術前評估為外科醫生建立了與患者和家庭建立融洽關係的重要機會，並向他們提供信息以及相關的風險和福利。作為其術前評價的一部分，我將所有正在接受選修手術的所有患者，以便我們的術前評估團隊進行許可，以進行麻醉。該團隊由內科醫生和家庭醫學專家組成。

徹底的術前評估涉及：

1. 與患者和家庭建立融洽關係，描述手術和恢複過程，
2. a review of past medical, surgical, personal, family, and social history and listing current medications and allergies,
3. 一般體檢和審查相關實驗室數據，以安排任何需要的進一步調查或磋商，
4. 組織上述數據，因此患者可以根據其術前條件和基於其術前條件進行適當的危險性危害外科醫生發病率
5. appropriate resources and plans are recruited to maximize operative safety and an expeditious recovery.

At the end of the evaluation, the patient’s informed consent is documented. The neurosurgeon should also consider the anesthetic concerns and prepare for good communication between the anesthesia and operative teams.

A patient’s preoperative health status can have a important impact on the effects of anesthesia, positioning during surgery, intraoperative events, postoperative pain, and recovery. Pre-existing medical conditions can be a cause of concern and require special attention throughout the preoperative, intraoperative, and postoperative periods.

All patients are given an ASA (American Society of Anesthesiologists) classification of physical status to stratify their pre-existing health status. Ranging from 1 (a normal healthy patient) to 6 (a patient declared brain-dead), the ASA physical status is an important predictor of postoperative outcome.

應進行徹底的病史，以評估可能改變術前，術中和術後管理的相關信息。

先前的手術和先前的麻醉並發症或疑慮（航空管理，IV訪問，術後疼痛等）是過去病史的重要組成部分。任何過敏（乳膠，抗生素，止痛藥等），類固醇使用（對腎上腺抑製和高血糖的關注），應記錄抗抑鬱治療（對Nondepolared肌肉鬆弛劑的抗性增加），以及抗凝/抗血小板治療應記錄。

Personal history such as smoking and alcohol and drug use may affect anesthesia and postoperative management including recovery. Relevant family history (anesthesia complications, coagulopathy) and social/religious beliefs (such as Jehovah’s Witness beliefs) should always be noted as well.

Of utmost importance is the general physical state of the patient. The assessment of the patient’s airway by an anesthesiologist is an important component of the preoperative evaluation.

頸椎不穩定或頸椎病變可以使神經外科患者的氣道管理複雜化。一個在術前體檢中偶然發現宮病理學保證脊柱成像自非士科術中主體/頸部位置（即，易於位置）可導致頸部延伸和嚴重的脊髓損傷。

潛在氣道並發症的識別允許適當準備輔助設備和資源，以幫助和管理患者的氣道。在手術前應評估和糾正體積狀態，以防止後施低血壓。手術前較低的顱神經功能障礙可能導致惡病毒和傷口愈合不良，因此預先或立即術後胃痛管放置可能是強製性的，以便於恢複。

應給予血液產品預先存在的貧血，並且如果預計涉及動脈瘤，動脈畸形，血管腫瘤和脊柱畸形矯正的手術，則隨時可用。

徹底的術前評價包括對神經係統功能的完全評估。意識水平可能會改變麻醉的需要。令人沮喪的術前意識可能導致麻醉延遲出現，並增加吸入風險。在這種情況下，患者可以保持過夜。

Moreover, a depressed level of consciousness exacerbates pre-existing atelectasis, requiring assisted mechanical ventilation postoperatively. Such preparations should be made in advance for transportation and with the intensive care unit team.

在患有預先存在的電動機缺陷的患者官員後，已經有威脅危及生命的高鉀血症。

顱神經IX和X功能障礙患者在患者的患者的願望下患者。這些神經的手術在恢複喂食前術後吞咽評估要求。

圍手術期呼吸係統並發症在患有預先存在的阻塞性或限製性肺病的患者中顯著增加。任何患有疑似肺病的患者應經過術前肺功能測試和動脈血氣采樣，以在操作之前評估和優化呼吸功能。

基於血氣采樣的升高的PACO2或低PO2是術後呼吸並發症的預測性，並且應該在程序之前得到補償。如果患者具有顯著的呼吸係統疾病或損傷，則表明術後機械通氣。在家中使用連續正氣道壓力裝置的患者應在整個住院住宿期間使用相同的設備。必須對接受患者進行患者進行特殊安排。

