• P Ravussin.
• Département d'anesthésiologie et de réanimation, hôpital de Sion, CH-1950 Sion, Suisse. patrick.ravussin@chr.ch
• Ann Fr Anesth Reanim. 2004 Apr 1;23(4):404-9.

Unlabelled1. Neurological state of patient.Procedures(low risk of ICP problems or ischemia, little need for brain relaxation). - Volatile-based technique; "high-risk" procedures (anticipated ICP problems, significant risk of intraoperative cerebral ischemia, need for excellent brain relaxation): use total intravenous anaesthesia. EXTRACRANIAL MONITORING: For example, cardiovascular or renal, venous air embolism. Intracranial monitoring. - General environment vs. specific functions-metabolic (jugular venous bulb), neurophysiological (EEG/EP), functional (transcranial Doppler). 4. Induction of anaesthesia.GoalsVentilatory control (early mild hyperventilation; avoid hypercapnia, hypoxemia); blood pressure control (avoid CNS arousal: adequate antinociception, anaesthesia); optimal position on ICP-volume curve. PATIENT POSITIONING: Pin holder application --> maximal nociceptive stimulus, block by deeper anaesthesia or analgesia and local anesthetic pin site infiltration. Alternative: antihypertensives. 5. Maintenance of anaesthesia.GoalsControlling brain tension via control of CMR and CBF: preventing CNS arousal (depth of anaesthesia, antinociception); treating consequences of CNS arousal (sympatholysis, antihypertensives); the "chemical brain retractor concept". NEUROPROTECTION: Maintenance of an optimal intracranial environment (matching cerebral substrate demand and supply). 6. Emergence from anaesthesia.GoalsMaintain intra/extracranial homeostasis. Avoid factors --> intracranial bleeding and/or increasing CBF/ICP. The patient should be calm, co-operative and responsive to verbal commands soon after emergence. EARLY VS. LATE EMERGENCE: Ideal: rapid emergence to permit early assessment of surgical results and postoperative neurological follow-up, but there are still some categories of patients where early emergence is not appropriate.

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