Neuroanesthesia

Fundamentals — 16 reading days, with a Friday consolidation quiz closing each week.

1. Day 01 The Territory Tells You the Vessel A new deficit in recovery is two different problems wearing the same face. Where it sits — inside one arterial territory, or on the seam between two — narrows the mechanism faster than how bad it looks. Cerebral circulation uncertain Consensus
2. Day 02 Flow Follows Metabolism The coupling is real and it survives anesthesia. What does not survive inspection is the arithmetic — flow overshoots oxygen use during activation, and the lower limit of autoregulation everyone draws at 50 is a population average that sits below where the average actually is. Cerebral circulation uncertain Consensus
3. Day 03 The Number and the Waveform Everyone knows the threshold. Almost nobody knows that the only randomized trial of monitoring against it was neutral, that the number is a dose rather than a line, and that the waveform which would actually tell you about compliance has never been shown to change anything. Intracranial pressure uncertain Trials
4. Day 04 Before the Dura Opens By the time the surgeon asks whether the brain is slack, every decision that determines the answer has already been made. The pre-dural hour is a sequence of anticipatable stimuli, each with a countermeasure that has to be given before it, not after. Supratentorial surgery supported Consensus
5. Friday Week One — Circulation, Pressure, and the Slack Brain Ten questions on the first four days. Most of them will not sit inside a single day, because the mistakes this week is guarding against happen where two days meet — a pressure target chosen from one day and a transducer zeroed by another. 10 questions no new material
6. Day 05 The Case Starts Before the Turn Turning a patient prone converts a set of ordinary decisions into permanent ones. Everything you would want in an emergency has to be in place while the patient is still supine, and the triggers for each of them are known before the case starts. Spine and spinal cord supported Consensus
7. Day 06 Padding Is a Neurovascular Manoeuvre How the patient sits on the frame sets the pressure in a valveless venous system that drains the spinal canal, and the pressure behind the eye. Both determine outcomes people usually attribute to the surgery. Positioning uncertain Consensus
8. Day 07 What the Signals Actually Watch Somatosensory and motor evoked potentials are not two views of the same thing. They follow different tracts, in different vascular territories, with different alarm criteria — and only one of those criteria is the tidy rule everyone quotes. Neuromonitoring supported Consensus
9. Day 08 The Long Fusion A multilevel instrumented fusion is defined by two quantities that get counted afterwards: how much blood was lost and how much opioid was needed. Both have real randomized evidence behind them, and in both cases the trial says something narrower than the slogan. Spine and spinal cord supported Trials
10. Friday Week Two — Turning, Watching, Bleeding Four days about the spine, and three of them are really about the same thing: decisions made before anything happens, because afterwards the patient is face-down on a frame and your options have gone. 10 questions no new material
11. Day 09 Three Kinds of Swelling, One Steroid Dexamethasone is dramatic in peritumoral oedema and does nothing for the cytotoxic kind. Giving it anyway is not a harmless hedge — in 10,008 adults with head injury, corticosteroids increased death. Cerebral oedema refuted Trials
12. Day 10 The Reflection Coefficient The cerebral capillary excludes sodium, so water movement into brain is governed by total osmolality and not by oncotic pressure. That single difference explains why hypertonic saline works, why albumin killed people, and why the drug that lowers pressure best has never improved an outcome. Cerebral oedema uncertain Trials
13. Day 11 The Metabolic Floor Why anesthetics cannot suppress cerebral metabolism past a fixed point, why hypothermia can, and why that advantage has never once produced a better patient. Cerebral protection refuted Trials
14. Day 12 Draining the Closed Box An external ventricular drain is two instruments that cannot be used at the same time. Open, it is a pressure prescription written in centimetres of water. Closed, it is a monitor. Most of the errors come from forgetting which one it currently is. Intracranial pressure supported Consensus
15. Friday Week Three — Water, Metabolism, and the Drain The week where naming the mechanism decides the treatment, and where two interventions with impeccable physiology turn out not to help. Both lessons are worth more than any single fact in them. 10 questions no new material
16. Day 13 The Bleeding You Caused Reversing an anticoagulant in an intracranial bleed is the clearest trade in neuroanaesthesia: you buy clot with thrombosis, and the patient was anticoagulated for a reason. One 2024 trial finally priced it. Haemostasis uncertain Trials
17. Day 14 The Number That Outlived Its Evidence The MAP target after acute spinal cord injury was never a trial result. In 2024 it was formally lowered, and the reason was not new evidence of benefit but the first honest accounting of what the vasopressors cost. Spine and spinal cord untested Consensus
18. Day 15 Sodium, Slowly Two syndromes produce identical laboratory findings and take opposite treatments, and the thing that separates them is not on the blood results. Getting it wrong causes cerebral infarction. Correcting it too fast causes something worse. Sodium and water supported Consensus
19. Day 16 Thirty Seconds That Undo the Case Autoregulation is impaired for hours after a craniotomy, and emergence supplies the hypertension. Coughing on the tube is the cheapest catastrophe in neuroanaesthesia — and the bleed it causes usually arrives long after everyone has stopped watching for it. Supratentorial surgery supported Consensus
20. Friday Week Four — Numbers That Outlived Their Evidence Four days about targets: one you buy with clot, one that came from an uncontrolled series and stood for thirty years, one where the laboratory cannot help you, and one where the harm arrives most of a day after the mistake. 10 questions no new material

Advanced — a 3-day re-entry diagnostic, 13 reading days, three Friday consolidations and a 40-question final.

