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Anesthesia for interventional neuroradiology
Anestesia en neuroradiología intervencionista
Chanhung Z. Lee
Corresponding author
clee4@anesthesia.ucsf.edu

Corresponding author at: 1001 Potrero Avenue, Building 10, Room 1206, San Francisco, CA 94110, United States.
Associate Professor of Anesthesiology, Department of Anesthesia and Perioperative Care, University of California, San Francisco, United States
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The aim of this article is to present the author&#39;s critical review of the literature and interpretation of the roles of the Anesthesiologist in the management of patients undergoing invasive endovascular procedures to treat vascular diseases&#44; primarily of the central nervous system&#44; emphasizing perioperative and anesthetic management strategies to prevent complications and minimize their effects if they occur&#46; This endovascular practice is usually termed Interventional Neuroradiology &#40;INR&#41; or endovascular neurosurgery&#46; There are several particular anesthetic concerns for INR procedures&#44; including&#58; &#40;1&#41; maintaining immobility during the procedure to facilitate imaging&#59; &#40;2&#41; rapid recovery from anesthesia to facilitate neurological examination and monitoring&#44; or to provide for intermittent evaluation of neurological function during the procedure&#59; &#40;3&#41; managing anticoagulation&#59; &#40;4&#41; managing sudden unexpected procedure-specific complications during the intervention&#44; i&#46;e&#46;&#44; hemorrhage or vascular occlusion&#44; which may involve manipulating systemic blood pressures&#59; &#40;5&#41; guiding the medical management of critical care patients during transport to and from the radiology suites&#59; &#40;6&#41; self-protection issues related to radiation safety&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pre-operative planning and patient preparation</span><p id="par0010" class="elsevierStylePara elsevierViewall">Baseline blood pressure and cardiovascular reserve should be assessed carefully because blood pressure manipulation is commonly required and treatment-related perturbations should be anticipated&#46; A clear sense of the patient&#39;s baseline blood pressure range needs to be established&#46; The concordance between blood pressure cuff and intra-arterial readings needs to be considered while decision is usually based on the individual cases&#46; For procedures involving the blood supply to the CNS&#44; beat-to-beat blood pressure monitoring is prudent&#46; Pre-operative blood pressure range is likely to be known through blood pressure cuff values&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Secure intravenous &#40;i&#46;v&#46;&#41; access&#8212;with secure connections&#8212;should be established with adequate extension tubing to allow drug and fluid administration at maximal distance from the image intensifier during fluoroscopy&#46; Infusions of primary anesthetics or vasoactive agents should be through proximal ports with minimal dead space&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A pulse oximeter probe can be placed on the great toe of the leg that will receive the femoral introducer sheath&#44; and may provide an early warning of femoral artery obstruction or distal thromboembolism&#44; if there is concern about ischemia in high risk patients&#46; Bladder catheters assist in fluid management as well as patient comfort&#44; given that a significant volume of heparinized flush solution and radiographic contrast may be used&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A fundamental knowledge of radiation safety is essential for working in an INR suite&#46; Assume that the X-ray machine is always on&#46; Exposure decreases proportionally to the inverse of the square of the distance from the source of radiation &#40;inverse square law&#41;&#46; Digital subtraction angiography &#40;DSA&#41; delivers considerably more radiation than fluoroscopy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Optimal protection includes use of lead aprons&#44; thyroid shields and radiation exposure badges&#46; A recent study also highlighted the importance of eye-protection for anesthesiologists working significant time in the INR suite&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Movable lead glass screens may provide additional protection&#46; With proper precautions&#44; the anesthesia team should be exposed to far less than the annual recommended limit for health care workers&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Anesthetic technique</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Choice of anesthetic technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">Most centers routinely use general endotracheal anesthesia for complex procedures or those of long duration&#46; There is no clear superior method within well-described considerations for operative neuroanesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Specific anesthesia management concerns for common NIR procedures are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">General anesthesia</span><p id="par0040" class="elsevierStylePara elsevierViewall">General anesthesia minimizes motion artifacts which improves image quality&#46; Intermittent apnea may be requested by the interventional team to even further reduce motion artifact during DSA&#46; The specific choice of anesthesia may be guided primarily by other cardiac- and cerebrovascular considerations&#46; Total intravenous anesthetic techniques&#44; or a combination of low inspired concentrations of inhalational with intravenous agents may optimize rapid emergence&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Relative normocapnia or slight hypocapnia consistent with the safe conduct of positive pressure ventilation should be