Anesthesia for Gamma Knife Surgery

  • Summit Dev Bloria
  • Ketan K. Kataria
  • Ankur Luthra


Gamma knife surgery is a type of radiation therapy, which utilizes highly sophisticated equipment to focus around 200 tiny beams of radiation on a tumor or other target with high accuracy. It is primarily used to treat benign brain tumors, craniopharyngiomas, AV malformations, pituitary adenomas, acoustic neuromas, brain metastases, other tumors of the skull base, and pineal region tumors. Most stereotactic radiosurgery procedures in adults are performed without anesthesia. However, general anesthesia is frequently required in the pediatric population and in some of the uncooperative adult patients. A stereotactic frame is applied to the patient for accurate site and positioning of the lesion to radiations. The advantages include incisionless surgery with minimal morbidity and reduced postoperative hospital stay and reduced expenditure. The problems encountered by the anesthesiologist are administration of sedation or anesthesia at remote locations, intrahospital transfers with all the monitoring to different suites, long duration surgeries, hypothermia, etc. All necessary equipment should be present at all the locations beforehand to ensure safe administration of anesthesia. Prior preparation and effective coordination between all the concerned specialties involved is the key to make anesthetic management of this procedure a success.


Radiosurgery Stereotactic Collimator Dosimetry Monitored anesthesia care Dexmedetomidine 


