Craniotomy for extracranial-intracranial revascularization

Craniotomy for extracranial-intracranial revascularization

File:EC-IC Bypass .jpg
Anesthesia type	General
Airway	ETT
Lines and access	PIV x 2 Art line CVC
Monitors	Standard ASA 5-lead EKG Core temp UOP ABG CVP EEG
Primary anesthetic considerations
Preoperative	Characterize neurologic deficits Consider small dose of anxiolytic
Intraoperative	Smooth induction Maintain CPP Maximize flow to ischemic areas Decrease CMRO2 Decrease intracranial volume
Postoperative	Careful control of BP PONV prophylaxis
Article quality
Editor rating	Comprehensive
User likes	2

Extracranial-intracranial (EC-IC) revascularization (also referred to as EC-IC bypass) is a surgical procedure to increase cerebral blood flow. The procedure involves connecting a branch of the external carotid artery (typically the superficial temporal artery) to a branch of the internal carotid artery (typically the middle cerebral artery). The anastomosis can be achieved via a vein graft or a direct connection.

EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. In children, this procedure is used to treat Moya-moya disease.

Preoperative management

Patient evaluation

System	Considerations
Neurologic	Patients typically presenting with focal neurologic symptoms. Pre-existing deficits should be well characterized and documented.
Cardiovascular	Hypertension is a common adaptive response to maintain CPP. A normal BP may be undesirable in the setting of severe cerebrovascular disease. Patients may have generalized vascular disease, including CAD.
Hematologic	Patients often on aspirin through day of surgery Anticoagulants impacting PT/PTT typically discontinued 1 week prior to surgery
Other

Labs and studies

• EKG
• Echo (if concern for cardiovascular disease)
• Coronary angiography (depending on cardiac risk factors)
• Complete blood count
• Chemistry panel
• Coagulation panel
• Cerebral angiography performed to identify cause of neurologic symptoms

Patient preparation and premedication

• Consider pre-op acetaminophen 1000mg PO
• Consider pre-op aprepitant if patient has history of severe PONV
• Consider small dose of anxiolytic
• Detailed discussion with patient regarding anesthetic plan

Regional and neuraxial techniques

• Scalp block can be considered for post-craniotomy analgesia

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications