Skip to Main Content

++

Major types of neurovascular disease:

++

  • Cerebral vessel stenosis (i.e., carotid stenosis)
  • Cerebral aneurysm
  • Cerebral vessel arteriovenous malformation

++

See Neurovascular surgery (Chapter 103)

++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Preop Evaluation/Considerations
Carotid stenosisCerebral aneurysmCerebral AVM
Past medical history
  • Hx of TIA?
  • Determine NORMAL baseline blood pressure
  • Cardiac hx? (high likelihood of CAD) Hx of MI? Angina? Exercise tolerance?
  • Hx of headaches?
  • Hx of smoking?
  • Determine NORMAL baseline blood pressure
  • Cardiac history?
Determine NORMAL baseline blood pressure
Physical examBaseline neurological exam (compare deficits)Baseline neurological exam (compare deficits)
  • Baseline neurological exam (compare deficits)
  • Evaluate for symptoms of large shunts: congestive heart failure, etc.
Medication historyAntihypertensive medication history (class, last dose timing), anticoagulation history (aspirin, etc.)Antihypertensive medication history, weight loss supplements?CHF meds?
Studies to reviewDoppler US, angiography, EKG, stress testCT, MRI, angiographyCT, MRI, angiography
Specific questions
  • How significant is the stenosis?
  • Is the patient symptomatic?
  • Is it unilateral or bilateral?
How many aneurysms? What is their size? For how long have they been managed? What was the date of the last MRI/Angio?What is the size of the AVM? What was the medical plan?
++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Anesthesia
Carotid stenosisCerebral aneurysmCerebral AVM
Monitors
  • Standard monitors/lines: EKG, BP cuff, pulse oximeter, temperature probe, peripheral IV
  • Additional monitors/lines: arterial line (preferably preinduction to monitor BP changes during induction and laryngoscopy)
  • Standard monitors/lines: EKG, BP cuff, pulse oximeter, esophageal/bladder temperature probe (especially important if cooling), peripheral IVs (2 or more)
  • Additional monitors/lines: arterial line (preferably preinduction to monitor BP changes during induction and laryngoscopy), Foley
  • Standard monitors/lines: EKG, BP cuff, pulse oximeter, esophageal/bladder temperature probe (especially important if cooling), peripheral IVs (2 or more)
  • Additional monitors/lines: arterial line (preferably preinduction to monitor BP changes during induction and laryngoscopy), Foley
InductionAvoid HYPOtension by either using agents such as etomidate, or following induction agent with a vasopressorAvoid HYPERtension by doing induction agent accordingly, doing test laryngoscopy, and have fast-acting antihypertensive (i.e., esmolol) readyAvoid HYPERtension by doing induction agent accordingly, doing test laryngoscopy, and have fast-acting antihypertensive (i.e., esmolol) ready
Airway managementAvoid pressure on the carotid, avoid excessive neck manipulation (to avoid dislodging possible emboli)Avoid prolonged intubation attempt: avoid prolonged laryngoscopyConsider possibility of co-present aneurysm: avoid prolonged larygoscopy
Blood pressure goalsMaintain adequate cerebral perfusion pressure: keep patient’s pressure on the high side of what THEIR normal pressure isAvoid hypertension and avoid sudden fluctuations in blood pressure (which put stress on the walls of the aneurysm)Meticulous BP control: avoid hypertension due to risk of aneurysm
EmergenceAvoid hypercarbia (which can decrease cerebral blood flow)Avoid hypertension, sudden changes in pressureAvoid hypertension, sudden changes in pressure
Possible agents to consider having on-hand
  • Phenylephrine infusion
  • Ephedrine
  • Etomidate (to avoid hypotension during induction)
Short-acting β-blockers, calcium channel blockers, opioids for smooth emergenceShort-acting ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.