類似於肺病，在進行任何神經外科手術之前，應優化預先存在的心血管疾病。具體地，在已知心血管疾病的患者中（即缺血性心髒病，心力衰竭，糖尿病，腎功能不全或腦血管疾病），perioperative heart-rate control with beta blockade is appropriate。以前沒有關於β-嵌體治療的患者可能增加了卒中和死亡率的速度。

In an acute surgical emergency, evaluation should be limited to hematocrit, electrolytes, renal function, and electrocardiography. For planned elective surgery, a thorough cardiac history should be taken, including details of previous cardiac surgery, ischemic heart disease, congestive heart failure, and cerebrovascular disease.It is recommended to wait at least 4 to 6 weeks after an acute myocardial infarction (MI) (<7 days of examination) or recent MI (from 7 days to 1 month of the examination) to perform elective surgery.

In patients with congestive heart failure, cardiac output is greatly reduced. Mannitol should be used sparingly in this patient population as the resultant increase in intravascular volume can exacerbate cardiac and renal failure.

慢性高血壓患者通常具有增加的腦血管血管阻力，導致腦血流（CBF）自療升高。當這些患者對急性低血壓差具有差的耐受性差，重要的是要意識到向更高壓力的轉變。

Certain neurosurgical conditions are associated with cardiovascular abnormalities, including association of aneurysms with coarctation of the aorta and hypertension.

A thorough review of the patient’s medication list is indicated, as some medications may need to be adjusted, particularly those requiring renal elimination. It may be necessary to monitor the blood levels of certain medications or adjust dosage based on the patient’s pre- and postoperative renal status.

To prevent renal failure, volume status may need to be carefully monitored by intra-arterial or central venous pressure catheters. Intravascular volume depletion, contrast dye, nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting-enzyme (ACE) inhibitors, and aminoglycoside antibiotics all place patients at risk for acute renal failure and should be minimized. Mannitol is avoided in anuric patients.

由於需要術後通風的腎功能衰竭引起的酸中毒的患者需要頻繁監測酸中毒。自發通風不足會導致高腺炎和呼吸酸中毒，這將惡化酸中毒，並將血清鉀增加到危險的水平，可能導致循環抑鬱症。

The patient’s bleeding tendency and clotting status should be known before surgery. Abnormalities should be corrected, and blood products, clotting factors, and/or platelets be readily available intraoperatively.

General recommendations for discontinuing antithrombolytics before surgery include Coumadin (warfarin) >7-10 days prior to surgery, Plavix (clopidogrel) 5-7 days before surgery, aspirin (acetylsalicylic acid) 7-10 days before surgery, and NSAIDs 5 days before surgery. The risks and benefits of any decision to discontinue anticoagulation for transient ischemic attacks, recent stent placements, or atrial fibrillation should be carefully discussed with the patient’s cardiologist. The considerations for resuming these medications after surgery should also be reviewed with the relevant physicians.

某些內分泌障礙在圍手術期時間框架期間需要特別注意，並且可以使激素測定進行排序以改善術前狀態。糖尿病患者的感染風險增加，傷口愈合不良，如果血糖不受良好控製，傷口愈合差和過氧性。

在手術前24-48小時應該停止二甲雙胍和磺酰脲，因為它們的長半衰期將患者視為低血糖風險。在手術前應使用胰島素在手術前維持嚴格的Euglycemia。此外，請記住，在臨時局灶性或全球缺血後，高血糖會對結果產生不利影響。

Patients with Cushing’s disease typically have hypokalemic metabolic alkalosis as a result of the excess glucocorticoids. Their volume status and electrolytes should be corrected before a transsphenoidal adenomectomy.

Patients who are steroid-dependent due to adrenal insufficiency require supplemental doses perioperatively. Similarly, patients with hyperthyroidism or hypothyroidism should be made euthyroid before any elective procedures, although mild to moderate abnormalities are not an absolute contraindication.

The ASA Task Force on preanesthesia evaluation recommends selective performance of preoperative tests on the basis of patients’ clinical characteristics for the purpose of guiding or optimizing perioperative management.

Most neurosurgical patients should have hemoglobin or hematocrit, serum glucose and electrolytes, and coagulation studies. If major blood loss is expected, their blood should be typed and cross-matched, whereas for minor procedures, the blood may be only typed and screened. To minimize the risk of postoperative seizures, anticonvulsant medications should reach the higher end of their therapeutic levels because perioperative events lead to an increase in their metabolism.

