Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content ++ Major types of neurovascular disease: ++ Cerebral vessel stenosis (i.e., carotid stenosis)Cerebral aneurysmCerebral vessel arteriovenous malformation ++ See Neurovascular surgery (Chapter 103) ++Table Graphic Jump Location | Download (.pdf) | PrintPreop Evaluation/ConsiderationsCarotid stenosisCerebral aneurysmCerebral AVMPast medical historyHx of TIA?Determine NORMAL baseline blood pressureCardiac hx? (high likelihood of CAD) Hx of MI? Angina? Exercise tolerance?Hx of headaches?Hx of smoking?Determine NORMAL baseline blood pressureCardiac history?Determine NORMAL baseline blood pressurePhysical 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, angiographySpecific questionsHow 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 | Download (.pdf) | PrintAnesthesiaCarotid stenosisCerebral aneurysmCerebral AVMMonitorsStandard monitors/lines: EKG, BP cuff, pulse oximeter, temperature probe, peripheral IVAdditional 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), FoleyStandard 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), FoleyInductionAvoid 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) readyAirway 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 larygoscopyBlood 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 aneurysmEmergenceAvoid hypercarbia (which can decrease cerebral blood flow)Avoid hypertension, sudden changes in pressureAvoid hypertension, sudden changes in pressurePossible agents to consider having on-handPhenylephrine infusionEphedrineEtomidate (to avoid hypotension during induction)Short-acting β-blockers, calcium channel blockers, opioids for smooth emergenceShort-acting β-blockers, calcium channel blockers, ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth