AnesthesiaHub
TutorialsDrugsCalcsEmergencySubsQ-BankResourcesAIBookmarks
All subspecialties
Subspecialty

Neuroanesthesia

ICP, CPP, and protecting the brain.

Neuroanesthesia balances surgical exposure with neuronal protection. Central concepts include cerebral perfusion pressure (CPP = MAP − ICP), autoregulation, the BBB, and avoiding secondary injury from hypoxia, hyper/hypocapnia, hyper/hypoglycemia, and hyperthermia.

Key concepts

CPP & ICP

Maintain CPP 60–70 mmHg in TBI. ICP > 22 mmHg requires intervention. Modulators: head-up 30°, normocapnia (avoid prolonged hypocapnia), 3% saline or mannitol, sedation/paralysis.

Choice of agents

TIVA (propofol + remifentanil) for neuro-monitoring (SSEPs, MEPs). Volatiles >1 MAC suppress motor evoked potentials. Nitrous can enlarge pneumocephalus.

Awake craniotomy

Asleep-awake-asleep or monitored anesthesia care with dexmedetomidine + remifentanil + scalp block. Cooperative patient is essential for cortical mapping.

Subarachnoid hemorrhage

Goals: prevent re-bleed (BP control, avoid hypertension before aneurysm secured) and prevent vasospasm (nimodipine, euvolemia).

Monitoring

  • Arterial line (transduce at tragus for CPP estimation)
  • Processed EEG (BIS) for TIVA
  • Motor & somatosensory evoked potentials
  • ICP monitor (EVD)
  • Cerebral oximetry

Common drugs

PropofolRemifentanilMannitol 0.25–1 g/kgHypertonic saline 3%PhenylephrineEsmololNimodipine

Clinical pearls

1Avoid succinylcholine in spinal cord injury > 48 h, prolonged immobilization, denervation — hyperkalemia risk.
2Anchor your hemodynamic targets to the patient's baseline BP, not population norms.

References & Further Reading

  1. 1
    Textbook

    Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

  2. 2
    Textbook

    Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, Sharar SR, Holt NF. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.

  3. 3
    Textbook

    Flood P, Rathmell JP, Shafer S. Stoelting's Pharmacology and Physiology in Anesthetic Practice. 5th ed. Philadelphia: Wolters Kluwer; 2015.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.