Intraoperative management of subarachnoid hemorrhage (SAH) is high-risk anesthesia with the potential for severe consequences. This chapter presents a case study of a 56-year-old African-American female smoker who presented with sudden onset of frontal headache, vomiting, and neck stiffness. Anesthesia for patients with SAH is challenging. The maintenance of an adequate mean arterial blood pressure, and hence cerebral perfusion pressure (CPP), during the induction of anesthesia is key to prevent ischemic secondary injury. CPP and transmural pressure are essentially influenced by the same variables and are equal to the mean arterial pressure minus intracranial pressure (ICP). Aneurysm rupture during laryngoscopy is an uncommon but life-threatening complication, which should be suspected if severe hypertension and bradycardia develop. Constant vigilance regarding hemodynamic control and preparedness for the possibility of intraoperative aneurysmal rupture are essential for good outcomes.

This chapter presents a case study of a 62-year-old female presented to the operating room with a diagnosis of two large intracranial aneurysms. The case is a discussion of the application of deep hypothermic circulatory arrest (DHCA) for patients undergoing large and/or complex intracranial aneurysm clipping and repair. The patient was brought to the operating room, noninvasive monitors placed, and under local anesthesia a right radial arterial line was established. The rationale behind the technique of DHCA stems from the significant advantage the surgeon has once blood flow has stopped circulating to the aneurysm. The margin for error is small, and success depends upon an experienced and knowledgeable team. The safe practice and management of DHCA requires an extensive understanding of cardiac and neurosurgical anesthetic practice, cardiopulmonary bypass (CPB), as well as careful consideration and proper planning.

Neurosurgery during pregnancy is rare and as a result there are few evidence-based recommendations in the literature to provide guidance. An understanding of maternal physiology and a multidisciplinary approach are imperative to ensure a successful outcome. This chapter presents a case study of a 37-year-old female with multiple hematologic co-morbidities presented at 18 weeks gestation with perioral and periocular twitching, memory lapses and a recent sensory loss and painful paresthesias affecting the right side of her body. After a multidisciplinary discussion involving neurosurgery, obstetrics, and hematology it was decided to proceed with intracranial aneurysm clipping via craniotomy at 18 weeks gestation. A smooth intravenous rapid sequence induction with cricoid pressure was performed using lidocaine, fentanyl, propofol, and succinylcholine. Neurosurgery in a pregnant patient is rare and requires a thorough understanding of the physiologic changes of pregnancy and the associated concomitant anesthetic risks to both mother and fetus.