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  • Image not available.An asymptomatic cervical bruit does not appear to increase the risk of stroke following surgery but increases the likelihood of coexisting coronary artery disease.
  • Image not available.Resistance to neuromuscular blockade—as assessed by train-of-four monitoring—may be observed in paretic extremities; neuromuscular blockade should therefore be monitored on the nonparetic side. Succinylcholine should be avoided in patients with a history of recent stroke as well as in those with extensive muscle wasting because of the risks of hyperkalemia.
  • Image not available.If a seizure occurs, maintaining an open airway and adequate oxygenation are the first priorities. Intravenous thiopental (50–100 mg), phenytoin (500–1000 mg slowly), or a benzodiazepine such as diazepam (5–10 mg) or midazolam (1–5 mg) can be used to terminate the seizure.
  • Image not available.Induction of anesthesia in patients receiving long-term levodopa therapy may result in either marked hypotension or hypertension.
  • Image not available.Increases in body temperature cause exacerbation of symptoms, presumably by decreasing nerve conduction.
  • Image not available.The major risk of anesthesia in patients with autonomic dysfunction is severe hypotension, compromising cerebral and coronary blood flow.
  • Image not available.Patients with high transections often have impaired airway reflexes and are further predisposed to hypoxemia by a decrease in functional residual capacity. Hypotension and bradycardia are often present prior to induction.
  • Image not available.Autonomic hyperreflexia should be expected in patients with lesions above T6 and can be precipitated by surgical manipulations.
  • Image not available.The most important interaction between anesthetic agents and tricyclic antidepressants is an exaggerated response to both indirect-acting vasopressors and sympathetic stimulation.
  • Image not available.Opioids should generally be used with caution in patients receiving monoamine oxidase inhibitors because rare but serious reactions to opioids have been reported. Most serious reactions are associated with meperidine, resulting in hyperthermia, seizures, and coma.

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Cerebrovascular disease is a major cause of morbidity and death. Patients with a history of stroke, transient ischemic attacks (TIAs), or asymptomatic extracranial vascular obstructions frequently present to the operating room for unrelated procedures. This chapter discusses a general approach to these patients as well as patients with other common neurologic disorders. Chapter 21 discusses anesthetic management of patients undergoing carotid artery surgery.

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Nonvascular neurologic diseases and psychiatric disorders are less frequently encountered in surgical patients and are often overlooked. Fortunately, unless increased intracranial pressure (ICP) is present, special anesthetic techniques are not usually required. Nonetheless, the anesthesiologist must have a basic understanding of the major neurologic and psychiatric disorders and their drug therapy; failure to recognize potentially adverse anesthetic interactions may result in avoidable perioperative morbidity.

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Preoperative Considerations

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The incidence of significant cerebrovascular disease in surgical patients is unknown but increases with age. Patients with known cerebrovascular disease typically have a history of TIAs or stroke. Asymptomatic cervical bruits occur in up to 4% of patients over age 40 but do not necessarily indicate significant carotid artery obstruction. Fewer than 10% of patients with completely asymptomatic bruits have hemodynamically significant carotid artery lesions. Moreover, the absence of a bruit does not exclude significant carotid obstruction.

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Image not available.The risk of postoperative stroke ...

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