1. Day 01 Read the Scan, Not the Note The report tells you the diagnosis. The images tell you the anaesthetic — how much room is left, which way things are moving, and which of the safety facts on this page apply to your patient today. Neuroimaging supported Consensus
2. Day 02 Which Way the Brain Is Moving Herniation is not one event. It is four routes with four sets of consequences, and the imaging finding that matters most to you is the one that makes a lumbar puncture lethal. Neuroimaging supported Consensus
3. Day 03 The Hostile Cranium In a brain with no compensatory reserve left, a fall in perfusion pressure raises intracranial pressure — and the loop runs both ways. The other half of the problem arrives twenty minutes later, when the clot comes out and the pressure the patient was generating for themselves stops. Emergency craniotomy supported Consensus
4. Day 04 Awake Enough to Map Only one of the three phases requires the patient to be genuinely awake. The rest of the anaesthetic is a choice between techniques that a meta-analysis of forty-seven studies could not separate — and a selection decision that matters more than either. Awake craniotomy uncertain Trials
5. Friday Week One — Scans, Cascades, and Selection The re-entry days behind you, four days that all turn on reading something correctly before acting: an image, a herniation route, a closing loop, and a patient who has to be able to lie still and talk. 10 questions no new material
6. Day 05 The Anesthetic That Was Not the Problem Registry after registry found that thrombectomy patients given general anesthesia did worse, and the field taught avoidance for a decade. Three randomized trials then compared the techniques head to head and found nothing of the kind. Neurointervention refuted Trials
7. Day 06 Through the Nose, Past the Chiasm The corridor to the pituitary has the optic chiasm as its roof and the carotid arteries as its walls — between 0 and 9 mm away, with little or no bone in between. That explains why immobility is not a comfort measure here. The other half of the day is that the patient's most dangerous week starts after they go home. Sellar and parasellar surgery supported Consensus
8. Day 07 Transmural Pressure The pressure that distends an aneurysm and the pressure that perfuses the brain are the same subtraction. You cannot lower one without lowering the other, which means every manoeuvre that relaxes the brain also loads the aneurysm — and the patient who tolerates hypotension best is not the one you would guess. Cerebral aneurysm surgery uncertain Trials
9. Day 08 The Clamp and the Collateral For a few minutes the surgeon stops the blood supply to one half of the brain on purpose, and whether that matters depends entirely on a piece of anatomy most of your patients do not have. The commonest thing anaesthetists do about it works least well in exactly the patients who need it most. Occlusive cerebrovascular disease uncertain Trials
10. Friday Week Two — One Number Pulled Two Ways Thrombectomy, the pituitary, the aneurysm and the carotid clamp. Three of the four turn on a quantity that serves two masters, and one turns on believing a large body of consistent data for the wrong reason. 10 questions no new material
11. Day 09 The Sitting Position Sitting the patient up drains the surgical field, opens the anatomy, and quietly subtracts a fixed number of millimetres of mercury from the pressure reaching the brain. The subtraction is arithmetic, it is invisible on the monitor unless you do one thing, and it is a bigger threat to most patients than the complication this position is famous for. Posterior fossa surgery uncertain Consensus
12. Day 10 The Triple Threat In every other operation the anaesthetic is a background condition. Here it is a variable in the measurement the surgeon is about to cut on. Your drugs can hide the focus, invent a focus that is not there, or start a seizure in a patient whose head is in pins — and the middle one is the one nobody watches for. Epilepsy surgery uncertain Consensus
13. Day 11 The Remote Location Everything that makes this room hard is about distance — from the patient, from help, from the drugs you did not bring. And when the catastrophe comes it arrives in one of two forms that look identical and want opposite blood pressures. The good news is that you are standing in the only place in the hospital where the test that tells them apart is already inside the patient. Interventional neuroradiology uncertain Consensus
14. Day 12 Awake, Still, and Mapped This is the third awake case in the curriculum and the first where the choice of drug is dictated by which nucleus the surgeon is aiming at. It is also the only one where you deliberately withdraw the patient's medication to make them worse, then bolt their head to the table — and the escape route from that is something you have to arrange before you start. Functional and stereotactic neurosurgery uncertain Consensus
15. Friday Week Three — Position, Provocation, and the Wrong Guess A pressure error that happens in every sitting case, three ways to ruin an epilepsy operation with a drug, a suite where guessing has a fifty per cent chance of making things worse, and a target that chooses your anaesthetic. 10 questions no new material
16. Day 13 Decompressive Craniectomy This operation does exactly what it claims. It opens the closed box, the pressure falls, and the number on the monitor obeys. Whether that helps the person depends on when it is done and on what you are willing to count as help — because the largest trial halved the mortality and moved most of those survivors into severe disability and vegetative state. Traumatic brain injury uncertain Trials
17. Final The Whole Rotation Forty questions across both levels — every unit from the cerebral circulation to decompressive craniectomy. It is longer than anything else here and it is meant to be: the point is to find what did not survive the eight weeks, while there is still time to go back and read it. 40 questions no new material