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Chapter 108. Asymptomatic Cerebrovascular Disease (for Non-Neurosurgery)

Zirka H. Anastasian, MD

Major types of neurovascular disease:

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

See Neurovascular surgery (Chapter 103)

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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?
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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 β-blockers, calcium channel blockers, ...

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