應考慮妊娠狀況未知的所有育齡年齡的婦女進行妊娠試驗。已知的心髒病或風險因素需要術前心電圖。已知的肺病，心髒病或最近的上呼吸道感染可能需要胸部射線照片。

ASA任務隊還建議，如果患者的病史在某些情況下可能需要更新的測試結果可能是必要的，則可以接受在手術的6個月內進行的測試結果和病史是可以接受的。

瘤旁水腫與preope應該控製rative steroid administration. Long-term (weeks) steroids for management of edema or increased intracranial pressure (ICP) may lead to suppression of the hypothalamic-pituitary axis, requiring supplemental steroids.

Intraoperatively, intracranial pressure may be reduced with the use of diuretics, most commonly mannitol. Volume status must be monitored closely to prevent hypotension and maintain adequate cerebral blood flow. Judicious early cerebrospinal fluid drainage through a lumbar drain, especially in the case of a large posterior fossa mass, can prevent dramatic cerebellar herniation and symptomatic acute brainstem dislocation upon dural opening.

異丙酚（Diprivan）已被證明降低ICP，並提供比異氟烷和Sevolphuran更好的腦鬆弛。因此，接受顱內手術的神經外科患者可能受益於使用異丙酚對吸入麻醉劑的。I do ask our anesthesiologists to use propofol if the patient’s brain is tense during surgery, and have had a good experience with this practice. This tactic has especially worked for posterior fossa operations.

由於其獨特的多種代謝紊亂，包括糖尿病，高血壓和心髒腫大，致肢患者呈現特殊困難。這些患者可能難以插管，並且它們的肥大韌帶可以使其徑向動脈導管插入液相表解。上麵討論了對緩衝疾病患者的擔憂。

應告知患者與顱內程序有關的一般並發症的風險，包括術後出血，癲癇發作，腦卒中，昏迷，死亡，腦積水，腦膜炎，與手術麵積相關的神經係統缺陷（癱瘓，以及語言，感官和小腦障礙）。患者應明確了解這些風險，並有能力提供同意。

在標題的專用章節中審查了喚醒Craniotomy和皮質映射的術前評估和麻醉細節Language Mappingor膠質瘤的傳感器映射。

Patients undergoing carotid endarterectomy typically have other comorbidities, including coronary artery disease, arterial hypertension, peripheral vascular disease, COPD, diabetes, or renal insufficiency. These other comorbidities should be carefully evaluated before surgery.

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) indicated that a history of MI or unstable angina and hypertension are independent risk factors for complications. The NASCET results also demonstrated that aggressive preoperative blood pressure control is associated with improved outcome, thus advocating for treatment of hypertension prior to the procedure.

動脈瘤蛛網膜下腔出血（SAH）患者的預後與他們呈現狩獵和HESS等級密切相關。較高的等級不僅有血管痙攣，ICP升高和腦自身損傷的風險增加，而且還具有較高的心律失常和心肌功能障礙，低血脂和高鼻血症的發生率。

當患者用蛛網膜下腔出血（SAH）呈現時，應評估所有這些風險。還有許多替代等級等級，包括世界神經外科醫生成績和費舍規模的聯合會。有關這些分級係統的詳細信息，請參閱本章Reference Tablesand itsVascular部分。

一個y patient presenting with SAH should also be evaluated for associated medical conditions, including hypertension and smoking history, coarctation of the aorta, polycystic kidney disease, and fibromuscular dysplasia. Patients should also be monitored for hyponatremia due to cerebral salt wasting from increased release of atrial natriuretic peptide. Hypertonic or isotonic saline should be used to correct hyponatremia.

在患者的40％至60％的患者中，可以在40％至60％的患者中看到心電圖（ECG）變化，包括ST段變化或T波反轉，特別是在患有貧困患者的患者中。這些ST異常可能是由於腎上腺素能或應激誘導的MI。然而，經常沒有發現在詳細的心髒鍛煉中發現心髒缺血的證據。高級SAH的患者中，室內功能障礙也可能更普遍。

Microsurgery or endovascular intervention for ruptured aneurysms should be postponed only if the patient is hemodynamically unstable, has a ventricular ejection fraction below 30%, or is clinically in heart failure.

