KEY POINTS • An important anatomic and physiologic characteristic of the cranium is its closed system. To provide adequate perfusion, the total volume of the brain parenchyma, cerebrospinal fluid, and blood should not increase. • Cerebral blood flow (CBF) and cerebral blood volume (CBV) are separate but related entities. Maintaining adequate CBF is important for neurons, but high CBF can increase the intracranial pressure (ICP). • Hemodynamic effects of anesthesia and changes in the Pa co 2 and cerebral metabolic rate can alter the CBV, ICP, and CBF.

• The management of most neurosurgical procedures requires invasive and specialized monitoring methods that can give information about blood supply, oxygen utilization, and electrical activity of the brain and spinal cord. • Maintaining an appropriate cerebral perfusion pressure and optimal surgical conditions is important during supratentorial and infratentorial craniotomies and other neurosurgical procedures. • Both secreting and nonsecreting pituitary tumors can cause significant changes in the function of many organ systems and affect the perioperative care of patients undergoing surgical procedures.

• Intracranial aneurysms and arteriovenous malformations are two important intracranial vascular abnormalities and require specific perioperative care. • Interventional neuroradiology is a new specialty for the nonsurgical management of cerebral aneurysms and arteriovenous malformations. Understanding interventional neuroradiological techniques and ensuring hemodynamic stability are important during anesthetic management. • The shunt and neuroendoscopy for obstructive hydrocephalus may cause hemodynamic changes such as severe bradycardia and can be associated with surgical complications such as hemorrhage and intracranial hypertension. • The prone position during spine surgery can be associated with a decrease in cardiac index. Neck movement must be minimized during intubation and positioning of patients with cervical spine injuries, and hypotension should be avoided to ensure adequate spinal cord perfusion. Risk factors for ischemic optic neuropathy and postoperative visual loss after spine surgery include obesity, longer anesthetic duration, and large-volume blood loss.

Neuroanesthesiology is the subspecialty of perioperative care of patients undergoing surgical procedures on the central and peripheral nervous system. These procedures include craniotomies, spine surgeries, and surgical procedures on the cranial and peripheral nervous system, as well as interventional neuroradiology (INR) procedures. The neuroanesthesiologist should be insightful about the anatomy and physiology of the central nervous system (CNS), pathophysiologic mechanisms of diseases, monitoring, and the effect of anesthetics on the nervous system. Improvements in the speed of transporting patients with acute intracranial and spinal traumatic or vascular problems to tertiary hospitals along with improved anesthesia and surgical techniques and technological advances have increased the patient population undergoing neurosurgical procedures. The development of new interventional methods has increased anesthetic challenges specific to this therapeutic modality. This chapter describes the essentials of neuroanesthesia, focusing on the important and unique features when compared to anesthesia for other organs. This chapter offers a review of neuroanesthesiology for general anesthesiologists who practice neurosurgical cases occasionally, as well as residents rotating through the neurosurgical anesthesia course.

Adobe Flash Player is required to view this feature. If you are using an operating system that does not support Flash, we are working to bring you alternative formats. Original Article A Randomized Comparison of Sentinel-Node Biopsy with Routine Axillary Dissection in Breast Cancer Umberto Veronesi, M.D., Giovanni Paganelli, M.D., Giuseppe Viale, F.R.C.Path., Alberto Luini, M.D., Stefano Zurrida, M.D., Viviana Galimberti, M.D., Mattia Intra, M.D., Paolo Veronesi, M.D., Chris Robertson, Ph.D., Patrick Maisonneuve, Eng., Giuseppe Renne, M.D., Concetta De Cicco, M.D., Francesca De Lucia, M.D., and Roberto Gennari, M.D. N Engl J Med 2003; 349:546-553 DOI: 10.1056/NEJMoa012782.

Results The number of sentinel nodes found was the same in the two groups. A sentinel node was positive in 83 of the 257 patients in the axillary-dissection group (32.3 percent), and in 92 of the 259 patients in the sentinel-node group (35.5 percent). Midas Gen 2014 Serial there.

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