu-rosurgery. As the title indicates, Drs. Lehecka,Laakso, and Hernesniemi have written aboutneurosurgery as performed in Helsinki. How-ever, they have done so much more than that —they have captured the deeply rooted spirit ofcamaraderie and commitment that has helpedbuild Helsinki into an international center ofneurosurgical excellence under the leadershipof Juha Hernesniemi and his colleagues. Nor isthe term international an overstatement whenapplied to a department in this far northernclime. Indeed, their list of distinguished visi-tors reads like an international Whos Who ofNeurosurgery.One can almost hear the Finnish cadences asthe authors share amusing vignettes (althoughsome were likely to have been alarming at thetime of their occurrence) from the history ofFinnish neurosurgery. More importantly, read-ers cannot miss the natural warmth, honesty,and integrity of these authors in their discus-sions of Helsinki philosophies, routines, andpractices. These qualities are underscored byseveral essays contributed by a variety of train-ees who each provide entertaining accounts oftheir time spent in Helsinki. That their liveswere altered profoundly by the experience isunmistakable. Juhas taciturn but gentle hu-mor, his intense devotion to perfecting his sur-gical expertise to better serve his patients, andhis dedication to mentoring inspire a lifelongadmiration and loyalty among his trainees andcolleagues. Of course, readers will find con-siderable practical advice on the fundamentalpractice of neurosurgery in chapters devoted toprinciples of microneurosurgery, approaches,specific strategies for treating various patholo-gies, and neuroanesthesiology. Especially important points are summarizedunder the heading, T&T, that is, Tricks and Tipsfrom Juha-Helsinki pearls. Seasoned surgeonswill benefit from analyzing how their own sur-gical style differs from that of Juhas.Every detail of the Helsinki approach to neu-rosurgery is covered, including how Juha ex-pects his operating room to run to lists of hispersonal habits and instruments intended toensure that his coworkers understand how hisoperations will proceed. The advantages to pa-tients of such a finely tuned team, sensitive tothe surgeons needs and expectation, shouldnever be underestimated. This refined team-work ensures that neurosurgical procedures arecompleted in as efficient and safe manner as ispossible, thereby optimizing the chances of agood outcome for the patient. Juhas ability topromote such precision teamwork is but one ofhis amazing talents.Juha is truly a master neurosurgeon and to beable to experience his passion for, insight into,and dedication to neurosurgery is a rare privi-lege. His philosophy of simple, clean, and fastsurgery that preserves normal anatomy is onethat we all should emulate. By sharing both hisexpertise and his humanity in this volume, Juhalights a Socratic path worth following, a pathbased on respect and tolerance for differentapproaches that encourages growth while stillrespecting proven expertise. Those fortunateenough to visit Helsinki experience these rarequalities firsthand; those unable to make thatpilgrimage can still count themselves lucky toread this volume. Robert F. Spetzler, MDPhoenix, Arizona; November 2010
Table of Contents1. INTRODUCTION 132. DEPARTMENT OF NEUROSURGERY, HELSINKI UNIVERSITY CENTRAL HOSPITAL 17 2.1. HISTORY OF NEUROSURGERY IN HELSINKI AND FINLAND 17 2.1.1. Aarno Snellman, founder of Finnish neurosurgery 17 2.1.2. Angiography in Finland 18 2.1.3. World War II and late 1940’s 19 2.1.4. Microneurosurgery and endovascular surgery 20 2.1.5. Changes towards the present time 21 2.2. PRESENT DEPARTMENT SETUP 24 2.3. STAFF MEMBERS 24 2.3.1. Neurosurgeons 25 2.3.2. Neurosurgical residents 30 2.3.3. Neuroanesthesiologists 30 2.3.4. Neuroradiologists 31 2.3.5. Bed wards 32 2.3.6. Intensive care unit (ICU) 34 2.3.7. Operating rooms 36 2.3.8. Administrative personnel 37 2.4. OPERATING ROOM COMPLEX 40 2.4.1. Operating room complex design 40 2.4.2. Operating room ambience 413. ANESTHESIA 45 3.1. GENERAL PHYSIOLOGICAL PRINCIPLES AND THEIR IMPACT ON ANESTHESIA 46 3.1.1. Intracranial pressure 46 3.1.2. Autoregulation of cerebral blood flow 47 3.1.3. CO2reactivity 48 3.1.4. Cerebral metabolic coupling 49 3.2. MONITORING OF ANESTHESIA 50 3.3. PREOPERATIVE ASSESSMENT AND INDUCTION OF ANESTHESIA 51 3.4. MAINTENANCE OF ANESTHESIA 53 3.5. TERMINATION OF ANESTHESIA 55 3.6. FLUID MANAGEMENT AND BLOOD TRANSFUSIONS 56 3.7. ANESTHESIOLOGICAL CONSIDERATIONS FOR PATIENT POSITIONING 57 3.7.1. Supine position 57 3.7.2. Prone, lateral park bench and kneeling positions 58 3.7.3. Sitting position 62 3.8. POSTOPERATIVE CARE IN THE ICU 63 3.9. SPECIAL SITUATIONS 65 3.9.1. Temporary clipping in aneurysm surgery 65 3.9.2. Adenosine and short cardiac arrest 66 3.9.3. Intraoperative neurophysiologic monitoring 66 3.9.4. Antithrombotic drugs and thromboembolism 674. PRINCIPLES OF HELSINKI MICRONEUROSURGERY 69 4.1. GENERAL PHILOSOPHY 69 4.2. PRINCIPLES OF MICRONEUROSURGERY 70 4.3. OPERATING ROOM SETUP 71 4.3.1. Technical setup 71 4.3.2. Displays 72 4.4. POSITIONING AND HEAD FIXATION 73 4.4.1. Operating table 73 4.4.2. Patient positioning 73 4.4.3. Neurosurgeon’s position and movement 74 4.4.4. Head fixation 76 4.5. NECESSARY OR USEFUL TOOLS 77 4.5.1. Operating microscope 77 4.5.2. Armrest 79 4.5.3. Bipolar and diathermia 79 4.5.4. High speed drill 80 4.5.5. Ultrasonic aspirator 82 4.5.6. Fibrin glue 83 4.5.7. Indocyanine green angiography 84 4.5.8. Microsurgical doppler and flowmeter 85 4.5.9. Neuronavigator 86 4.5.10. Intraoperative DSA 87 4.6. MICROINSTRUMENTS 88 4.7. SOME HABITS IN PREPARATION AND DRAPING 90 4.8. GENERAL PRINCIPLES OF CRANIOTOMY 92 4.9. BASIC MICROSURGICAL PRINCIPLES OF HELSINKI STYLE MICRONEUROSURGERY 94 4.9.1. Simple, clean, fast and preserving normal anatomy 94 4.9.2. Movements under the microscope 95 4.9.3. Moving the microscope 98 4.9.4. Left hand – suction 99 4.9.5. Right hand 100 4.9.6. Bipolar forceps 101 4.9.7. Microscissors 102 4.9.8. Cottonoids 102 4.9.9. Sharp and blunt dissection 103 4.9.10. Irrigation and water dissection 103 4.9.11. Minimal retraction 104
4.10. CLOSING 104 4.11. KEY FACTORS IN HELSINKI STYLE MICRONEUROSURGERY 105 4.12. LIST OF PROF. HERNESNIEMI’S GENERAL HABITS AND INSTRUMENTS 1065. COMMON APPROACHES 111 5.1. LATERAL SUPRAORBITAL APPROACH 111 5.1.1. Indications 111 5.1.2. Positioning 112 5.1.3. Incision and craniotomy 113 5.2. PTERIONAL APPROACH 118 5.2.1. Indications 118 5.2.2. Positioning 119 5.2.3. Incision and craniotomy 119 5.3. INTERHEMISPHERIC APPROACH 124 5.3.1. Indications 124 5.3.2. Positioning 125 5.3.3. Incision and craniotomy 125 5.4. SUBTEMPORAL APPROACH 132 5.4.1. Indications 132 5.4.2. Positioning 133 5.4.3. Skin incision and craniotomy 135 5.5. RETROSIGMOID APPROACH 144 5.5.1. Indications 145 5.5.2. Positioning 146 5.5.3. Skin incision and craniotomy 149 5.6. LATERAL APPROACH TO FORAMEN MAGNUM 156 5.6.1. Indications 156 5.6.2. Positioning 156 5.6.3. Skin incision and craniotomy 157 5.7. PRESIGMOID APPROACH 160 5.7.1. Indications 160 5.7.2. Positioning 162 5.7.3. Skin incision and craniotomy 162 5.8. SITTING POSITION – SUPRACEREBELLAR INFRATENTORIAL APPROACH 170 5.8.1. Indications 171 5.8.2. Positioning 173 5.8.3. Skin incision and craniotomy 177 5.9. SITTING POSITION – APPROACH TO THE FOURTH VENTRICLE AND FORAMEN MAGNUM REGION 183 5.9.1. Indications 183 5.9.2. Positioning 183 5.9.3. Skin incision and craniotomy 1836. SPECIFIC TECHNIQUES AND STRATEGIES FOR DIFFERENT PATHOLOGIES 195 6.1. ANEURYSMS 195 6.1.1. Approaches for different aneurysms 195 6.1.2. General strategy for ruptured aneurysms 196 6.1.3. General strategy for unruptured aneurysms 197 6.1.4. Release of CSF and removal of ICH 197 6.1.5. Dissection towards the aneurysm 199 6.1.6. Opening of the Sylvian fissure 200 6.1.7. Temporary clipping 201 6.1.8. Final clipping and clip selection 203 6.1.9. Intraoperative rupture 203 6.1.10. Adenosine 206 6.2. ARTERIOVENOUS MALFORMATIONS 207 6.2.1. General strategy in AVM surgery 207 6.2.2. Preoperative embolization 207 6.2.3. Approaches 208 6.2.4. Dural opening and initial dissection 208 6.2.5. Further dissection and use of temporary clips 210 6.2.6. Coagulation and dissection of small feeders 211 6.2.7. Final stage of AVM removal 212 6.2.8. Final hemostasis 212 6.2.9. Postoperative care and imaging 212 6.3. CAVERNOMAS 214 6.3.1. General strategy in cavernoma surgery 214 6.3.2. Intraoperative localization 214 6.3.3. Approaches 215 6.3.4. Dissection and removal 216 6.3.5. Postoperative imaging 217 6.4. MENINGIOMAS 218 6.4.1. General strategy with convexity meningiomas 218 6.4.2. General strategy with parasagittal meningiomas 219 6.4.3. General strategy with falx and tentorium meningiomas 221 6.4.4. General strategy with skull base meningiomas 222 6.4.5. Tumor consistency 224 6.4.6. Approaches 224 6.4.7. Devascularization 225 6.4.8. Tumor removal 225 6.4.9. Dural repair 226 6.5. GLIOMAS 227 6.5.1. General strategy with low-grade gliomas 227 6.5.2. General strategy with high-grade gliomas 228 6.5.3. Approaches 229
6.5.4. Intracranial orientation anddelineation of the tumor 2296.5.5. Tumor removal 2306.6. COLLOID CYSTS OF THE THIRD VENTRICLE 2316.6.1. General strategy with colloid cystsurgery 2316.6.2. Positioning and craniotomy 2316.6.3. Interhemispheric approach andcallosal incision 2326.6.4. Colloid cyst removal 2336.7. PINEAL REGION LESIONS 2346.7.1. General strategy with pineal regionsurgery 2346.7.2. Approach and craniotomy 2356.7.3. Intradural approach 2356.7.4. Lesion removal 2356.8. TUMORS OF THE FOURTH VENTRICLE 2366.8.1. General strategy with fourthventricle tumors 2366.8.2. Positioning and craniotomy 2376.8.3. Intradural dissection towards thefourth ventricle 2376.8.4. Tumor removal 2386.9. SPINAL INTRADURAL TUMORS 2406.9.1. General strategy with intraduralspinal lesions 2406.9.2. Positioning 2416.9.3. Approach 2426.9.4. Intradural dissection 2436.9.5. Closure 2437. NEUROSURGICAL TRAINING, EDUCATIONAND RESEARCH IN HELSINKI 2457.1. NEUROSURGICAL RESIDENCY IN HELSINKI 2457.1.1. Residency program 2457.1.2. How to become a neurosurgeonin Helsinki – the resident years –Aki Laakso 2467.2. ACADEMIC AND RESEARCH TRAINING 2507.2.1. PhD program 2507.2.2. Making of a PhD thesis in Helsinki,my experience – Johan Marjamaa 2507.3. MICRONEUROSURGICAL FELLOWSHIPWITH PROFESSOR HERNESNIEMI 2537.4. MEDICAL STUDENTS 2547.5. INTERNATIONAL VISITORS 2547.6. INTERNATIONAL LIVE SURGERY COURSES 2567.6.1. Helsinki Live Course 2567.6.2. LINNC-ACINR course (Organizedby J. Moret and C. Islak) 2587.7. PUBLICATION ACTIVITY 2607.8. RESEARCH GROUPS AT HELSINKINEUROSURGERY 2617.8.1. Biomedicum group for researchon cerebral aneurysm wall 2617.8.2. Translational functionalneurosurgery group 2627.8.3. Helsinki Cerebral AneurysmResearch (HeCARe) group 2628. VISITING HELSINKI NEUROSURGERY 2658.1. TWO YEAR FELLOWSHIP –JOUKE S. VAN POPTA (ZARAGOZA, SPAIN) 2658.1.1. Why to do a fellowship? 2658.1.2. In search of a fellowship 2668.1.3. Checking it out 2668.1.4. Arrival in Helsinki 2668.1.5. The very first day 2668.1.6. A day in the life (of a fellow) 2678.1.7. Assisting in surgery 2678.1.8. Nurses 2688.1.9. Anesthesiologists 2688.1.10. Music in the OR 2698.1.11. Rounds 2698.1.12. Visitors 2718.1.13. Pins and their stories 2718.1.14. LINNC and Live Course 2718.1.15. Weather and the four seasons 2728.1.16. Apartments 2738.1.17. Helsinki 2738.1.18. Finnish food 2738.1.19. Languages 2738.1.20. Famous words 2748.1.21. Practice, practice, practice 2748.1.22. Video editing 2748.1.23. The surgery of Juha Hernesniemi 2748.1.24. The choice of a fellowship 2758.2. ADAPTING TO FINNISH CULTURE ANDSOCIETY – ROSSANA ROMANI (ROME, ITALY) 2768.2.1. The difference between “to talkthe talk” and “to walk the walk” 2768.2.2. Difficult to learn but good for life:The Finnish language 2748.2.3. When in Finland do as the Finns 2808.2.4. Never good weather 2818.2.5. Finnish attitude: “Sisu” 2838.2.6. He and she = hän 2838.2.7. Conclusions 2838.3. IMPRESSIONS OF HELSINKI: ACCOUNT OFA VISIT – FELIX SCHOLTES (LIÈGE, BELGIUM) 2848.4. TWO YEARS OF FELLOWSHIP AT THEDEPARTMENT OF NEUROSURGERY IN HEL-SINKI – REZA DASHTI (ISTANBUL, TURKEY) 290TABLE OF CONTENTS
