This chapter discusses the anaesthetic management of intracranial vascular abnormalities with particular emphasis on subarachnoid haemorrhage (SAH), arteriovenous malformations (AVMs) and carotid artery stenosis. Cerebral aneurysms occur mainly at vascular bifurcations within the circle of Willis or proximal cerebral artery. Patients with salt-wasting syndrome are hypovolaemic and require fluid to prevent intravascular volume contraction. Interventional neuroradiology is being used increasingly to treat central nervous system (CNS) disease by either delivering therapeutic devices or by administering drugs at the point of need. During periods of acute vascular occlusion or vasospasm, induced hypertension can maintain cerebral perfusion by increasing flow across the circle of Willis. Patients presenting for carotid surgery are elderly and often have coexisting medical problems common to patients with vascular disease. These include coronary artery disease, chronic pulmonary airway disease and diabetes mellitus.

This chapter reviews the major clinical trials on carotid endarterectomy and carotid angioplasty, and summarizes the technique used by the authors for carotid endarterectomy. The evolution of carotid endarterectomy, carotid angioplasty, and stenting and extracranial-intracranial (EC-IC) has been predicated on the results of clinical trials. The EC-IC bypass trial introduced the concept of multicenter prospective randomized trials to the neurosurgical community. The ongoing carotid revascularization endarterectomy versus stent trial (CREST) is prospectively randomizing patients with symptomatic carotid stenosis to either carotid endarterectomy or carotid angioplasty, and stenting with distal embolic protection (DEP), regardless of perioperative risk stratification. Assessing perioperative risk is essential in the evaluation of patients in whom carotid endarterectomy, carotid angioplasty and stenting or EC-IC bypass is being considered. Patients with symptomatic carotid occlusions may benefit from EC-IC revascularization provided they suffer from diminished cerebrovascular reserve.