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Chapter 103. Neurovascular Surgery

Zirka H. Anastasian, MD

Major types of neurovascular disease:

  • Cerebral vessel stenosis (i.e., carotid stenosis): See Chapter 104
  • Cerebral aneurysm
  • Cerebral arteriovenous malformation (AVM)

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Pathophysiology
Cerebral aneurysmCerebral AVM
EpidemiologyAbout 1–6% of asymptomatic adultsAbout 0.1% of population, usually present between ages 10 and 40 years
Location (most common)About 85% are in anterior circulation (especially circle of Willis)About 90% are supratentorial
Mechanism
  • Saccular: thin-walled protrusions from the intracranial arteries with thin or absent tunica media (most responsible for SAH)
  • Fusiform: dilation of entire circumference of vessel
  • Mycotic: from infected emboli
  • Causes: multifactorial, hemodynamic stress, and turbulent flow cause damage
  • Risks: HTN, smoking, connective tissue disease
Pathogenesis unclear: considered sporadic congenital developmental vascular lesions, higher rate with hereditary hemorrhagic telangiectasia. About 20% of patients with AVMs also have cerebral aneurysms due to flow rate disruptions
Treated when:
  • Depends on size of aneurysm (5-year rupture rate 7–12 mm: 2.6%, >25 mm: 40%), risk of rupture (also location dependent: posterior have highest risk of rupture, cavernous carotid artery aneurysm are the lowest risk, anterior circulation: intermediate risk) and patient’s age
  • Preferred treatment modality (endovascular versus open surgical clipping) depends on size, location, neck: dome ratio, and medical status of patient
  • Acute or chronic hypertension does not seem to increase risk of hemorrhage
  • Risk factors for hemorrhage: hemorrhage as initial clinical presentation, deep venous drainage, deep brain location, increased patient age. Tx. Depends on patient’s age, lesion size and location, and prior history of intracerebral hemorrhage (annual risk of hemorrhage with 0 factors: 0.9%, risk with 3 factors: 34.4%)
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Preoperative Evaluation/Considerations
Cerebral aneurysmCerebral AVM
Past medical history
  • Hx of headaches?
  • Hx of smoking?
  • Determine normal baseline BP
  • Cardiac history?
  • Determine normal baseline BP
  • Did the patient have embolization (successful or attempted) of vessels preoperatively?
Physical examinationBaseline neurological examination (compare deficits)
  • Baseline neurological examination (compare deficits)
  • Evaluate for symptoms of large shunts: congestive heart failure
Medication history
  • Antihypertensive medication history,
  • Weight loss supplements?
  • CHF meds? (mannitol often requested by surgeon)
CHF meds?
Studies to reviewCT, MRI, AngiographyCT, MRI, Angiography
Specific questionsHow many aneurysms? What is their size (assess rupture potential)? For how long have they been managed? What was the date of the last MRI/angiography? Has coiling/clipping been done in the past?What is the size of the AVM? What was the medical plan?
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Anesthesia and Intraoperative Issues
Cerebral aneurysmCerebral AVM
Monitors
  • 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 pre-induction to monitor BP changes during laryngoscopy), possible spinal drain (if ruptured), foley catheter, neuromuscular blockade monitor, consider central line
  • Standard monitors/lines: EKG, BP cuff, pulse oximeter, esophageal/bladder temperature probe, peripheral IVs (2 or more)
  • Additional monitors/lines: arterial line (preferably ...

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