8.5. MY MEMORIAL OF “GO GO SURGERY” IN HELSINKI - KEISUKE ISHII (OITA, JAPAN) 294 8.5.1. The first impression of Finns 294 8.5.2. The Helsinki University Central Hospital 294 8.5.3. Professor Hernesniemi and his surgical techniques 294 8.5.4. My current days in Japan 295 8.5.5. To conclude 295 8.6. AFTER A ONE-YEAR FELLOWSHIP – ONDREJ NAVRATIL (BRNO, CZECH REPUBLIC) 296 8.7. ONE-YEAR FELLOWSHIP AT THE DEPART- MENT OF NEUROSURGERY IN HELSINKI – ÖZGÜR ÇELIK (ANKARA, TURKEY) 300 8.8. SIX MONTH FELLOWSHIP – MANSOOR FOROUGHI (CARDIFF, UNITED KINGDOM) 302 8.8.1 How it began 302 8.8.2. The place and the people 303 8.8.3. The Rainbow team and its Chairman 304 8.9. TWO MONTH FELLOWSHIP – ROD SAMUELSON (RICHMOND, VIRGINIA) 308 8.10. MEMORIES OF HELSINKI – AYSE KARATAS (ANKARA, TURKEY) 3129. SOME CAREER ADVICE TO YOUNG NEUROSURGEONS 315 9.1. READ AND LEARN ANATOMY 316 9.2. TRAIN YOUR SKILLS 316 9.3. SELECT YOUR OWN HEROES 316 9.4. KEEP FIT 317 9.5. BE A MEDICAL DOCTOR, TAKE RESPONSIBILITY! 318 9.6. LEARN YOUR BEST WAY OF DOING YOUR SURGERY 318 9.7. OPEN DOOR MICROSURGERY 319 9.8. RESEARCH AND KEEP RECORDS 319 9.9. FOLLOW UP YOUR PATIENTS 320 9.10. WRITE AND PUBLISH 320 9.11. KNOW YOUR PEOPLE 321 9.12. ATMOSPHERE 32110. LIFE IN NEUROSURGERY: HOW I BECAME ME – JUHA HERNESNIEMI 33311. FUTURE OF NEUROSURGERY 333APPENDIX 1. PUBLISHED ARTICLES ON MICRO-NEUROSURGICAL AND NEUROANESTHESIOLO-GICAL TECHNIQUES FROM HELSINKI 337APPENDIX 2. LIST OF ACCOMPANYING VIDEOS 342
131. INTRODUCTIONSuch a complex labyrinthine approach throughthe cranium and brain, however, requires accu-rate preoperative planning and the preparationof a prospective surgical concept (includinganticipated variations), which is based on afirm knowledge of anatomy, microtechniques,and surgical experience. These elements con-stitute the art of microneurosurgery.M.G. Yaşargil 1996 (Microneurosurgery vol IVB)Much of the merit of an approach is a matterof surgical experience. We always attemptedto make these operations simpler, faster and topreserve normal anatomy by avoiding resectionof cranial base, brain or sacrifice of veins.C.G. Drake, S.J. Peerless, and J. Hernesniemi 1996Sometimes I look into the small craniotomy ap-proach without the help of a microscope, andthink of the neurosurgical pioneers, Olivecronafrom Stockholm and his pupils here in Helsinki,Snellman and af Björkesten. I was never trainedby them, they came before my time, but I re-ceived my neurosurgical training already at thehands of their pupils. I also think of ProfessorC.G. Drake, what might have been his feelingswhen approaching the basilar tip for the firsttime. Personally, I am terrified of this tiny deepgap, the lack of light, the fear of all the thingsthat might lie in there, of all the things thatcannot be seen with the bare eye. But at thesame time, I also feel happiness because of allthe different tools and techniques we nowa-days have. Tools that have changed our wholeperception of neurosurgery from somethingscary into something extremely delicate. Micro-neurosurgical techniques, mainly introduced byProfessor Yaşargil, have revolutionized our pos-sibilities to operate in a small and often verydeep gap in total control of the situation andwithout the fear of the unknown. I still feelfear before every surgery, but it is no longerthe fear of the unknown; rather, it is a fear ofwhether I will be successful in executing thepre-planned strategy with all its tiny detailsand possible surprises along the way. But allthis anxiety subsides immediately once the fas-cinating and beautiful microanatomical worldopens up under the magnification of the oper-ating microscope. This loss of fear means bet-ter surgery, as hesitance and tremor associatedwith fear are replaced with a strong feeling ofsuccess, determination and steady hands. Thefear is also in an equal way lost to a minimumwhen looking around and seeing the experi-enced and supporting Helsinki team around,and exchanging few words with them beforeand during surgery. As Bertol Brecht said, Finn-ish people are queit in two languages.Big resistance against microsurgery was stillseen at the end of 70s when I was trained inHelsinki. The reluctance towards new think-ing, although often irrational, is very commonboth in surgical as well as other human areas.Arguments such as "the really good neuro-surgeons can operate on aneurysms withouta microscope..." were common at that time.Fortunately, this kind of thinking has alreadydisappeared among Finnish neurosurgeons, butthe same thoughts still prevail in many partsof the world. In many countries unskilled neu-rosurgeons with old-fashioned thinking stillcontinue cruel surgery, and bring misery to thepatients, families and the surrounding society.The motto "do not harm" is forgotten. It is clearthat an epidural hematoma can be removedwithout a microscope, but already removing abig convexity meningioma using microneuro-surgical techniques helps in getting far betterresults.Microneurosurgery does not solely refer to theuse of the operating microscope; rather, it is aconceptual way of planning and executing allstages of the operation utilizing the delicatetechniques of handling the different tissues. Atrue microsurgical operation starts already out-Introduction | 1
14side of the operating room with careful preop-erative planning and continues throughout allthe steps of the procedure. Mental preparation,repetition of earlier experience, good knowl-edge of microanatomy, high quality neuroan-esthesia, seamless cooperation between theneurosurgeon and the scrub nurse, appropriatestrategy and its execution are all essential ele-ments of modern microneurosurgery.In this book we want to share our experiencefrom Helsinki on some of the conceptual think-ing behind what we consider modern microne-urosurgery. We want to present an up-to-datemanual of basic microneurosurgical principlesand techniques in a cookbook fashion. It is myexperience, that usually the small details de-termine whether the procedure is going to besuccessful or not. To operate in a simple, clean,and fast way while preserving normal anatomy;that has become my principle during and aftermore than 12,000 microsurgical operations.Juha HernesniemiHelsinki, August 15th 20101 | Introduction
17History of Neurosurgery in Helsinki and Finland | 22.1. HISTORY OF NEUROSURGERY IN HELSINKIAND FINLAND2.1.1. Aarno Snellman, founder ofFinnish neurosurgeryThe first neurosurgical operations in Finlandwere performed in the beginning of the 20thcentury by surgeons such as Schultén, Krogius,Faltin, Palmén, Kalima and Seiro, but it is AarnoSnellman who is considered the founder ofneurosurgery in Finland. The Finnish Red CrossHospital, which was the only center for Finnishneurosurgery until 1967, was founded in 1932by Marshall Mannerheim and his sister SophieMannerheim as a trauma hospital. It is in thissame hospital where the Helsinki Neurosur-gery is still nowadays located. Already duringthe first years the number of patients with dif-ferent head injuries was so significant that anevident need for a trained neurosurgeon andspecial nursing staff arose. In 1935, professorof surgery Simo A. Brofeldt sent his youngercolleague, 42-year old Aarno Snellman, to visitprofessor Olivecrona in Stockholm. Snellmanspent there half a year, closely observing Ol-ivecronas work. Upon his return, he performedthe first neurosurgical operation on 18th Sep-tember 1935. This is generally considered asthe true beginning of neurosurgery in Finland.Figure 2-1. The Finnish Red Cross Hospital AAAAAAAAAA(later Töölö Hospital) in 1932.2. DEPARTMENT OF NEUROSURGERY,HELSINKI UNIVERSITY CENTRAL HOSPITAL
182.1.2. Angiography in FinlandThe initially relatively poor surgical resultswere mainly due to insufficient preoperativediagnostics. Realizing the importance of pr-eoperative imaging, Snellman convinced hiscolleague from radiology, Yrjö Lassila, to visitprofessor Erik Lysholm in Stockholm. The firstcerebral angiographies were performed afterLassilas return to Helsinki in 1936. At that timethe angiography was often performed only onone side as it required surgical exposure of thecarotid artery at the neck and four to six staffmembers to perform the procedure that tooka relatively long time: one to hold the needle,one to inject the contrast agent, one to use theX-ray tube, one to change the films, one to holdthe patients head, and one who was responsi-ble for the lighting. The procedure was quiterisky for the patients; there was one death inthe first 44 cases, i.e. 2% mortality. There werealso some less expected complications such asone situation, when the surgeon injecting thecontrast agent got an electric shock from theX-ray tube and fell unconscious to the floor!While falling he accidentally pulled on the loopof silk thread, passed under the patients ca-rotid artery, causing total transsection of thisartery. Fortunately, the assistant was able tosave the situation and as Snellman stated in hisreport, "no one was left with any permanentconsequences from this dramatic situation".Before 1948 the number of cerebral angiogra-phies was only 15-20 per year, but with theintroduction of the percutaneous technique atthe end of 1948, the number of angiographiesstarted gradually to rise, with more than 170cerebral angiographies performed in 1949.2 | History of Neurosurgery in Helsinki and FinlandFigure 2-2. (b) Professor Sune Gunnar af Björkesten(painting by Pentti Melanen in 1972).Figure 2-2. (a) Professor Aarno Snellman(painting by Tuomas von Boehm in 1953).
