Anesthesia for Supratentorial Craniotomy — MCQs

10 questions

A case of trauma comes to the emergency. On examination there is evidence of head injury, BP is 90/60 mmHg, and pulse is 150/min. Which of the following anesthetic agent should be used for induction?

In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

A patient was operated for right upper lobe resection. He was shifted to post awakening recovery after completion of surgery with vitals- BP 100/70 mm of Hg, HR - 94bpm, SPO2 100. After 2 hrs when he was assessed ,his vitals was BP 70/50 mm of Hg. HR-126 bpm ,SPO2 92 and surgical drain was filled with blood. Immediate re-exploration was planned. IV anaesthetic agent of choice -

A 40-year-old male with a head injury presents with a GCS of 8, BP of 90/60, and HR of 120. A CT scan shows an epidural hematoma. What are the immediate management priorities?

Child with aspiration risk needs emergency surgery. Best induction sequence is:

Which of the following should be considered as the cause of generalized convulsions 20 minutes postoperatively?

Anesthetic agent contraindicated in raised ICT is?

Emergence delirium is associated with –

Inhalational agent of choice for neurosurgery?

Q10

Which of the following drugs is contraindicated in a patient with raised intracranial pressure ?

Anesthesia for Supratentorial Craniotomy Indian Medical PG Practice Questions and MCQs

Question 1: A case of trauma comes to the emergency. On examination there is evidence of head injury, BP is 90/60 mmHg, and pulse is 150/min. Which of the following anesthetic agent should be used for induction?

A. Halothane
B. Succinylcholine
C. Thiopentone (Correct Answer)
D. Ketamine

Explanation: ***Thiopentone*** - It is a **short-acting barbiturate** that causes **rapid unconsciousness** and **reduces cerebral blood flow** and **intracranial pressure (ICP)**, which is beneficial in head injury. - It also has **cardiovascular-depressant effects** that can help manage hypertension, though in this hypotensive patient, careful titration is needed, but its **ICP-lowering effect** is crucial. *Halothane* - Halothane is a **volatile anesthetic** that can cause **dose-dependent myocardial depression** and a **decrease in blood pressure**, which would worsen the patient's existing hypotension. - It also tends to **increase cerebral blood flow**, which is counterproductive in a patient with a head injury and potential increased ICP. *Succinylcholine* - Succinylcholine is a **neuromuscular blocker** used for **rapid sequence intubation**, not as an anesthetic induction agent. - It can cause a **transient increase in ICP** and **hyperkalemia**, both of which can be detrimental in a trauma patient with head injury. *Ketamine* - Ketamine is a dissociative anesthetic that can **increase heart rate** and **blood pressure**, which could be beneficial in a hypotensive patient. - However, it also tends to **increase cerebral blood flow** and **intracranial pressure (ICP)**, making it less ideal for a patient with a head injury.

Question 2: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

A. 20% Mannitol (Correct Answer)
B. Lasix
C. Glycine
D. Steroids

Explanation: ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.

Question 3: A patient was operated for right upper lobe resection. He was shifted to post awakening recovery after completion of surgery with vitals- BP 100/70 mm of Hg, HR - 94bpm, SPO2 100. After 2 hrs when he was assessed ,his vitals was BP 70/50 mm of Hg. HR-126 bpm ,SPO2 92 and surgical drain was filled with blood. Immediate re-exploration was planned. IV anaesthetic agent of choice -

