Vascular Neurosurgery - Cerebro-vascular Malformations and Neurocritical Care

Cerebral vascular malformations refer to conditions related to abnormal vascular configurations in the brain. A direct arterial-venous connection without an intervening capillary network characterizes arteriovenous malformations (AVMs). Moyamoya disease is a rare arteriopathy defined by progressive stenosis of the internal carotid arteries and their branches, forming a collateral pathway that appears as a “puff of smoke.” Dural arteriovenous fistulas (DAVF) are abnormal fistulous communications within the dural leaflets that usually occur near dural venous sinuses but can develop anywhere within the intracranial dura mater. Carotid-cavernous fistulas (CCF) are characterized by an aberrant connection between branches of the carotid artery and the cavernous sinus, leading to the shunting of blood from the high-pressure arterial system into the low-pressure venous circulation. There is not enough evidence-based data regarding these patients’ best anesthetic and postoperative management. Induced hypotension to maintain a systolic blood pressure < 120 mmHg during the postoperative period is related to a lower incidence of hemorrhage in the postoperative period of AVMs resections. In Moyamoya disease, hyperventilation and hypotension can lead to vasoconstriction of the diseased vessels, reducing cerebral blood flow and worsening brain ischemia. Therefore, it is crucial to maintain strict control of the blood pressure of these patients intra and postoperatively. The blood pressure should be kept at normal or slightly higher levels, avoiding the use of noradrenaline, which impairs microcirculation. Polycythemia is undesirable as it increases viscosity and also impairs microcirculation. Salicylic acid should be reintroduced early in the postoperative period.