19History of Neurosurgery in Helsinki and Finland | 22.1.3. World War II and late 1940sThe World War II had a significant effect on thedevelopment of neurosurgery in Finland. Onone hand the war effort diminished the possi-bilities to treat civilian population, on the otherhand the high number of head injuries boostedthe development of the neurosurgical treat-ment of head trauma. During this period sev-eral neurosurgeons from other Scandinaviancountries worked as volunteers in Finland help-ing with the high casualty load. Among othersthere were Lars Leksell, Nils Lundberg and OlofSjöqvist from Sweden, and Eduard Busch fromDenmark. After the war, it became evident thatneurosurgery was needed as a separate special-ty. Aarno Snellman was appointed as a profes-sor of neurosurgery at the Helsinki Universityin 1947 and the same year medical studentshad their first, planned course in neurosurgery.The next year, Teuvo Mäkelä, who worked inneurosurgery since 1940 and took care of thehead injury patients, was appointed as the firstassistant professor in neurosurgery. An impor-tant administrative change took place in 1946when the Finnish government decided that thestate would pay for the expenses for the neu-rosurgical treatment. With this decision neuro-surgical treatment became, at least in theory,available for the whole Finnish population. Thelimiting factors were hospital resources (therewas initially only one ward available) and therelatively long distances in Finland. This isone of the reasons why especially in the earlyyears, e.g. aneurysm patients came for opera-tive treatment several months after the initialrupture, and only those in good condition wereselected. Neurosurgery remained centralized inHelsinki until 1967, when the department ofneurosurgery in Turku was founded, later fol-lowed by neurosurgical departments in Kuopio(1977), Oulu (1977) and Tampere (1983).Figure 2-3. Neurosurgical units in Finland and the yearsthey were established.
202.1.4. Microneurosurgery andendovascular surgeryThe first one to use the operating microscopein Finland was Tapio Törmä in Turku in the be-ginning of 1970s. The first operating micro-scope came to the neurosurgical departmentin Helsinki in 1974. The economic departmentof that time managed to postpone purchase ofthis microscope by one year as they consideredit a very expensive and unnecessary piece ofequipment. Initially, the microscope was usedby neurosurgeons operating on aneurysms,small meningiomas, and acoustic schwanno-mas. Laboratory training in microsurgical tech-niques was not considered necessary and sur-geons usually started to use them immediatelyin the operating room (OR). A Turkish born neu-rosurgeon Davut Tovi from Umeå held a labora-tory course in Helsinki in January 1975, dur-ing which he also demonstrated the use of themicroscope in the OR while the intraoperativescene could be observed from a TV monitor. In-terestingly, during the first years of microneu-rosurgery on aneurysms, intraoperative rupturemade the neurosurgeon often to abandon themicroscope and move back to macrosurgeryso that he could "see better" the rupture site.But the younger generation already startedwith microsurgical laboratory training, amongthem Juha Hernesniemi, who operated his firstaneurysm in 1976. He has operated all of hisnearly 4000 aneurysms under the microscope.In 1982 Hernesniemi visited Yaşargil in Zürich,and after this visit started, as the first in Fin-land in 1983, to use a counterbalanced micro-scope with a mouthswitch. Surgery on unrup-tured aneurysms in patients with previous SAHstarted in 1979, and the first paper on surgeryof aneurysms in patients with only incidental,unruptured aneurysms was published in 1987.Endovascular treatment of intracranial aneu-rysms started in Finland in 1991.2 | History of Neurosurgery in Helsinki and Finland
21History of Neurosurgery in Helsinki and Finland | 22.1.5. Changes towards the present timeDuring the last decades of the 20th century,advances in the society, technology, neuroim-aging, and medicine in general also meant aninevitable gradual progression in neurosurgery,which had its impact on Helsinki Neurosur-gery as well. The annual number of opera-tions increased from 600 in the 70s to about1000 in the 80s and 1500 in the early 90s.In the intensive care unit (ICU), although theclinical neurological condition and the levelof consciousness of the patients were closelymonitored, no invasive monitoring was usedin the early 1980s. Transferring a critically illpatient to a routine CT scan might have hadcatastrophic consequences. However, little bylittle, significant advances in neuroanesthesi-ology began to lead to safer and less tumultu-ous neurosurgical operations. Development inthis field also had its impact on neurointensivecare, and invasive monitoring of vital functions– both at the ICU and during transfer of criti-cally ill or anesthetized patients - as well ase.g. intracranial pressure monitoring becameroutine. Treatment attitude in the ICU changedfrom maintaining the patients while wait-ing for the illness and the physiological repairmechanisms to take their natural course, to anactive one with strong emphasis on secondaryinjury prevention. Much of this development inHelsinki was due to the work of neuroanesthe-siologists Tarja Randell, Juha Kyttä and PäiviTanskanen, as well as Juha Öhman, the headof neurosurgical ICU (now the Professor andChairman of the Department of Neurosurgeryin Tampere University Hospital).Still, many aspects of life and daily work atthe Department in 1990s looked very differ-ent from the present state of affairs. The staffincluded only six senior neurosurgeons, threeresidents and 65 nurses. Three to four patientsa day were operated in three ORs. Operationswere long; in a routine craniotomy, in additionto intracranial dissection and treatment of thepathology itself, just the approach usually tookan hour, and the closure of the wound from oneto two hours. With no technical staff to help,scrub nurses had to clean and maintain theinstruments themselves at the end of the day,meaning that no elective operation could startin the afternoon. All surgeons operated sitting;unbalanced microscopes had no mouthpieces.Convexity meningiomas and glioblastomaswere even operated on without a microscope.The attitude towards elderly and severely illpatients was very conservative compared withpresent day standards – for example, high-grade SAH patients were not admitted forneurosurgical treatment unless they started toshow signs of recovery. International contactsand visitors from abroad were rare. The staffdid participate in international meetings, butlonger visits abroad and clinical fellowshipstook only seldom place. Scientific work was en-couraged and many classical pearls of scientificliterature were produced, such as Prof. HenryTroupps studies of natural history of AVMs,Juha Jääskeläinens (now Professor of Neuro-surgery in Kuopio University Hospital) studiesof outcome and recurrence rate of meningi-omas, and Seppo Juvelas studies on the riskfactors of SAH and hemorrhage risk of unrup-tured aneurysms. However, it was very difficultespecially for younger colleagues to get properfinancial support for their research at the time.Doing research was a lonely job – researchgroups, as we know them now, did not reallyexist at the Department, and the accumulationof papers and scientific merit was slow.Probably no one anticipated the pace and ex-tent of changes that were about to take placewhen the new chairman was elected in 1997.Juha Hernesniemi, a pupil of the Departmentfrom the 70s, having spent almost two decadeselsewhere - mainly in Kuopio University Hospi-
22tal - returned with intense will and dedicationto shape the Department according to his vi-sion and dream. In only three years, the annualnumber of operations increased from 1600 to3200, the budget doubled from 10 to 20 mil-lion euros. It is a common fact in any trade,that the election of a new leader or a manageris followed by a "honeymoon" period, duringwhich the new chief fiercely tries to implementchanges according to his or her will, and tosome extent the administration of the organi-zation is supposed to support the aims of thisnewly elected person – he or she was given theleadership position by the same administration,after all. In this particular case, however, peoplein the administration got cold feet because ofthe volume and the speed of the development.Since the Department had the same populationto treat as before, where did this increase inpatient numbers come from? Were the treat-ment indications appropriate? Could the treat-ment results be appropriate? Soon, an internalaudit was initialized, questioning the actionsof the new chairman. The scrutiny continuedfor over a year. The treatment indications andresults were compared to those of other neu-rosurgical units in Finland and elsewhere inEurope, and it became evident that the treat-ment and care given in the Department wereof high quality. The new chairman and his ac-tive treatment policy also received invaluablesupport in form of Professor Markku Kaste, thehighly distinguished chairman of Departmentof Neurology. After the rough ride through theearly years, the hospital administration and thewhole society started to appreciate the refor-mation and the high quality of work that stillcontinues.But what was the anatomy of this unprec-edented change? Surely, one person alone, nomatter how good and fast, cannot operate ad-ditional 1600 patients a year. The size of thestaff has almost tripled since 1997 – today,the staff includes 16 senior neurosurgeons,six (nine trainees) residents, 154 nurses andthree OR technicians, in addition to adminis-trative personnel. The number of ICU beds hasincreased from six to 16. The number or ORshas increased only by one, but the operationsstart nowadays earlier, the patient changes areswift, and there is sufficient staff for longerworkdays. The most significant change, how-ever, was probably the general increase in thepace of the operations, mostly because of theexample set by the new chairman, "the fastestneurosurgeon