ANESTHESIA FOR STEREOTAXIC RADIOSURGERY IN CHILDREN

The development of stereotactic radiosurgery has been a major advance in the treatment of intracranial lesions. By using a stereotactic head frame attached to the skull, large doses of radiation can be delivere d precisely to the lesion while sparing surrounding tissues. Although adults can usually undergo this procedure with local anesthesia or con scious sedation alone, children frequently require general anesthesia. This report describes our experience with the anesthetic management o f all children who have received this therapy at our institution since the inception of our stereotactic radiosurgery program in 1986 throug h June 1993. Sixty-eight radiosurgery procedures were performed in 65 patients. Anesthesia time averaged 9.2 h (range, 7-15). Twenty-two pat ients (ages 11-17; mean 14.3) received local anesthesia alone, two pat ients (ages 11 and 15) received local anesthesia plus i.v. sedation, a nd 44 patients (ages 2-14; mean, 7.3) received general anesthesia. Fou r potentially serious anesthesia-related events occurred; in one child (age 7) receiving general anesthesia, an endotracheal tube obstructio n developed during radiosurgery requiring rapid reintubation while the child was still in the head frame; another (age 7) who was undergoing chemotherapy and had neutropenia and rhinitis had a lobar collapse wh ile intubated, requiring mechanical ventilation and endotracheal tube suctioning for lung expansion. Another (age 5) with a recent upper res piratory tract infection had copious endotracheal secretions and sinus itis (ethmoid and maxillary) noted on initial computed tomography scan ning and was given antibiotics and decongestants (following nasotrache al extubation), and another (age 15) receiving sedation without endotr acheal intubation vomited an undigested meal midway through the proced ure while her head was partially immobilized in the head frame. All pa tients were treated successfully and none suffered any adverse consequ ences of the anesthesia. One teenager (age 16) who had the procedure p erformed with local anesthesia alone complained of discomfort despite analgesic medications and regretted not having general anesthesia. Pro blems following the procedure included vomiting (11 patients), headach e treated with analgesics (26 patients), postextubation croup (eight p atients), and prolonged lethargy (one patient). Children who undergo s tereotactic radiosurgery are at risk for the development of serious pr oblems, largely because of the need to immobilize the head in a head f rame. A stereotactic head frame that permits access to the airway has been developed and should be used for these procedures. Special concer ns arise in children who require sedation or general anesthesia, espec ially since the procedure is performed in many different locations ove r a prolonged period. Anesthesiologists caring for these patients shou ld be aware of the potential difficulties that can develop and all chi ldren should be observed carefully throughout the procedure.