A. Thiopentone
B. Propofol
C. Ketamine (Correct Answer)
D. Etomidate

Explanation: ***Ketamine*** - The patient is experiencing **hypovolemic shock** due to hemorrhage, characterized by **hypotension** (BP 70/50), **tachycardia** (HR 126), and **hypoxia** (SpO2 92). Ketamine is the preferred agent in this scenario due to its **sympathomimetic effects**, which help to **maintain hemodynamic stability** by increasing heart rate and systemic vascular resistance. - Unlike other intravenous anesthetics, ketamine typically **preserves pharyngeal and laryngeal reflexes** and causes minimal respiratory depression, which is advantageous in a critically ill patient. *Thiopentone* - This drug is a **barbiturate** known for its significant **myocardial depressant effects** and tendency to cause marked **vasodilation**, both of which would further exacerbate the patient's existing hypotension and shock state. - It also causes direct **respiratory depression** and abolished airway reflexes, making it unsuitable for a hemodynamically unstable patient. *Propofol* - Propofol is a potent **vasodilator** and **myocardial depressant**, leading to a dose-dependent decrease in blood pressure through reduction of systemic vascular resistance and cardiac output. - It lacks analgesic properties and can cause significant **respiratory depression** and apnea, which would be detrimental to a patient with compromised oxygen saturation. *Etomidate* - While etomidate is known for its **hemodynamic stability** and minimal impact on blood pressure, it causes **adrenocortical suppression** by inhibiting 11-beta-hydroxylase, which can be detrimental in a stressed patient requiring an adequate stress response. - It also has a high incidence of **myoclonus** and **postoperative nausea and vomiting**, which are undesirable in a patient requiring emergency re-exploration when other options with more beneficial effects are available.

Question 4: A 40-year-old male with a head injury presents with a GCS of 8, BP of 90/60, and HR of 120. A CT scan shows an epidural hematoma. What are the immediate management priorities?

A. Intubation and ventilation (Correct Answer)
B. Administer mannitol for intracranial pressure management
C. Perform immediate craniotomy
D. Administer intravenous fluids and monitor vital signs

Explanation: ***Intubation and ventilation*** - A GCS of 8 or less mandates **immediate intubation** to protect the airway and prevent aspiration in a patient who cannot maintain their airway. - In the **ATLS primary survey sequence**, airway management is the first priority, though in practice this is done **simultaneously** with fluid resuscitation. - Maintaining **adequate oxygenation and normocapnia** is crucial for preventing secondary brain injury and managing intracranial pressure. - **Critical point**: While this patient requires both airway management AND fluid resuscitation urgently, securing the airway takes immediate precedence as the patient cannot protect their airway at GCS 8. *Administer mannitol for intracranial pressure management* - While mannitol can reduce ICP, it is **not an immediate priority** before securing airway, breathing, and circulation. - Mannitol is **contraindicated in hypovolemic/hypotensive patients** as it acts as an osmotic diuretic and can worsen hypotension. - ICP management with mannitol should only be considered after hemodynamic stabilization and in the context of signs of herniation. *Perform immediate craniotomy* - Although epidural hematomas typically require **urgent surgical evacuation**, the patient must first be physiologically stabilized. - **No patient should go to the operating room in hemorrhagic shock** without ABC stabilization. - Airway protection, ventilation, and circulatory resuscitation must precede definitive neurosurgical intervention to ensure the patient can safely tolerate anesthesia and surgery. *Administer intravenous fluids and monitor vital signs* - This is a **critical and equally urgent priority** - the patient is in shock (BP 90/60, HR 120), likely from associated injuries or blood loss. - **Hypotension (SBP <90 mmHg) is the most detrimental secondary insult** in head-injured patients and doubles mortality (per Brain Trauma Foundation guidelines). - Fluid resuscitation should begin **simultaneously** with airway management to restore cerebral perfusion pressure. - However, in the ATLS sequence, airway (A) precedes circulation (C), making intubation the first listed priority, though both must be addressed concurrently in practice.

Question 5: Child with aspiration risk needs emergency surgery. Best induction sequence is:

A. Preoxygenation-ketamine-succinylcholine
B. Sevoflurane-propofol-succinylcholine
C. Midazolam-propofol-rocuronium
D. Preoxygenation-propofol-succinylcholine (Correct Answer)