in the world". The previous ratherconservative treatment policy was replaced bya very active attitude, and attempts to salvagealso critically ill patients are being made, andoften successfully. Chronological high age perse is no longer a "red flag" preventing admissionto the Department, if the patient otherwise haspotential for recovery and might benefit fromneurosurgical intervention.Despite the increased size of staff, the new ef-ficient approach to doing things meant moreintense and longer workdays. However, perhapssomewhat surprisingly, the general attitudeamong the staff towards these kind of changeswas not only of resistance. The realization ofthe outstanding quality and efficiency of thework the whole team in the Department is do-ing, has also been the source of deep profes-sional satisfaction and pride, both among theneurosurgeons and the nursing staff. An impor-tant role in the acceptance of all these changesplayed also the fact that Prof. Hernesniemi hasalways been intensely involved in the dailyclinical work instead of hiding in the corridorsof administrative offices. The price for all thishas not been cheap, of course. The workload,effort and the hours spent to make all this hap-pen have been, and continue to be, massive,and require immense dedication and ambition.What else has changed? For sure, much moreattention is being paid to the microneurosurgi-cal technique in all operations. Operations arefaster and cleaner, the blood loss in a typicaloperation is minimal, and very little time isspent on wondering what to do next. Almostall operations are performed standing, and allthe microscopes are equipped with mouthpiec-2 | History of Neurosurgery in Helsinki and Finland
23History of Neurosurgery in Helsinki and Finland | 2es and video cameras to deliver the operativefield view to everybody in the OR. Operativetechniques are taught systematically, startingfrom the very basic principles, scrutinized andanalyzed, and published for the global neuro-surgical community to read and see. Postop-erative imaging is performed routinely in allthe patients, serving as quality control for oursurgical work. The Department has becomevery international. There is a continuous flowof long- and short-term visitors and fellows,and the Department is involved in two inter-national live neurosurgery courses every year.The staff travels themselves, both to meetingsand to other neurosurgical units, to teach andto learn from others. The opponents of doctoraldissertations are among the most famous neu-rosurgeons in the world. The flow of visitorsmay sometimes feel a bit intense, but at theend of the day makes us proud of the work wedo. The scientific activity has increased signifi-cantly, and is nowadays well-funded and eventhe youngest colleagues can be financially sup-ported. The visibility of the Department and itschairman in the Finnish society and the inter-national neurosurgical community has defi-nitely brought support along with it.Overall, the changes during the past two dec-ades have been so immense that they seemalmost difficult to believe. If there is a lessonto be learned, it could be this: with sufficientdedication and endurance in the face of resist-ance, almost everything is possible. If you trulybelieve the change you are trying to make isfor the better, you should stick to it no matterwhat, and it will happen.Table 2-1.Professors of Neurosurgery in University of Helsinki:Aarno Snellman 1947-60Sune Gunnar Lorenz af Björkesten 1963-73Henry Troupp 1976-94Juha Hernesniemi 1998-
242.2. PRESENT DEPARTMENT SETUPBy 2009, the Department of Neurosurgerywhich has an area of only 1562 m2, utilizing upto 16 ICU beds, 50 beds on two regular wardsand four operating rooms, was carrying out atotal of 3200 cases per year. Only 60% of pa-tients are coming for planned surgery and 40%are coming through the emergency unit. Thismeans that the care given in all our units isvery acute in nature and the patients often havetheir vital and neurological functions threat-ened. The needed care has to be given fast andaccurately in all units. The departments teamhas become successful in setting standards inquality, efficiency and microneurosurgery, notjust in Nordic countries but worldwide. Often,patients are sent here from around Europe, andeven from outside Europe, for microneurosurgi-cal treatment of their aneurysm, AVM or tumor.The department, managed by Professor andChairman Juha Hernesniemi and Nurse Man-ager Ritva Salmenperä (Figure 2-4), belongsadministratively to Head and Neck Surgery,which is a part of the operative administrativesection of Helsinki University Central Hospital.As a university hospital department, it is theonly neurosurgical unit providing neurosurgicaltreatment and care for over 2 million people inthe Helsinki metropolitan area and surroundingSouthern and Southeastern Finland. Because ofpopulation responsibility, there is practically noselection bias for treated neurosurgical casesand patients remain in follow-up for decades.These two facts have helped to create some ofthe most cited epidemiological follow-up stud-ies e.g. in aneurysms, AVMs and tumors over thepast decades. In addition to operations and in-patient care, the department has an outpatientclinic with two or three neurosurgeons seeingdaily patients coming for follow-up check-upsor consultations, with approximately 7000 vis-its per year.2.3. STAFF MEMBERSIn neurosurgery success is based on team effort.The team at Helsinki Neurosurgery currentlyconsists of 16 specialist neurosurgeons, sevenneurosurgical residents, six neuroanesthesi-ologists, five neuroradiologists, and one neu-rologist. There are 150 nurses working on thedifferent wards, four physiotherapists, threeOR technicians, three secretaries and severalresearch assistants. In addition, we have a veryclose collaboration with teams from neuropa-thology, neuro-oncology, clinical neurophysiol-ogy, endocrinology and both adult and pediat-ric neurology.Figure 2-4. Nurse Manager Ritva Salmenperä2 | Present department setup
25Neurosurgeons | Staff members | 22.3.1. NeurosurgeonsAt the beginning of the year 2010 there were16 board certified neurosurgeons and one neu-rologist working at Helsinki Neurosurgery:Juha Hernesniemi, MD, PhDProfessor of Neurosurgery and ChairmanMD: 1973, University of Zürich, Switzerland;PhD: 1979, University of Helsinki, Finland,"An Analysis of Outcome for Head-injured Pa-tients with Poor Prognosis"; Board certifiedneurosurgeon: 1979, University of Helsinki,Finland; Clinical interests: Cerebrovascularsurgery, skull base and brain tumors; Areas ofpublications: Neurovascular disorders, braintumors, neurosurgical techniques.Jussi Antinheimo, MD, PhDStaff neurosurgeonMD: 1994, University of Helsinki, Finland; PhD:2000, University of Helsinki, Finland, "Meningi-omas and Schwannomas in Neurofibromatosis2"; Board certified neurosurgeon: 2001, Uni-versity of Helsinki, Finland; Clinical interests:Complex spine surgery; Areas of publications:Neurofibromatosis type 2.Göran Blomstedt, MD, PhDAssociate Professor, Vice Chairman,Head of section (Outpatient clinic)MD: 1975, University of Helsinki, Finland; PhD:1986, University of Helsinki, Finland, "Postop-erative infections in neurosurgery"; Board cer-tified neurosurgeon: 1981, University of Hel-sinki, Finland; Clinical interests: Brain tumors,vestibular schwannomas, epilepsy surgery,peripheral nerve surgery; Areas of publication:Neurosurgical infections, brain tumors, epi-lepsy surgery.
26Atte Karppinen, MDStaff neurosurgeonMD: 1995, University of Helsinki, Finland;Board certified neurosurgeon: 2003, Universityof Helsinki, Finland; Clinical interests: Pediatricneurosurgery, epilepsy surgery, pituitary sur-gery, neuroendoscopy.Leena Kivipelto, MD, PhDStaff neurosurgeonMD: 1987, University of Helsinki, Finland; PhD:1991, University of Helsinki, Finland, "Neu-ropeptide FF, a morphine-modulating peptidein the central nervous system of rats"; Boardcertified neurosurgeon: 1996, University ofHelsinki, Finland; Clinical interests: Cerebrov-ascular surgery, bypass surgery, pituitary sur-gery, spine surgery; Areas of publications:Neuropeptides of central neurvous system,neuro-oncology.Riku Kivisaari, MD, PhDAssistant ProfessorMD: 1995, University of Helsinki, Finland; PhD:2008, University of Helsinki, Finland, "Radio-logical imaging after microsurgery for intrac-ranial aneurysms"; Board certified radiologist:2003, University of Helsinki, Finland; Boardcertified neurosurgeon: 2009, University ofHelsinki, Finland; Clinical interests: Endovascu-lar surgery, cerebrovascular diseases ; Areas ofpublications: Subarachnoid hemorrhage, cer-ebral aneurysms.2 | Staff members | Neurosurgeons
27Neurosurgeons | Staff members | 2Miikka Korja, MD, PhDStaff neurosurgeonMD: 1998, University of Turku, Finland; PhD:2009, University of Turku, Finland, "Molecularcharacteristics of neuroblastoma with specialreference to novel prognostic factors and diag-nostic applications"; Board certified neuro-surgeon: 2010, University of Helsinki, Finland;Clinical interests: Cerebrovascular surgery,functional neurosurgery, skull base surgery,neuroendoscopy; Areas of publications: Tumorbiology, subarachnoid hemorrhage, neuroimag-ing, bypass surgery.Aki Laakso, MD, PhDStaff neurosurgeon, Associate Professorin NeurobiologyMD: 1997, University of Turku, Finland; PhD:1999, University of Turku, Finland, "DopamineTransporter in Schizophrenia. A Positron Emis-sion Tomographic Study"; Board certifiedneurosurgeon: 2009, University of Helsinki,Finland; Clinical interests: Cerebrovascular dis-eases, neuro-oncology, neurotrauma, neuroin-tensive care; Areas of publications: Brain AVMsand aneurysms, basic neuroscience.Martin Lehecka, MD, PhDStaff neurosurgeonMD: 2002, University of Helsinki, Finland; PhD:2009, University of Helsinki, Finland, "DistalAnterior Cerebral Artery Aneurysms"; Boardcertified neurosurgeon: 2008, University ofHelsinki, Finland; Clinical interests: Cerebrov-ascular surgery, bypass surgery, skull base andbrain tumors, neuroendoscopy; Areas of publi-cations: Cerebrovascular diseases, microneuro-surgical techniques.