One final concern for patients presenting with SAH is pulmonary aspiration. Because loss of consciousness is often associated with the ictus of hemorrhage, the risk of aspiration increases the risk for impaired gas exchange. Neurogenic pulmonary edema due to SAH compounds this problem.

As AVMs are highly vascular, intraoperative massive blood loss is a significant risk during microsurgery, so patients should be typed and cross-matched and generous vascular access should be available. The patient’s Spetzler-Martin grade can predict the surgical risk associated with AVM resection.

由於腦血管自動調節和“正常灌注壓力突破”現象，我在手術期間將患者的收縮壓〜20-30％以下低於其術前基線值。術後，該範圍嚴格持續約2-3天，以最大限度地減少術後血腫和水腫的顯著風險。抗驚厥藥物的Supratherapeutic水平與預防圍手術期癲癇發作和相關的血壓相關的尖刺。

Procedures in the posterior fossa typically require that the patient be placed in a lateral position to allow access to the cerebellopontine angle, clivus, petrous ridge, and foramen magnum. Positioning for these procedures can exert excess demand on the cardiopulmonary systems that should be examined preoperatively. Preoperative evaluation should also consider the symptoms and signs of brainstem compression.

Manipulation of cranial nerves (CNs), especially CNs V, IX, and X, as well as tentorium and petrous dura, may lead to temporary asystole or cardiac arrhythmias. Appropriate precautions for treatment of these cardiac irregularities are warranted.

Electrophysiologic monitoring may be used in any neurosurgical procedure, but most often during posterior fossa and brainstem surgery around the cranial nerves. Somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs) and electromyography (EMG) may be used for monitoring and mapping cranial nerves and spinal cord function. Brainstem auditory evoked potentials (BAERs) monitor the function of the brainstem and CN VIII. Anesthetic adjustments, including avoidance of paralytic medications during monitoring motor function, are required.

頭部受傷的患者最常經曆應急手術，因此由於時間限製，它們的術前評估受到限製。維護足夠的氣道，呼吸和循環是至關重要的。

目標是避免任何可能是由低氧血症，高曲線，枯草/高血壓，高血糖，ICP，癲癇發作和血管痙攣引起的任何進一步的神經損傷。頸椎損傷使氣管插管複雜化。一旦建立了氣道，應最小化HEAC / HYPOCAPNIA，應優化腦灌注壓力並保持在60 mmHg以上。血液產品應盡快打字和交叉匹配。

可以在局部麻醉下與患者進行癲癇手術，其中令人醒來的CRANIOROMY最小的IV鎮靜。這允許外科醫生與患者通信，並更準確地映射使用電壓識別的切除位置和程度。

應仔細調整抗驚厥藥物的血液水平。Phenytoin（Dilantin）導致更多對Nondepolizing神經肌肉阻斷藥物的抗性，這對麻醉感應和維護很重要。

If a patient has previously undergone an operation by another surgeon, a phone conversation with the primary surgeon is important to elucidate the difficulties encountered during the initial operation. Review of the operative notes can be nonrevealing and at times confusing. Similarly, if a patient has undergone an operation by the same surgeon, all operative notes should be reviewed in detail.

Most patients are referred after their MR imaging or CT scan. Imaging studies older than 3 months should be repeated because lesional progression during this time period may affect operative planning.

我檢查手術計劃和所需的理療logic parameters (blood pressure and volume parameters) immediately before surgery with the anesthesia team. I also describe the risk of blood loss or necessity for electroencephalographic burst suppression. Neurophysiologic monitoring needs are also discussed because these needs will affect the mode of anesthesia.

如果考慮了醒來的Craniotomy，我通常會在手術前一天審查這種情況的細節，並在手術前立即允許額外的時間來描述對患者的映射並討論關注和問題。

In select patients who are suspected to have poor nutritional status, a serum prealbumin level test can assess their nutritional status. Importantly, a consultation with a nutritionist is essential to optimize the patient's status before surgery.

• Although many general principles for preoperative evaluation apply to neurosurgical patients, these patients suffer from different pathologic conditions and are undergoing procedures that require tailored evaluation and monitoring in the perioperative period.
• Successful intraoperative management relies on a thorough preoperative evaluation and an understanding of the patient’s physiology, the lesion’s pathophysiology, and the demands on the patient during the procedure.

Contributor: Jonathan M. Parish, MD

DOI：https://doi.org/10.18791/nsatlas.v2.01