Airway Management in Neurosurgical Patients

Airway management for the neurosurgical patient requires thoughtfulness and occasional creativity. Patients may present with problems such as increased intracranial pressure, a ruptured aneurysm, or limited cervical spine movement (or all three combined). It is important to know the initial neurologic status of the patient, as well as the airway exam when it is possible. Many pharmacologic and physiologic techniques can be employed to ensure adequate intracranial dynamics before intubation and after the airway is secured. Airway management is carefully approached in the setting of acute trauma and requires planned steps with alternatives in the case of failure. The variety of elective neurosurgical cases provides unique challenges, such as “awake craniotomy” or surgery within a stereotactic headframe. While the flexible intubation scope is an essential tool, the newer video-assisted laryngoscopes are proving to be invaluable in many situations of difficult or failed intubation. The use of a supraglottic airway as a rescue or preferred technique is becoming accepted in appropriate patients. Lastly, the art of extubation and the decision-making required is constantly evolving.