28Mika Niemelä, MD, PhDAssociate Professor, Head of section(Neurosurgical OR)MD: 1989, Univeristy of Helsinki, Finland; PhD:2000, Univeristy of Helsinki, Finland, "Heman-gioblastomas of the CNS and retina: impactof von Hippel-Lindau disease"; Board certifiedneurosurgeon: 1997, University of Helsinki,Finland; Clinical interests: Cerebrovasculardiseases, skull base and brain tumors; Areas ofpublications: Cerebrovascular disorders, braintumors, basic research on aneurysm wall andgenetics of intracranial aneurysms.Minna Oinas, MD, PhDStaff neurosurgeonMD: 2001, University of Helsinki, Finland; PhD:2009,UniversityofHelsinki,Finland,"α-Synucleinpathology in very elderly Finns"; Board certifiedneurosurgeon: 2008, University of Helsinki, Fin-land; Clinical interests: Pediatric neurosurgery,skull base and brain tumors; Area of publica-tions: Neurodegenerative diseases, tumors.Juha Pohjola, MDStaff neurosurgeonMD: 1975, University of Zürich, Switzerland;Board certified neurosurgeon: 1980, Universityof Helsinki, Finland; Clinical interests: Complexspine surgery, functional neurosurgery.Esa-Pekka Pälvimäki, MD, PhDStaff neurosurgeonMD: 1998, University of Turku, Finland; PhD:1999, University of Turku, Finland, "Interac-tions of Antidepressant Drugs with Serotonin5-HT2C Receptors."; Board certified neuro-surgeon: 2006, University of Helsinki, Finland;Clinical interests: Spine surgery, functionalneurosurgery; Areas of publications: Neurop-harmacology, functional neurosurgery.2 | Staff members | Neurosurgeons
29Jari Siironen, MD, PhDAssociate Professor, Head of section (ICU)MD: 1992, University of Turku, Finland; PhD:1995, University of Turku, Finland, "Axonal reg-ulation of connective tissue during peripheralnerve injury"; Board certified neurosurgeon:2002, University of Helsinki, Finland; Clinicalinterests: Neurotrauma, neurointensive care,spine surgery; Areas of publications: Subarach-noid hemorrhage, neurotrauma, neurointensivecare.Matti Seppälä, MD, PhDStaff neurosurgeonMD: 1983, University of Helsinki, Finland; PhD:1998, University of Helsinki, Finland, "Long-term outcome of surgery for spinal nerve sheathneoplasms"; Board certified neurosurgeon:1990, University of Helsinki, Finland; Clinicalinterests: Neuro-oncology, radiosurgery, spinesurgery; Areas of publications: Neuro-oncolo-gy, neurotrauma, spine surgery.Matti Wäänänen, MDStaff neurosurgeonMD: 1980, University of Kuopio, Finland; Boardcertified general surgeon: 1986, University ofKuopio, Finland; Board certified orthopedicsurgeon: 2003, University of Helsinki, Finland;Board certified neurosurgeon: 2004, Universityof Helsinki, Finland; Clinical interests: Complexspine surgery, peripheral nerve surgery.Maija Haanpää, MD, PhDAssociate Professor in NeurologyMD: 1985, University of Kuopio, Finland; PhD:2000, University of Tampere, Finland, "Herpeszoster – clinical, neurophysiological, neurora-diological and neurovirological study"; Boardcertified neurologist: 1994, University of Tam-pere, Finland; Clinical interests: Chronic painmanagement, neurorehabilitation, headache;Areas of publications: Pain management, neu-ropathic pain, neurorehabilitation.Neurosurgeons | Staff members | 2
30Figure 2-22. Neuroanesthesiologists at Töölö Hospital. Back: Marja Silvasti-Lundell, Juha Kyttä, Markku Määttänen, PäiviTanskanen, Tarja Randell, Juhani Haasio, Teemu Luostarinen. Front: Hanna Tuominen, Ann-Christine Lindroos, Tomi Niemi2 | Staff members | Neurosurgical residents | Neuroanesthesiologist2.3.2. Neurosurgical residentsThere are currently nine neurosurgical residentsin different phases of their 6-year neurosurgi-cal training program:Juhana Frösén, MD, PhDEmilia Gaal, MDAntti Huotarinen, MDJuri Kivelev, MDPäivi Koroknay-Pál, MD, PhDHanna Lehto, MDJohan Marjamaa, MD, PhDAnna Piippo, MDJulio Resendiz-Nieves, MD, PhD2.3.3. NeuroanesthesiologistsThe team of anesthesiologists at Helsinki Neu-rosurgery, six of them specialists in neuroan-esthesia, is led by Associate Professor TomiNiemi. In addition there are usually a coupleof residents or younger colleagues in training.During daytime four of the anesthesiologistsare assigned to the ORs and two work at theneurosurgical ICU. Collaboration between an-esthesiologists and neurosurgeons is very closeboth in and out of the OR. There are joinedrounds at the ICU twice a day.Tomi Niemi, MD, PhDHanna Tuominen, MD, PhDJuha Kyttä, MD, PhD (1946-2010)Juhani Haasio, MD, PhDMarja Silvasti-Lundell, MD, PhDMarkku Määttänen, MDPäivi Tanskanen, MDTarja Randell, MD, PhD
31Figure 2-23. Neuroradiologists at Töölö Hospital. From left: Kristiina Poussa, Jussi Laalo, Marko Kangasniemi,Jussi Numminen, Goran Mahmood.Neuroradiologists | Staff members | 22.3.4. NeuroradiologistsA dedicated team of five neuroradiologists andone or two residents or younger colleagues islead by Associate Professor Marko Kangasnie-mi. The neuroradiological team is taking careof all the neuroimaging. That includes CT, MRI,and DSA imaging. Endovascular procedures arecarried out in a dedicated angio suite by neuro-radiologists in close collaboration with neuro-surgeons. Every morning at 08:30 AM there isa joined neuroradiological meeting that is at-tended by all the neurosurgeons and the neu-roradiologists.Marko Kangasniemi, MD, PhDJussi Laalo, MDJussi Numminen, MD, PhDJohanna Pekkola, MD, PhDKristiina Poussa, MD
322 | Staff members | Bed wardsFigure 2-24. Staff of bed ward No. 6, with head nurse Marjaana Peittola (sitting, second from right)2.3.5. Bed wardsThe department of neurosurgery has a total of50 beds in two wards. Of the 50 beds, seven areintermediate care beds and 43 unmonitoredgeneral beds. In addition, there are two isola-tion rooms. The isolation rooms are equippedwith full monitoring possibilities and can beused for intensive care purposes as well, ifneeded.Patients coming for minor operations, for ex-ample spinal surgery, usually spend relativelyshort time on the ward, 1-2 days after opera-tion before being discharged. Patients comingfor major surgery, for example brain tumor orunruptured aneurysm, stay for 5 to 8 days, andemergency patients recovering from severedisease or brain injury can stay in the depart-ment for up to 2 months. Average stay for allpatients is 4.6 days.The staff at bed wards consists of one headnurse at each ward, nursing staff of 45 nursesand 3 secretaries. There are two physiothera-pists present at both wards and ICU. The staffis professional and motivated in their work.One of the main duties for ward nurses is toperform neurological assessment and registerfindings so that the continuity of care is en-sured. They also take care of medication, nu-trition and electrolyte balance, interview pa-tients for health history, perform wound careand stitch removal, give information and homeinstructions and educate the patients.The intermediate care room is meant for pa-tients who still require ventilator support butdo no longer fulfill the criteria for intensivecare treatment. Typical patients are recoveringfrom severe head trauma or acute hemorrhagic
33Bed wards | Staff members | 2Figure 2-25. Staff of bed ward No. 7, with head nurse Päivi Takala (left)stroke. Patients can have problems with breath-ing, still need respiratory care, have problemswith nutrition, anxiety and pain; all this care isgiven by our staff nurses. There are one or twonurses present at all times. When needed, thenurses alert also neurosurgeons and anesthesi-ologists based on their observations. The nursesin the two wards rotate in intermediate careroom so that everyone is able to take care ofall critically ill patients.
342 | Staff members | Intensive care unit (ICU)Figure 2-26. Staff of ICU, with head nurse Petra Ylikukkonen (front row, third from left).2.3.6. Intensive care unit (ICU)The neurosurgical ICU has 14 beds and two re-covery beds for patients with minor operationswho only need a couple of hours of monitor-ing and observation. Additionally, there aretwo isolation rooms for severe infections, orpatients coming for treatment from outside ofScandinavia (to prevent spread of multiresist-ent micro-organisms). The staff consists of thehead nurse, 59 nurses and a ward secretary. Inthe ICU one nurse is usually taking care of twopatients with some exceptions. Small childrenand parents have special needs and have theirown nurse. Critically ill and unstable patients,e.g. high intracranial pressure or organ donorpatients also have their own nurse.All patients undergoing surgery are treated inthe ICU that also functions as a recovery room.In 2009, 3050 patients were treated in the ICU.Half of the patients stay at the ICU for less than6 hours recovering from surgery. Intensive carenurses take care of patient monitoring and dothe hourly neurological assessment. Monitor-ing includes for example vital signs, pCO2, GCS,SvjO2, EEG, intracranial pressure and cerebralperfusion pressure, depending on the patientsneeds. Nurses also take care of pain and anxietyrelief. Neurosurgeons make the majority of thedecisions concerning patient care, discuss withthe patient and family members, make notes tothe charts and perform required bedside sur-gical interventions, such as percutaneous tra-cheostomies, ventriculostomies and implantingICP monitoring devices. Neuroanesthesiologistsare in charge of medication, respiratory man-agement, nutrition and monitoring of labora-tory parameters. Joint rounds between neuro-surgeons, neuroanesthesiologists and nursestake place twice a day, in the morning and inthe afternoon. The multidisciplinary team alsoincludes physiotherapists and, when needed,consultants of different disciplines, like infec-tious diseases and orthopedic, maxillofacialand plastic surgery.
35Intensive care unit (ICU) | Staff members | 2The ICU is a very technical environment withelectronic patient files and computerized datacollection. ICU nurses have to provide safe andcontinuous care to the patient who is facingan acute, life-threatening illness or injury. De-pending on the nurses previous backgroundand experience, the critical care orientationprogram takes 3-5 weeks of individual train-ing with preceptors, and after that the amountof more independent work increases gradually.Critically ill patients, organ donors and smallchildren are allocated to nurses only after he orshe has sufficient experience in common proce-dures and protocols. The last step after two orthree years of experience is to work as a teamleader during the shift, i.e. the nurse in charge.Nurses in the ICU perform strenuous shift workand many prefer working long shifts of 12.5hours, which gives them the opportunity tohave more days off than working the normal 8hour shift. ICU nurses have autonomy in plan-ning the shifts, making it easier to accommo-date work and personal life. This principle ofplanning the working hours is the same in allunits, but it works especially well in the ICUwhere the staff is quite large.