Explanation: ***Preoxygenation-propofol-succinylcholine*** - This sequence describes a **rapid sequence intubation (RSI)**, which is the preferred method for patients at high risk of aspiration, including children needing emergency surgery with an unknown fasting status. - **Preoxygenation** provides an oxygen reserve during the apneic period, **propofol** offers rapid induction with good hemodynamic stability, and **succinylcholine** provides fast-onset, short-acting neuromuscular blockade, crucial for preventing aspiration. *Preoxygenation-ketamine-succinylcholine* - While preoxygenation and succinylcholine are appropriate for RSI, **ketamine** may not be the optimal choice for a child with aspiration risk due to its potential to increase secretions and maintain laryngeal reflexes, which could complicate intubation. - Ketamine can also cause **emergence delirium** in some children, making it less favorable for a smooth anesthetic course compared to propofol. *Sevoflurane-propofol-succinylcholine* - **Sevoflurane** is an inhaled anesthetic often used for mask induction in children due to its non-pungent odor and rapid onset. However, it is generally **not suitable for RSI** in patients with aspiration risk as it has a slower induction time compared to intravenous agents and can cause coughing or laryngospasm. - Using both sevoflurane and propofol for induction in an RSI scenario is redundant and prolongs the induction phase, increasing aspiration risk. *Midazolam-propofol-rocuronium* - **Midazolam** is a benzodiazepine used for anxiolysis and sedation but has a **slower onset** and longer duration of action compared to propofol for rapid induction. - **Rocuronium** is a non-depolarizing neuromuscular blocker with a slower onset of action than succinylcholine, making it less ideal for RSI where immediate paralysis for intubation is critical to prevent aspiration.

Question 6: Which of the following should be considered as the cause of generalized convulsions 20 minutes postoperatively?

A. Enflurane (Correct Answer)
B. Halothane
C. Isoflurane
D. Sevoflurane

Explanation: ***Enflurane*** - **Enflurane** is well-known to cause **generalized convulsions** or seizure-like activity during emergence from anesthesia, particularly when inspired concentrations exceed 3.0% or with hypocapnia. - The risk of seizures is a significant reason why enflurane is rarely used in modern anesthetic practice compared to newer volatile agents. *Halothane* - **Halothane** is associated with cardiac arrhythmias and hepatotoxicity but generally does not cause generalized convulsions as a primary side effect. - While it can lower the seizure threshold, overt seizures are not a common complication of halothane administration. *Isoflurane* - **Isoflurane** is associated with CNS depression and can, in rare cases, cause myoclonus, but it is not typically linked to generalized tonic-clonic convulsions. - It is often used in neurosurgery due to its beneficial effects on cerebral blood flow and minimal seizure-inducing potential. *Sevoflurane* - **Sevoflurane**, while capable of causing excitatory movements or myoclonus during induction and emergence, is not a common cause of clear-cut generalized convulsions in healthy patients. - High concentrations in pediatric patients or those with pre-existing seizure disorders might slightly increase the risk of seizure-like EEG changes, but it is less epileptogenic than enflurane.

Question 7: Anesthetic agent contraindicated in raised ICT is?

A. Thiopentone
B. Etomidate
C. Ketamine (Correct Answer)
D. Sevoflurane

Explanation: ***Ketamine*** - **Ketamine** is known to increase **cerebral blood flow** and metabolic rate, which can lead to a significant increase in **intracranial pressure (ICP)**. - This effect makes **ketamine** contraindicated in situations of elevated ICP, as it can worsen neurological outcomes. *Thiopentone* - **Thiopentone** is a barbiturate that typically causes a dose-dependent **decrease in cerebral blood flow** and **metabolic rate**, leading to a *reduction* in ICP. - It is often used to *lower* ICP in neurosurgical settings rather than being contraindicated. *Etomidate* - **Etomidate** also causes a **reduction in cerebral blood flow** and **cerebral metabolic rate**, leading to a *decrease* in ICP. - It is considered a relatively **hemodynamically stable** induction agent, making it suitable in many cases with neurological concerns. *Sevoflurane* - **Sevoflurane**, an inhaled anesthetic, can cause **cerebral vasodilation** at higher concentrations, potentially *increasing* ICP. - However, this effect is often *attenuated* by concurrent hyperventilation, and its overall impact on ICP is less pronounced than **ketamine's** and often manageable.

