|Intervention||Type of anesthesia||Approximate duration (h)|
|Wada test1||MAC/no sedation||1½|
|Cerebral aneurysm repair (endovascular “coiling”)||GA||3–4|
|Cerebral artery angioplasty (dilatation)||MAC or GA||1½|
|Cerebral AVM embolization||GA||2½|
|Medullar artery embolization||MAC||1½|
|Cerebral intra-arterial thrombolysis||MAC or GA||1½|
|Cerebral artery angioplasty (“cerebral stenting”)||GA||2|
|Carotid artery angioplasty (“carotid stenting”)||MAC||1½|
NB: see diagram of Circle of Willis in Chapter 99 to identify the vessel where the procedure is being performed.
- 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)
Monitoring and Equipment
|Standard monitoring||Standard equipment||Invasive monitoring (if clinical indication)||Other (if clinical indication)|
- Pulse oximetry
- 5-lead ECG
- NMB monitoring (for GA)
- Peripheral venous line
- Supplemental oxygen (for MAC)
- Foley catheter (if procedure >4 hours)
- Central venous line
- Transcranial Doppler
If MAC, consider low-dose sedation (propofol, midazolam, fentanyl)
- Full stomach: rapid sequence induction
- Avoid hypertensive peaks at induction, laryngoscopy
- 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
- Sufficient anesthesia depth and neuromuscular blockade!
- N2O contraindicated!
- 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
- Hyperventilation causes cerebral vasoconstriction, potentiates cerebral ischemic lesions
- Moderate and transient hyperventilation PaCO2 4.5 kPa (35 mm Hg) only if intracranial hypertension (ICH)
- 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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