36Figure 2-27. Operating room staff, with head of section Dr. Mika Niemelä (standing in the back), head nurse Saara Vierula(front row, first from right) and head nurse Marjatta Vasama (front row, fourth from right).2 | Staff members | Operating rooms2.3.7. Operating roomsThe four ORs are located in a recently reno-vated and redecorated area. It gives a nicesurrounding for a work that in many aspectsis very technical and demanding. The focusof nursing care in the OR is to treat patientssafely and individually, even though emergencysituations may require such rapid thinking anddecision-making that things may almost ap-pear to happen by themselves.There are two head nurses (surgical and an-esthesiological), 28 nurses and three OR tech-nicians working in four ORs. Nurses are dividedinto two groups: scrub nurses and neuroan-esthesiological nurses. Nurses are working intwo shifts, and two scrub nurses and one an-esthesiological nurse are on call starting from8 PM to 8 AM. Because almost half of our pa-tients are emergency patients, the active work-ing hours for those on call usually continuesuntil midnight or later, and the next day is free.During weekends the nurses are also on call,and two teams share one weekend.The staff is relatively small, the work in neu-rosurgical OR is highly specialized, and thefamiliarization and orientation takes severalmonths under the supervision of the precep-tor. The tasks of scrub nurses include patientpositioning (done together with technicians,the neurosurgeon and the anesthesiologist),the skin preparation, draping, instrumentation,and dressing. Anesthesiological nurses do thepreparations for anesthesia and intraoperativemonitoring and take care of reporting and doc-umentation. Anesthesiological nurses also takepatients to neuroradiological examinations andinterventions and take care of and monitor pa-tients during these procedures.Work rotation is encouraged between all units.After a couple of years of concentrating ei-ther on anesthesia or instrumentation we tryto encourage the nurses, who are interestedin expanding their knowledge and skills, to beable to work both as an scrub nurse and ananesthesiological nurse. There is also work ro-
37Fig 2-28. Administrative assistants Heli Holmström, Eveliina Salminen and Virpi Hakala.Administrative personnel | Staff members | 2tation between ICU and OR, ICU and bed wards,and we have nurses who have been working inall three units.Nursing students are trained continuously in allunits. Special attention is paid to inspire an in-terest in neurosurgery in them, since they mightbe our future employees. We hope that bothstudents and our nurses approach neurosurgicalnursing from a perspective of career rather thanmerely a job. This can result in a high level ofsatisfaction and more options for professionaladvancement. There is a well-established co-operation with Finnish Association of Neuro-science Nurses (FANN), European Association ofNeuroscience Nurses (EANN) and World Federa-tion of Neuroscience Nurses (WFNN). This givesan opportunity to do national and internationalco-operation and gives possibilities to attendmeetings, meet colleagues in the same field andvisit other interesting neurosurgerical depart-ments in world in the same way as many visi-tors are attending our department nowadays.2.3.8. Administrative personnelA small but absolutely invaluable part of theDepartments personnel is found on the ad-ministrative floor, where three administrativeassistants, Virpi Hakala, Eveliina Salminen andHeli Holmström, take care of myriads of thingsto ensure e.g. that patient referral letters arehandled reliably and in timely fashion, thewhole staff gets their paychecks, needs of for-eign visitors are accommodated, Prof. Hernes-niemis flight tickets and hotel reservations areup-to-date despite last minute changes of anextremely busy schedule… In other words, thisis work that you may not appreciate enoughbecause these things are managed so smoothlyand professionally "behind the scenes" that youdo not even realize the immense workload re-quired to keep the wheels of the Departmentlubricated – unless there would be a glitch andnothing would work anymore!
38Fig 2-29. Overview of the OR12 | Operating room complex
402 | Operating room complex2.4. OPERATING ROOM COMPLEX2.4.1. Operating room complex designThe OR complex in Helsinki is dedicated solely toneurosurgery. It has four separate ORs arrangedin semicircular fashion. The whole complex wasrefurbished in 2005 according to the needs ofmodern microneurosurgery, with emphasis onefficient workflow, open and inviting atmos-phere, and teaching with high quality audio-visual equipment. Besides the actual ORs, thecomplex includes also storage rooms, offices foranesthesiologists and nursing staff, a meetingroom with library and an auditorium in the lob-by of the complex. The setup in each of the ORsis similar and equipment can be easily movedfrom one room to the other. From each OR livevideo image can be displayed on big screen inthe lobby. All ORs are used every day from 8 AMto 3 PM, one OR is open until 6 PM and one ORis used around the clock for emergency cases.The operating room in Helsinki is also the anes-thetic room. Some other countries and institu-tions have them separate. The advantage of us-ing the same room is the avoidance of patienttransfer and the inherent risks associated withthis. The disadvantage is that the room has tohave the appropriate space, storage, equip-ment, and ambience for both functions. In ourexperience, the time that is saved by having aseparate anesthetic room is very limited com-pared to the length of the actual procedure,transferring the patient and the time spent re-connecting all the necessary cables and lines.After trying both options, we have settled forhandling the whole anesthesia and patient po-sitioning inside the operating room.
41Operating room complex | 22.4.2. Operating room ambienceThe atmosphere in any OR, let alone one wheremodern microneurosurgery is performed, maywell be crucial for the difference between suc-cess and failure in the operation. Mutual re-spect between all members in the team is akey factor in creating a successful ambience.We also feel that it is a great asset that thenurses are dedicated to and very experiencedin neurosurgical operations – often the cor-rect instrument is handed over to the surgeonimmediately without a need to say a word.Since working atmosphere and ambience maybe difficult to evaluate from within the team(especially if it is good!), a testimony from avisitor with a wider perspective may elucidatethe situation better. In the following, Dr. Man-soor Foroughi has described his observationsand feelings:"It is said that the ideal socialist health caresystem provides the best health care at thelowest cost! In the Helsinki experience and theschool of Juha Hernesniemi there are other ma-jor staff factors, which are included in the idealhealth care system besides financial cost! Theseare a sense of professionalism, being valued,worker dignity, morale, sense of belonging to agreater good, solidarity and general happinessand welfare. These factors are not easily com-promised on or sacrificed for a lower cost! Theprofessionals that work here are easily worthmore than their weight in gold. They seem tobe happy here despite the heavy workload andnumber of visitors. This is in comparison to oth-er places visited. Without a doubt they deservemore money and greater financial incentivesthan that we have been informed they get. Wehope all societies reward those that work hard,train long and acquire special skills!""Several members of the staff repeat the storyof how they moved from place to place andthen ended up staying here as they really likedit. The reasons seem to be the following:- They feel valued and appreciated. Thesurgeon habitually and genuinely thanksthe theatre staff, especially after a difficultor long case. They are always listened to andtheir wishes and concerns noted. Whether itwould be about lack of a piece of equipmentor the choice of music in theatre. The scrubnurses look forward to the gentle nudge orother gestures of appreciation from Juhaafter a difficult or complex case. They clearlyfeel they are making a difference. So theypass the instruments with accuracy andefficiency, listen attentively, set up equip-ment promptly on demand, observe closely(using the excellent audiovisual equipmentprovided in theatre), operate the bipolarpedal with unerring calm & accuracy, followthe suture during closure and apply dress-ings. In general they want be involved a lotprobably because they feel they are valuedand making a difference.- Professionalism and code of conduct. Noneof the fellows have ever witnessed on anyoccasion any suggestion or sign of rude orlewd behavior, loss of temper, shouting,intimidation, crying, obvious mental distressor bad conduct. This is most unusual forsome visitors who are culturally or tradi-tionally used to and accept the disturbingchat in theatre and even shouting. Somevisitors accept the expressions of the surgi-cal "artistic temperament" as normal every-day life.On the other hand we have neverseen a frustrated or distressed surgeonbecause equipment is not available, or aninstrument is not passed, or the bipolar is
422 | Operating room complexnot on or off at the appropriate time, or thenursing staff question the validity of arequest for a laborious tool or an expensiveitem. What is needed is asked for by thesurgeon, and it is immediately and efficient-ly provided!""It is hard to quantify happiness at work in abusiness plan, or highlight the importance ofwelfare for staff using some kind of scoringsystem or study. But if you visit Helsinki andspend sometime talking to the staff, you willcome to know that they are generally content,and their performance is excellent because theyare happy at work and happy with their leader!This is an example to the world.""This is a place of order, peace, focus and pro-fessionalism. The anesthetist, surgeon, nursingstaff and assistants all need to communicate.There should however be great consideration,respect and courtesy towards a neurosurgeonwho is carrying out microneurosurgery in some-ones brain. His or her senses are heightenedand consequently the surgeon is very sensitiveto the surroundings. Sudden interruptions, loudnoises, audible telephone conversations andthe rising volume of background chat can bedangerous. All such noises are discouraged andhandled politely but appropriately. However afeeling of fear, anxiety and tension is also notappreciated or conducive for morale and wel-fare of staff, especially if the aim is to do goodlong term. All are generally calm, respectful andavoid commotion. There is no disturbing chat inthe theatre complex in Helsinki no matter whois operating. You really feel the difference andcontrast between the Nordic calm and profes-sionalism and for example the Latino expres-sion of emotion and commotion. If you want tobe able to focus and encourage good surgeryas a team, then learn from the Helsinki theatreambience. All must be calm and respectful, butallowed basic freedoms. Basic freedoms meanto come and go very quietly, be seated or standcomfortably and be allowed a good view of thesurgery. At all times there is great considerationand respect for the team and the patient whomall are there to serve!""Some theatres ban the use of music but inJuhas theatre there is one radio station chosenfor its neutral soft background music. Thisrelaxes the staff and lessens any possible ten-sion felt in theatre. If the surgeon, anesthetistor scrub nurse wish to turn this off or down,they can. The staff clearly appreciate this music,and many have stated that it relaxes them. Thechoice of the station is limited to one Finn-ish language station. The radio is switched offwhen there is extreme concentration, as well asimmediate action and reaction needed from theteam. This may be during temporary clippingor when there is haemorrhage from a rupturedaneurysm. Some visitors and especially fellowshave had the same tunes, songs and evenadverts imprinted in their memory while theywere closely observing masterful surgery. Untilthey have learned how to listen and how not tolisten! The surgeon they come to see is calmedby the music, but mostly seems to switch off tothe music. He isolates himself from the world,and lives in the moment of surgery. There is alesson on how to train yourself and compromisewith your senses and those around you."