  1. 1.
    Lawrence TS, Ten Haken RK, Giaccia A. Principles of radiation oncology. In: Cancer: principles and practice of oncology. 8th ed. Philadelphia: Lippincott Williams and Wilkins; 2008.Google Scholar
  2. 2.
    Chang SD, Adler JR Jr, Hancock SL. Clinical uses of radiosurgery. J Oncol. 1998;12(8):1181–8.Google Scholar
  3. 3.
    Sweitzer BJ. Preoperative patient evaluation for anaesthesia care outside of the operating room. In: Anaesthesia outside the operating room. New York: Oxford University Press; 2011. p. 8–19.CrossRefGoogle Scholar
  4. 4.
    Ghisi D, Fanelli A, Tosi M, Nuzzi M, Fanelli G. Monitored anaesthesia care. Minerva Anestesiol. 2005;71(9):533–8.PubMedGoogle Scholar
  5. 5.
    Venn RM, Grounds RM. Comparison between dexmedetomidine and propofol for sedation in the intensive care unit: patient and clinician perceptions. Br J Anaesth. 2001;87(5):684–90.CrossRefGoogle Scholar
  6. 6.
    Bustillo MA, Lazar RM, Finck DA, Fitzsimmons B, Berman MF, Spellman JP, et al. Dexmedetomidine may impair cognitive testing during endovascular embolization of cerebral arteriovenous malformations: a retrospective case report series. J Neurosurg Anesthesiol. 2002;14:209–12.CrossRefGoogle Scholar
  7. 7.
    Bloom M, Beric A, Bekker A. Dexmedetomidine infusion and somatosensory evoked potentials. J Neurosurg Anesthesiol. 2001;13(4):320–2.CrossRefGoogle Scholar
  8. 8.
    Bekker A, Kaufman B, Samir H, Doyle W. The use of dexmedetomidine infusion for awake craniotomy. Anesth Analg. 2001;92:1251–3.CrossRefGoogle Scholar
  9. 9.
    Fahy CJ, Okumura M. Sedation for paediatric stereotactic radiosurgery: the dexmedetomidine experience. Anesth Intensive Care. 2004;32(6):809–11.CrossRefGoogle Scholar
  10. 10.
    Pearson RC, McCloy RF, Morris P, Bardhan KD. Midazolam and flumazenil in gastroenterology. Acta Anaesthesiol Scand Suppl. 1990;92:214.Google Scholar
  11. 11.
    Church JA, Pollock JSS, Still DM, Parbrook GD. Comparison of two techniques for sedation in dental surgery. Anaesthesia. 1991;46:780–3.CrossRefGoogle Scholar
  12. 12.
    Liang CL, Lu K, Liliang PC, Chung MC, Chi SC, Chen HJ. Topical anaesthetic EMLA for postoperative wound pain in stereotactic gamma knife radiosurgery: a perspective, randomized, placebo-controlled study. Minim Invasive Neurosurg. 2011;54(2):75–8.CrossRefGoogle Scholar
  13. 13.
    Duenas SM, Pun J, Radwan HA, Akerman M, Schulder M. A randomized trial on the efficacy of topical anaesthesia for pain reduction during frame placement for gamma knife radiosurgery. Stereotact Funct Neurosurg. 2016;94(4):259–64.CrossRefGoogle Scholar
  14. 14.
    Harris EA. Sedation and anaesthesia options for paediatric patients in the radiation oncology suite. Int J Paediatr. 2010;2010:1–9.CrossRefGoogle Scholar
  15. 15.
    Safaee M, Burke J, McDermott MW. Techniques for the application of stereotactic head frames based on a 25-year experience. Cureus. 2016;8(3):e543.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Vitali AM, Steinbok P. Depressed skull fracture and epidural hematoma from head fixation with pins for craniotomy in children. Childs Nerv Syst. 2008;24(8):917–23.CrossRefGoogle Scholar
  17. 17.
    Berry C, Sandberg DI, Hoh DJ, Krieger MD, Mc Comb JG. Use of cranial fixation pins in paediatric neurosurgery. Neurosurgery. 2008;62(4):913–8.CrossRefGoogle Scholar
  18. 18.
    Pang D. Air embolism associated with wounds from a pin-type headholder. Case report J Neurosurg. 1982;57(5):710–3.PubMedGoogle Scholar
  19. 19.
    Reichter RE, Park HM, Hall D. Skull defects due to Mayfield head stabilizer. Clin Nucl Med. 1983;8(11):553.CrossRefGoogle Scholar
  20. 20.
    Venkatraghavan L, Luciano M, Manninen P. Review article: anesthetic management of patients undergoing deep brain stimulator insertion. Anesth Analg. 2010;110(4):1138–45.PubMedGoogle Scholar
  21. 21.
    Venkatraghavan L, Manninen P, Mak P, Lukitto K, Hodaie M, Lozano A. Anaesthesia for functional neurosurgery: review of complications. J Neurosurg Anesthesiol. 2006;18(1):64–7.CrossRefGoogle Scholar
  22. 22.
    Santos P, Valero R, Arguis MJ, Carrero E, Salvador L, Rumia J, et al. Preoperative adverse events during stereotactic microelectrode-guided deep brain surgery in Parkinson’s disease. Rev Esp Anestesiol Reanim. 2004;51(9):523–30.PubMedGoogle Scholar
  23. 23.
    Verma V, Beethe AB, LeRiger M, Kulkarni RR, Zhang M, Lin C. Anaesthesia complications of paediatric radiation therapy. Pract Radiat Oncol. 2016;6(3):143–54.CrossRefGoogle Scholar
  24. 24.
    Evans P, Chisholm D. Anaesthesia and paediatric oncology. Curr Anaesth Crit Care. 2008;19(2):50–8.CrossRefGoogle Scholar
  25. 25.
    Fortney JT, Halperin EC, Hertz CM, Schulman SR. Anaesthesia for paediatric external beam radiation therapy. Int J Radiat Oncol Biol Phys. 1999;44(3):587–91.CrossRefGoogle Scholar
  26. 26.
    Nishina K, Mikawa K, Maekawa N, Takao Y, Obara H. Clonidine decreases the dose of thiamylal required to induce anaesthesia in children. Anesth Analg. 1994;79(4):766–8.CrossRefGoogle Scholar
  27. 27.
    Yao Y, Qian B, Chen Y, Zhou L, Liu J. Intranasal dexmedetomidine premedication reduces the minimum alveolar concentration of sevoflurane for tracheal intubation in children: a randomized trial. J Clin Anesth. 2014;26(4):309–14.CrossRefGoogle Scholar
  28. 28.
    von Ungern-Sternberg BS, Erb TO, Habre W, Sly PD, Hantos Z. The impact of oral premedication with midazolam on respiratory function in children. Anesth Analg. 2009;108(6):1771–6.CrossRefGoogle Scholar
  29. 29.
    Morris RJ, Woodcock JP. Evidence-based compression: prevention of stasis and deep vein thrombosis. Ann Surg. 2004;239(2):162–71.CrossRefGoogle Scholar
  30. 30.
    Sutin KM, Longaker MT, Wahlander S, Kasabian AK, Capan LM. Acute biceps compartment syndrome associated with the use of a noninvasive blood pressure monitor. Anesth Analg. 1996;83(6):1345–6.CrossRefGoogle Scholar
  31. 31.
    Edler A. Special considerations for stereotactic radiosurgery in children. J Clin Anesth. 2007;19(8):616–8.CrossRefGoogle Scholar
  32. 32.
    Bauman GS, Brett CM, Ciricillo SF, Larson DA, Sneed P, Staplers LJ, et al. Anaesthesia for paediatric stereotactic radiosurgery. Anaesthesiology. 1998;89(1):255–7.CrossRefGoogle Scholar
  33. 33.
    Bone ME, Bristow A. Total intravenous anesthesia in steroeotactic surgery—one year’s clinical experience. Eur J Anaesthesiol. 1991;8(1):47–54.PubMedGoogle Scholar
  34. 34.
    Weninger B, Czerner S, Steude U, Weninger E. Comparison between TCI-TIVA, Manual TIVA and balanced anaesthesia for stereotactic biopsy of brain. Anaesthesiol Intensivmed Notfallmed Schmerzther. 2004;39(4):212–9.CrossRefGoogle Scholar
  35. 35.
    Kamata K, Hayashi M, Muragaki Y, Iseki H, Okada Y, Ozaki M. How to control propofol infusion in paediatric patients undergoing gamma knife radiosurgery. Acta Neurochir Suppl. 2013;116:147–50.PubMedGoogle Scholar
  36. 36.
    Grainger D. Devices bulletin: safety guidelines for magnetic resonance imaging equipment in clinical use. London: MHRA; 2015.Google Scholar
  37. 37.
    Sessler DI. Mild perioperative hypothermia. N Engl J Med. 1997;336(24):1730–7.CrossRefGoogle Scholar
  38. 38.
    Stokes MA, Soriano SG, Tarbell NJ, Loeffler JS, Alexander E 3rd, Black PM, Rockoff MA. Anesthesia for stereotactic radiosurgery in children. J Neurosurg Anesthesiol. 1995;7(2):100–8.CrossRefGoogle Scholar
  39. 39.
    Kondziolka D, LoPresti M, Tyburczy A, Golden C, Seto T, Boulio L, Doody C, Yeh B, Silverman J. Quality of the patient experience during radiosurgery: measurement toward improvement. Stereotact Funct Neurosurg. 2016;94(3):134–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Summit Dev Bloria
    • 1
  • Ketan K. Kataria
    • 1
  • Ankur Luthra
    • 1
  1. 1.Department of Anaesthesia and Intensive CarePostgraduate Institute of Medical Education and ResearchChandigarhIndia

Personalised recommendations