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Intervention Types
InterventionType of anesthesiaApproximate duration (h)
Diagnostic angiography
Cerebral angiographyMAC1
Medullar angiographyMAC
Carotid angiographyMAC1
Wada test1MAC/no sedation
Interventional angiography
Cerebral aneurysm repair (endovascular “coiling”)GA3–4
Cerebral artery angioplasty (dilatation)MAC or GA
Cerebral AVM embolizationGA
Medullar artery embolizationMAC
Cerebral intra-arterial thrombolysisMAC or GA
Cerebral artery angioplasty (“cerebral stenting”)GA2
Carotid artery angioplasty (“carotid stenting”)MAC

1Selective injection of a barbiturate into each internal carotid artery to determine which hemisphere is responsible for vital functions such as speech and memory, prior to ablative surgery for epilepsy.

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NB: see diagram of Circle of Willis in Chapter 99 to identify the vessel where the procedure is being performed.

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  • Standard preoperative medical evaluation and anesthetic risk stratification (ASA score)
  • Baseline neurologic status: GCS, pupils, focal neurologic deficits, seizures, grade Hunt/Hess, WFNS, Fisher (see pp. 454–455)
  • Monitor specifically for changes in level of consciousness and/or focal neurologic deficits
  • Monitor for signs of raised ICP
  • Cardiac status: ECG, arrhythmia, HTN, cardiac enzymes as indicated
  • Consider insertion of arterial line prior to induction if hemodynamic instability or risk of hypertensive peak during induction/laryngoscopy
  • Avoid premedication with benzodiazepines and neuroleptics (impairment of baseline neurologic status)

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Monitoring and Equipment
Standard monitoringStandard equipmentInvasive monitoring (if clinical indication)Other (if clinical indication)
  • Pulse oximetry
  • 5-lead ECG
  • NIBP
  • Capnography
  • NMB monitoring (for GA)
  • Peripheral venous line
  • Supplemental oxygen (for MAC)
Arterial line
  • Foley catheter (if procedure >4 hours)
  • Central venous line
  • Transcranial Doppler
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Induction

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If MAC, consider low-dose sedation (propofol, midazolam, fentanyl)

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If GA:

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General considerations
  • Pre-oxygenation
  • Full stomach: rapid sequence induction
  • Avoid hypertensive peaks at induction, laryngoscopy
Induction drugs
  • Propofol 2–3 mg/kg IV, or etomidate 0.3 mg/kg IV, or thiopental 3–5 mg/kg IV
  • Fentanyl 3–5 μg/kg IV, or sufentanil 0.3–0.5 μg/kg IV
  • Succinylcholine 1–1.5 mg/kg IV, or rocuronium 0.6 mg/kg IV
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Maintenance
General considerations
  • Sufficient anesthesia depth and neuromuscular blockade!
  • N2O contraindicated!
Maintenance drugs/volatiles
  • Propofol 60–200 μg/kg/h IV, or sevoflurane (avoid high %: vasodilatory effect!)
  • Fentanyl 1–2 μg/kg/h IV, or sufentanil 0.1–0.2 μg/kg/h IV, or remifentanil 0.125 μg/kg/h IV infusion
  • Rocuronium 0.15 mg/kg IV bolus
Ventilation strategy
  • Normoventilation
  • Hyperventilation causes cerebral vasoconstriction, potentiates cerebral ischemic lesions
  • Moderate and transient hyperventilation PaCO2 4.5 kPa (35 mm Hg) only if intracranial hypertension (ICH)
Hemodynamic strategy
  • Control BP to maintain cerebral perfusion pressure >60 mm Hg (CPP = MAP − ICP)
  • BP at induction/until endovascular treatment of lesion: normal arterial blood pressure, CPP >60 mm Hg, MAP 70–90 mm Hg
  • BP after endovascular treatment of lesion: ...

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