45Anesthesia | 33. ANESTHESIAby Tomi Niemi, Päivi Tanskanen and Tarja RandellIn Helsinki University Central Hospital, the De-partment of Neuroanesthesia in Töölö Hospi-tal has six neuroanesthesiologists. Daily fouranesthesiologists of whom at least two arespecialized in neuroanesthesia, work in theneurosurgical ORs and in the radiology suite,and two (at least one of them specialized inneuroanesthesia) at the neurosurgical ICU, andin the emergency room (ER) when needed. Theperioperative anesthesia care includes preoper-ative assessment, management of the patientsin the OR, and postoperative care in the ICUand also at the wards as required. In addition,one of three anesthesiologists who are on callin the hospital overnight is assigned to neu-roanesthesia and neurointensive care.In the Finnish system, the neuroanesthesianurses are trained to take care of the patientsin the OR, and also in the radiology suite, ac-cording to the clinical protocol and individualanesthesiologists instructions. The anesthe-siological nurses assist anesthesiologists in theinduction of anesthesia, and during emergence;also, the anesthesiologist is always present dur-ing positioning. The maintenance of anesthesiais usually managed by the nurse, but the an-esthesiologist is always available, and presentif clinically required.The principles of neuroanesthesia are basedon general knowledge of cerebral blood flow(CBF), cerebral perfusion pressure (CPP), cere-bral carbon dioxide (CO2) reactivity, and meta-bolic coupling, none of which can be continu-ously monitored during routine anesthesia. Webase our clinical practice on the assumptionthat in most patients scheduled for craniotomyirrespective of the indication, the intracranialpressure (ICP) is on the steep part of the ICP-compliance-curve, with minimal reserve tocompensate for any increases in the pressure(Figure 3-1). However, once the dura is opened,ICP is considered to be zero and mean arterialpressure (MAP) equals CPP. The anesthesiolo-gists must estimate these physiological princi-ples according to the pathology of the centralnervous system (CNS) before and during eachanesthesia and he or she must understand theeffects of all the perioperatively used drugs onthem.The objective of neuroanesthesia is to main-tain optimal perfusion and oxygen delivery tothe CNS during the treatment. Intraoperatively,we aim to provide good surgical conditions,i.e. slack brain, by means of various methodsat our disposal (Table 3-1). Neurophysiologicmonitoring during certain operations presentsa challenge, knowing that most anesthesiaagents interfere with monitoring of electrone-uromyography (ENMG), evoked potentials andelectroencephalography (EEG). Finally, we wantto believe that our anesthesiological practiceprovides neuroprotection although there is nostrong scientific evidence to support this ideain humans.ICPIntracranial volumeV1 V2P2P1Figure 3-1. Intracranial pressure (ICP)-compliance curveindicating the relation of intracranial volume and ICP. Onthe steep part of the ICP-compliance-curve, the patient hasminimal reserve to compensate for any increases in the ICPNeuroanesthesiologist Hanna Tuominen, MD, PhD
463 | Anesthesia | General physiological principles3.1. GENERAL PHYSIOLOGICAL PRINCIPLESAND THEIR IMPACT ON ANESTHESIA3.1.1. Intracranial pressureThe rigid cranium presents a challenge to ourclinical practice in neuroanesthesia, especiallywhen the compensatory mechanisms seemto be limited in acute changes of the intrac-ranial volume. Translocation of cerebrospinalfluid (CSF) to the spinal subarachnoid space,or reduction of the intracranial arterial bloodvolume by optimizing arterial CO2tension, orensuring cerebral venous return by optimalhead position and elevation above chest level,or osmotherapy may create more space prior tosurgical removal of an intracranial space oc-cupying lesion.All inhalation anesthetics are potent cerebralvasodilators, and without concomitant mildhyperventilation they may cause significantincreases in the ICP, when the compensatorymechanisms are exhausted. Therefore, induc-tion of anesthesia with inhalation anestheticsis contraindicated in our department, especiallybecause normoventilation or mild hyperventila-tion cannot be ensured during this critical phaseof anesthesia. Also, induction would require aconcentration of anesthetic that exceeds the 1MAC (minimum alveolar concentration) upperlimit (see below). In patients with space oc-cupying intracranial lesions with verified highICP, or brain swelling during surgery, propofol isused for the maintenance of anesthesia, afterthe induction with thiopental. Inhalation anes-thetics are contraindicated in such a situation.Propofol is known to decrease ICP, so wheneverpropofol infusion is used, hyperventilation iscontraindicated. Nitrous oxide (N2O) is knownto diffuse into air-containing spaces, resultingin their expansion, or in case of non-compliantspace, in increased pressure. Therefore, N2O iscontraindicated in patients who have under-gone previous craniotomy within two weeks, orwho show intracranial air on the preoperativeCT-scan. In these patients the use of N2O couldresult in increase of the ICP due to enlarge-ment of intracranial air bubbles.PositioningHead 15–20 cm above heart level in all positionsExcessive head flexion or rotation is avoided ensuresgood venous returnOsmotherapyOne of the three options below, given early enough beforedura is openedMannitol 1g/kg i.v.Furosemide 10–20 mg i.v. + mannitol 0.25–0.5 g/kg i.v.NaCl 7.6% 100 ml i.v.Choice of anestheticsHigh ICP anticipated Propofol infusion without N2ONormal ICP Propofol infusion or volatile anesthetics(sevoflurane/isoflurane ± N2O)Ventilation and blood pressureNo hypertensionMild hyperventilationNote! With volatile anesthetics, hyperventilate up toPaCO2= 4.0–4.5kPaCSF drainageLumbar drain in lateral park bench positionRelease of CSF from cisterns or third ventricle throughlamina terminalis intraoperativelyEVD if difficult access to cisternsTable 3-1. Helsinki concept of slack brain during craniotomy
47General physiological principles | Anesthesia | 33.1.2. Autoregulation of cerebral blood flowAdequacy of the CPP must be assessed individu-ally. CBF autoregulation is absent, or disturbed,at least locally in most neurosurgical patients,so that CBF becomes linearly associated withsystemic arterial blood pressure (Figure 3-2).In addition, the CBF-CPP-autoregulation curvemay also be shifted either to the right (espe-cially in subarachnoid hemorrhage patients), orto the left (in children or in arteriovenous mal-formation patients), implying respective higheror lower CPP requirements to ensure adequateCBF (Figure 3-3). Furthermore, increased sym-pathetic activity, chronic hypertension, liverdysfunction, infection or diabetes may disturbCBF autoregulation.CBF(ml/100g/min)100500CPP (mmHg)NormalAbsent0 50 100 150Figure 3-2. Normal or absent autoregulation of cerebralblood flow (CBF). CPP, cerebral perfusion pressureThe limits of autoregulation are estimated byassessing the effect of increase, or decrease, inMAP on CBF by means of ICP (or CBF) measure-ment. The static autoregulation is expressed asthe percentage change of ICP (or CBF) relatedto the change of MAP over the predeterminedinterval. The dynamic autoregulation indicatesthe rate (in seconds) of response of the changein ICP (or CBF) to the rapid change in MAP. Asthe presence of intact autoregulation or thelimits of autoregulation cannot be estimatedin routine anesthesia practice, we must rely onthe assumption of its state. In patients withSAH, or acute brain injury, autoregulation maybe disturbed or absent altogether, whereas, insome other neurosurgical patients it may benormal. As a result, normotension or estimatedCPP of 60 mmHg or higher is the goal of ourtreatment. In SAH patients the lower limit ofautoregulation may be much higher.The volatile anesthetics are known to impairautoregulation in a dose-dependent fashion,whereas intravenous agents generally do nothave this effect. Isoflurane and sevoflurane canbe administered up to 1.0 and 1.5 MAC respec-tively, whereas desflurane impairs autoregula-tion already in 0.5 MAC. Therefore, isofluraneand sevoflurane are suitable for neuroanesthe-sia, and can be delivered either in oxygen-N2Omixture or in oxygen-air mixture. When N2O isused, the targeted anesthetic depth is achievedwith smaller gas concentrations than withoutN2O. Bearing in mind that high concentrationsof all inhaled anesthetics may evoke general-ized epileptic activity, adding N2O to the gas ad-mixture seems advantageous. The pros and consof N2O are also discussed in section 3.4. Forsevoflurane, it is not recommended to exceed3% inhaled concentration in neuroanesthesia.CBF(ml/100g/min)100500CPP (mmHg)?Increased sympathetic activityChronic hypertensionSAHAVMNormal0 50 100 150Figure 3-3. The assumed shift of the cerebral blood flow(CBF)- cerebral perfusion pressure (CPP)-autoregulationcurve in subarachnoid hemorrhage (SAH) or in arteriove-nous malformation (AVM) patients. The safe limits of theCPP must be assessed individually
483 | Anesthesia | General physiological principles3.1.3. CO2reactivityThe second clinically important factor regulat-ing CBF is arterial CO2tension (PaCO2) (cerebralCO2reactivity). We generally normoventilatethe patients during anesthesia. In patientswith high intracranial pressure (ICP) or severebrain swelling, we may use slight hyperven-tilation, but in order to avoid brain ischemiaPaCO2should not be allowed to decrease below4.0 kPa. When even lower PaCO2is needed inthe ICU, global cerebral oxygenation should bemonitored by brain tissue oxygen tension todetect possible excessive vasoconstriction in-duced ischemia. In clinical practice it is of ut-most importance to highlight the impairmentof cerebral CO2reactivity during hypotension(Figure 3-4). The reactions of hypercapnia-induced cerebral vasodilatation (CBF, ICP) orhypocapnia-induced cerebral vasoconstriction(CBF, ICP) are impaired if the patient has hy-potension. Thus, CBF and ICP may remain un-changed although PaCO2tension is modified inhypotensive patients. In contrast to the effectof PaCO2on CBF, the PaO2does not affect onCBF if PaO2is above 8 kPa, which is the criti-cal level for hypoxemia. A powerful increase inCBF is seen when PaO2is extremely low, e.g. <6.0 kPa.While CO2reactivity is disturbed by vari-ous pathological states, it is rather resistantto anesthetic agents. In patients with an in-creased ICP or those with limited reserve forcompensation, even modest increases of PaCO2may cause marked further increase in the ICP.Therefore, periods without ventilation must bekept as short as possible, for instance duringintubation or awakening. As a categorical rulefor craniotomy patients, hypoventilation mustbe avoided during awakening, because possiblepostoperative intracranial bleeding togetherwith increased PaCO2may result in a detrimen-tal increase in ICP.12080400-40RelativechangeinCBF(%)1.5 6.5 10PaCO 2 (kPa)MAP80 mmHg50 mmHg30 mmHg4.0Figure 3-4. The effect of arterial carbon dioxide tension(PaCO2) on cerebral blood flow (CBF) at various mean arteri-al pressure (MAP) levels
49General physiological principles | Anesthesia | 33.1.4. Cerebral metabolic couplingThe third clinically important neuroanesthe-siological aspect is cerebral metabolic coupling(Table 3-2). CBF is regulated by the metabolicrequirements of brain tissue (brain activationCBF, rest or sleep CBF). Of brain cell metabo-lism, 40-50% is derived from basal cell metab-olism and 50-60% from electrical activity. Theelectrical activity can be abolished by anes-thetic agents (thiopental, propofol, sevoflurane,isoflurane), but only hypothermia can decreaseboth the electrical activity and the basal cellmetabolism. Propofol seems to preserve cou-pling, but volatile agents do not. N2O seems toattenuate the disturbance. Impaired couplingresults in CBF exceeding the metabolic demand(luxury perfusion).CMRO2 CBF ICP vasodilatationIsoflurane (*) (*) +Sevoflurane (*) (*) +N2O +Thiopental -Propofol -Midazolam -Etomidate -Droperidol -Ketamine +*with mild hyperventilationTable 3-2. The effects of anesthetic agents on cerebral metabolic rate for oxygen (CMRO2)cerebral blood flow (CBF), intracranial pressure (ICP) and cerebral arterial vasodilatation.
