Anaesthetic management of intracranial aneurysms, arteriovenous malformationsand carotid endarterectomy

Spontaneous subarachnoid haemorrhage is usually caused by rupture of intracranial aneurysms or arteriovenous malformations and requires treatment using surgical or endovascular techniques. Careful preparation of the patients is required before surgery. Intensive observation and management are required perioperatively to prevent rebleeding or cerebral ischaemia and to provide optimal operating conditions for the neurosurgeon. Rapid awakening after the operation allows early neurological assessment and treatment of operative complications. After surgery these patients should be managed on a high-dependency unit or an intensive care unit to allow rapid detection and treatment of post-operative complications. Hypertensive, hypervolaemic haemodilution may be indicated if cerebral vasospasm develops. Carotid endarterectomy can be performed under local or general anaesthesia and each technique has advantages and disadvantages. Careful monitoring is required to ensure adequate cerebral perfusion during cross-clamping of the artery and to detect and manage post-operative complications without delay.