Chapter 30 - Central Nervous System Disease

Abstract

The perioperative care of patients with central nervous system disease or who are at risk for central nervous system complications requires a sound understanding of the relevant neuroanatomy and cerebral physiology. The importance of neuroanatomy is illustrated by 1) the effect of abnormal cerebrovascular anatomy on cerebral perfusion (e.g., incomplete Circle of Willis, stenotic atherosclerotic lesions) and 2) the role of intraoperative stimulation mapping of eloquent brain structures during intracranial surgery to preserve language or sensorimotor function. The regulation of cerebral blood flow (CBF) is a key component of cerebral physiology not only because it determines the adequacy of cerebral perfusion in meeting the cerebral metabolic demand but also because it can be manipulated to improve brain relaxation and treat intracranial hypertension. Brain relaxation and intracranial pressure (ICP) are distinctive, albeit related, concepts. Underlying neurologic diseases, surgery and anesthesia, can influence CBF (global or regional), brain relaxation, ICP, and neurophysiological monitoring (e.g., evoked potentials) and these relationships are important to consider during the perioperative care of patients. The anesthetic goals for patients with various central nervous system diseases include to 1) maintain adequate CBF for cerebral metabolic demand; 2) optimize cerebral oxygenation; 3) facilitate brain relaxation during intracranial surgery; 4) treat intracranial hypertension when the cranium is closed; 5) avoid secondary neurological complications; and 6) facilitate rapid postoperative neurological assessment.