503 | Monitoring of anesthesiaTable 3-3. Routine monitoring for craniotomy• ECG• Invasive blood pressure (zeroed at the level of Foramen Monroe)• SpO2• EtCO2• Side stream spirometry, airway gas monitoring• Hourly urine output• Core temperature• Neuromuscular blockade• CVP and cardiac output (with PICCO™ or Vigileo™) – not monitored routinely** only in major bypass surgery, in microvascular freeflaps in skull base surgery or if medically indicated.3.2. MONITORING OF ANESTHESIARoutine monitoring in neuroanesthesia in-cludes heart rate, ECG (lead II with or with-out lead V5), peripheral oxygen saturation, andnon-invasive arterial blood pressure beforeinvasive monitoring is commenced (Table 3-3).A radial or femoral arterial cannula is insertedfor direct blood pressure measurements in allcraniotomy patients or whenever the patientsmedical condition requires accurate monitor-ing of hemodynamics or determination of re-peated blood gas analyses.The invasive arterial transducer set is zeroedat the level of the foramen of Monro. Centralvenous line for central venous pressure (CVP)measurements or right atrial catheter for pos-sible air aspiration is not routinely insertedbefore surgery, not even for patients in sittingposition. CVP, cardiac index and systemic vas-cular resistance may be monitored by meansof arterial and central venous catheters (arte-rial pressure-based cardiac output, Vigileo™ or Picco™) in patients on vasoactive agents or needing extensive fluid administration at theOR or ICU. Hourly urine output is measured inall craniotomy patients.Side-stream spirometry and airway gas pa-rameters (inspired O2, end-tidal CO2and O2,end-tidal sevoflurane/isoflurane, and MAC) aremonitored after intubation. Ventilatory andairway gas measurements are performed fromthe breathing circuit at the connection piecewith a filter and flexible tube at 20 cm distanceto the tip of the intubation tube. The light dis-posable breathing circuit minimizes the risk ofmovement of the endotracheal tube during theactual positioning of the patient for the sur-gery. The cuff pressure of intubation tube ismeasured continuously.Core temperature is measured with a nasopha-ryngeal temperature probe in all patients, andperipheral temperature with a finger probe inpatients undergoing cerebrovascular bypass ormicrovascular reconstructions. During anesthe-sia blood gas analysis uncorrected for tempera-ture is performed routinely to ensure optimalPaCO2and PaO2. In some cases, ICP is measuredvia ventriculostomy or intraparenchymal trans-ducer before the dura is opened. In the sittingor semi-sitting position the precordial dopplerultrasonography probe is placed over the fifthintercostal space, just to the right of the ster-num, to detect possible venous air emboli inthe right atrium.The neuromuscular blockade is monitored by aneurostimulator (train of four or double burststimulation). The twitch response is evaluatedfrom the arm that is not affected by a possiblehemiparesis.
51Preoperative assessment and induction of anesthesia | 33.3. PREOPERATIVE ASSESSMENT ANDINDUCTION OF ANESTHESIAOn most occasions, preoperative evaluation isperformed the day before the scheduled sur-gery, but in complicated cases, the patient canbe invited to the hospital for a separate preop-erative visit. In addition to clinical examination,ECG and laboratory tests are obtained (Table3-4). As a general rule, patients health statusis optimized if the delay is not considered toworsen the patients neurosurgical outcome.Elective patients with normal consciousnessare premedicated with oral diazepam, exceptfor certain special procedures (e.g. surgery forepilepsy under neurophysiologic monitoring).Small children are premedicated with mida-zolam. Preoperatively, spontaneously breathingpatients are usually not given any opioids infear of respiratory depression and accumula-tion of CO2leading to an increase in ICP. Anti-convulsants are not discontinued preoperative-ly. However, in patients scheduled for epilepsysurgery, the preoperative dosage or type of an-ticonvulsants may be modified to enable intra-operative localization of epileptic foci by corti-cal EEG. Other prescribed drugs are consideredindividually. The cessation of antithromboticdrugs are discussed in section 3.7.4.Before the induction of anesthesia we recom-mend glycopyrrolate 0.2 mg intravenously. Theanesthesia for craniotomy is induced with in-travenous fentanyl (5-7 µg/kg) and thiopental(3-7 mg/kg). Thiopental is preferred to propo-fol because of its verified antiepileptic prop-erty. The dose of fentanyl (5-7 µg/kg) is suf-ficient to prevent the hemodynamic responseto laryngoscopy and intubation without delay-ing emerging from anesthesia. Orotracheal in-tubation is used, unless the surgical approachrequires nasotracheal intubation. Supraglotticairways, such as laryngeal mask, are not used.The intubation tube is fixed firmly with tapewithout compressing jugular veins.Possible hypotension (estimated CPP < 60mmHg) is corrected immediately by incrementsof intravenous phenylephrine (0.025-0.1 mg)or ephedrine (2.5-5 mg). After intubation, me-chanical volume controlled ventilation withoutany positive end-expiratory pressure (PEEP) isadjusted according to the end-tidal CO2to-gether with hemodynamical profile. Later on,gas exchange is confirmed by arterial blood gasanalysis. Volatile anesthetics are not adminis-tered until mild hyperventilation is confirmed.Coagulation profileNormal proceed normallyAbnormal corrective stepsConsciousnessNormal proceed normallyDecreased no sedative premedication, planfor delayed extubation at NICUNeurological deficitsLower cranial nerve dysfunction warn patientof prolonged ventilator therapy andpossible tracheostomyPre-op CT/MRI scansNormal ICP proceed normallySigns of raised ICP plan anesthesia accordingly(mannitol, choice of anesthetics)Planning of approach and positioningI.v.-lines, arterial cannula in appropriate extremityEasy access to airwaysPossibility of major bleeding have blood crosscheckedSpecial techniques will be employed (e.g. adenosine) prepare accordinglyTable 3-4. Preoperative assessment by the anesthesiologist
523 | Preoperative assessment and induction of anesthesiaFigure 3-5. (a-c) Nasal endotracheal intubation under local anesthesia and light sedation in a patientwith instability of cervical spine, performed by Dr. Juhani Haasio (published with patient‘s permission)A BCNeuromuscular blockade is achieved with ro-curonium. Succinylcholine is administered, un-less contraindicated, to facilitate intubationin patients requiring instant preparation forneurophysiological monitoring (motor evokedpotential, MEP), or in selected cases of antici-pated difficult airway. In patients with antici-pated difficult intubation or instability in thecervical spine, nasal endotracheal intubationunder local anesthesia and light sedation (fen-tanyl 0.05-0.1 mg i.v., diazepam 2.5-5 mg i.v.)is performed with fiberscope (Figure 3-5). Topi-cal anesthesia of the nasal passage is achievedwith cotton sticks soaked in 4% lidocaine orcocaine, and topical anesthesia of the pharynx,larynx and trachea by injecting 4% lidocaineeither transtracheally or sprayed through theworking channel of the fiberscope.
53Maintenance of anesthesia | 33.4. MAINTENANCE OF ANESTHESIAThe anesthesia method is selected according tothe CNS pathology and the effects of variousanesthetic agents on CBF and ICP (Table 3-2).Patients can be roughly divided into two cat-egories: (1) those without any signs of raisedICP, scheduled for elective craniotomy, and (2)those with known high ICP, any acute trauma,or intracranial bleeding (Table 3-5). In selectedcases, special approaches are needed.If there are no signs of brain swelling or elevat-ed ICP, anesthesia is maintained with sevoflu-rane or isoflurane in oxygen mixed with eitherN2O or air up to 1.0 MAC. In our practice, N2Ois usually a component of inhalation anesthe-sia. It allows lower inspired concentrations ofsevoflurane or isoflurane to achieve the ad-equate depth of anesthesia (1.0 MAC). Oneshould remember, that the cerebral vasodila-tory effect of N2O is blunted by the simultane-ous administration of intravenous barbiturates,benzodiazepins or propofol. The poor solubilityof N2O permits rapid recovery from anesthe-sia. We continue to give N2O until the end ofsurgery. N2O equilibrates with intracranial airbefore the dura is closed. Thus, once the durais closed and N2O discontinued, the amount ofintracranial air will decrease as N2O diffusesback into the bloodstream. The use of N2O dur-ing neurosurgery does not cause detrimentallong-term neurologic or neuropsychologicaloutcome. N2O is contraindicated in patientswith increased risk of venous air embolism(VAE), recraniotomy within a few weeks, severecardiovascular disease or excessive air in bodycavities (e.g. pneumothorax, intestinal occlu-sion or perforation).In patients with signs of high ICP, acute braininjury, or tight brain during surgery, anesthesiais maintained with propofol infusion (6-12 mg/kg/hour) without any inhaled anesthetics. Thediscontinuation of all inhaled anesthetics of-ten promptly decreases brain swelling withoutany further interventions. However, if the braincontinues to swell and threatens to herniatethrough the dural opening, additional dosesof mannitol, hypertonic saline and thiopentalmay be given. Momentary deep hyperventila-tion (PaCO23.5 kPa) and head elevation canalso attenuate brain congestion.For intraoperative analgesia, either fentanyl bo-luses (0.1 mg) or remifentanil infusion (0.125-0.25 µg/kg/min) is administered. Fentanyl isgenerally preferred in patients who are likelyto need controlled ventilation postoperatively,and remifentanil in those who will be extubatedimmediately after surgery. The dose of opioidsis adjusted according to the pain stimuli duringcraniotomy. Remifentanil effectively blocks thehemodynamic response induced by pain andcan be given in 0.05 to 0.15 mg boluses priorto anticipated painful stimuli to prevent hyper-tension. Remifentanil bolus is recommendedbefore the application of the head holder pins.We do not routinely inject local anesthetics atthe site of these pins except in awake patients.The site of skin incision is infiltrated with amixture of ropivacaine and lidocaine combinedwith adrenalin. The most painful phases of cra-nial surgery are the approach through the softtissues as well as wound closure. The repetitivesmall doses of fentanyl should be administeredcautiously since the same total amount of fen-tanyl can cause markedly higher plasma con-centrations given as small boluses comparedto a greater single dose. In cases of suddenprofound changes in blood pressure or heartrate, the neurosurgeon must be immediatelynotified, since surgical manipulation of certainbrain areas may induce hemodynamical distur-bances. Neuromuscular blockade is maintainedwith boluses of rocuronium as needed.