Question 8: Emergence delirium is associated with –

A. Halothane
B. Pentothal sodium
C. Droperidol
D. Ketamine (Correct Answer)

Explanation: ***Ketamine*** - **Ketamine**, an N-methyl-D-aspartate (NMDA) receptor antagonist, is known to cause **emergent delirium** or **psychotic reactions** during recovery from anesthesia due to its dissociative properties. - This adverse effect is more common in adults and can manifest as **hallucinations**, **vivid dreams**, and **confusion**, particularly when used as a sole anesthetic agent. *Halothane* - **Halothane** is an inhalational anesthetic that was associated with relatively slow emergence, but not typically with **delirium** as a prominent feature. - Its primary concern was **hepatotoxicity** (halothane hepatitis) and **malignant hyperthermia**, rather than emergence delirium. *Pentothal sodium* - **Pentothal sodium** (thiopental) is a short-acting barbiturate used for induction of anesthesia, known for rapid onset and offset. - While it can cause some **post-operative drowsiness**, it is not primarily associated with **emergent delirium**; instead, it provides a smooth and calm recovery. *Droperidol* - **Droperidol** is an antipsychotic and antiemetic agent often used to prevent post-operative nausea and vomiting, and can cause **sedation**. - It is known to **reduce** the incidence of emergence delirium caused by other agents, rather than causing it itself.

Question 9: Inhalational agent of choice for neurosurgery?

A. Halothane
B. Enflurane
C. Isoflurane (Correct Answer)
D. N2O

Explanation: ***Isoflurane*** - **Isoflurane** is preferred in neurosurgery due to its minimal impact on **cerebral blood flow** and **intracranial pressure (ICP)**, allowing cerebral autoregulation to be largely preserved. - It maintains **cerebral perfusion pressure** well and has a relatively fast onset and offset, facilitating neurological assessment post-operatively. *Halothane* - **Halothane** significantly increases **cerebral blood flow** and **intracranial pressure (ICP)**, which is undesirable in neurosurgical patients. - Its slow elimination can prolong recovery and neurological assessment, making it unsuitable for neurosurgery. *Enflurane* - **Enflurane** can cause central nervous system excitation and has been associated with **seizure activity** at higher concentrations, making it contraindicated in neurosurgical procedures. - Like halothane, it can also increase **cerebral blood flow** and **intracranial pressure**. *N2O* - **Nitrous oxide (N2O)** should be avoided in neurosurgery, especially if there's a risk of **intracranial air** or **pneumocephalus**, as it can expand air-filled spaces and increase ICP. - It also has a weak anesthetic effect and is often combined with other agents, but its cerebral vasodilatory properties can still be problematic.

Question 10: Which of the following drugs is contraindicated in a patient with raised intracranial pressure ?

A. Ketamine (Correct Answer)
B. Midazolam
C. Propofol
D. Thiopentone

Explanation: ***Ketamine*** - **Ketamine** typically causes an increase in **cerebral blood flow** and **intracranial pressure (ICP)**, making it contraindicated in patients with raised ICP. - This effect is due to its action as a **dissociative anesthetic** which can lead to cerebral vasodilation. *Midazolam* - **Midazolam**, a benzodiazepine, can decrease **cerebral metabolic rate** and **cerebral blood flow**, thereby reducing ICP, making it a suitable option for sedation in patients with raised ICP. - It provides **sedation** and **anxiolysis** without significantly increasing ICP. *Propofol* - **Propofol** is a common choice for sedation in patients with raised ICP because it significantly reduces **cerebral blood flow**, **cerebral metabolic rate**, and thus **intracranial pressure**. - Its rapid onset and offset allow for precise control of depth of sedation and neurological assessment. *Thiopentone* - **Thiopentone**, a barbiturate, effectively reduces **cerebral blood flow** and **cerebral metabolic rate**, leading to a decrease in **intracranial pressure**. - It is often used for inducing anesthesia and as a neuroprotective agent in situations with acute brain injury.

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