maintained unless intracranial pressure is a concern&#46; If a patient has increased intracranial pressure&#44; mild hypocapnia may be indicated prior to apnea during induction and to overcome any vapor-induced vasodilation during maintenance&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Intravenous sedation</span><p id="par0050" class="elsevierStylePara elsevierViewall">One major benefit of intravenous sedation is to allow continual assessment of neurological functions during the procedure&#46; A variety of sedation regimens are available&#44; and specific choices are based on the experience of the practitioner and the goals of anesthetic management&#46; Common to all intravenous sedation techniques is the potential for upper airway obstruction&#46; Placement of nasopharyngeal airways may cause troublesome bleeding in anticoagulated patients and is generally avoided&#46; Dexmedetomidine should be used with care because of the tendency to cause relatively low blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">For intravenous sedation cases&#44; careful padding of pressure points and comfortable positioning may decrease the requirement for sedation&#44; anxiolysis and analgesia&#46; Evaluation of the potential ease of laryngoscopy in an emergent situation should take into account access to the airway when imaging is underway&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Anticoagulation</span><p id="par0060" class="elsevierStylePara elsevierViewall">Careful management of coagulation prevents thromboembolic complications during and after the procedure&#46; Generally&#44; after a baseline activated clotting time &#40;ACT&#41; is obtained&#44; intravenous heparin &#40;70<span class="elsevierStyleHsp" style=""></span>units&#47;kg&#41; is given to a target prolongation of 2&#8211;3 times of baseline upon the request from the interventionists&#44; especially if therapeutic procedures are planned&#46; Then heparin often can either be given continuously or as an intermittent bolus with hourly monitoring of ACT as in typical therapeutic regimens&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Heparin-induced thrombocytopenia &#40;HIT&#41; is a rare but important adverse event for heparin anticoagulation&#46; Development of heparin dependent antibodies after initial exposure leads to a prothrombotic syndrome&#46; In high-risk patients&#44; direct thrombin inhibitors can be applied and their effect can be monitored by either aPTT or ACT&#46; Lepirudin and bivalirudin&#44; synthetic derivatives&#44; have half-lives of 40&#8211;120<span class="elsevierStyleHsp" style=""></span>min and about 25<span class="elsevierStyleHsp" style=""></span>min&#44; respectively&#46; Because these drugs undergo renal elimination&#44; dose adjustments may be needed in patients with renal dysfunction&#46; Argatroban is an alternative agent that undergoes primarily hepatic metabolism&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Antiplatelet agents &#40;aspirin&#44; the glycoprotein IIb&#47;IIIa receptor antagonists and the thienopyridine derivatives&#41; are increasingly being used for cerebrovascular disease management&#46; Abciximab &#40;Rheopro&#41; has been used to treat thromboembolic complications&#46; Abciximab&#44; eptifibatide and tirofiban are glycoprotein IIb&#47;IIIa receptor antagonists&#46; The long duration and potent effect of Abciximab also increase the likelihood of major bleeding&#46; The smaller molecule agents&#44; eptifibatide and tirofiban&#44; are competitive blockers and have a shorter half-life of about 2<span class="elsevierStyleHsp" style=""></span>h&#46; Thienopyridine derivatives &#40;ticlopidine and clopidogrel&#41; bind to the platelet&#39;s ADP receptors and permanently alter the receptor&#59; therefore&#44; the duration of action is the life span of the platelet&#46; The addition of clopidogrel to the antiplatelet regimen is commonly used for procedures that require placement of devices&#44; such as stents&#44; coiling or stent-assisted coiling&#44; primarily in patients that have not had an acute event&#44; such as unruptured aneurysms&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">At the end of the procedure or at occurrence of hemorrhagic complication&#44; heparin may be reversed with protamine&#46; Since there is no specific antidote for the direct thrombin inhibitors or the antiplatelet agents&#44; the biological half-life is one of the major considerations in drug choice&#44; and platelet transfusion is a non-specific therapy&#44; should reversal be indicated&#46; There is no currently available accurate test to measure platelet function in patients taking the newer antiplatelet drugs&#46; Desmopressin &#40;DDAVP&#41; has been reported to shorten the prolonged bleeding time of individuals taking antiplatelet agents such as aspirin and ticlopidine&#46; Specific clotting factors&#44; including recombinant factor VIIa and factor IX complex&#44; may be used to rescue severe life-threatening bleeding&#44; including intracranial hemorrhage uncontrolled by standard transfusion therapy&#46; The safety and efficacy of these coagulation factors remain to be investigated&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Deliberate hypertension</span><p id="par0080" class="elsevierStylePara elsevierViewall">During acute arterial occlusion or vasospasm&#44; a practical way to increase collateral blood flow may be an augmentation of the collateral perfusion pressure by raising the systemic blood pressure&#46; The Circle of Willis is a primary collateral pathway but may be incomplete in as many as more than 20&#37; of otherwise normal subjects&#46; There are also secondary collateral channels that bridge adjacent major vascular territories&#44; most importantly for the long circumferential arteries that supply the hemispheric convexities&#46; These pathways are known as the pial-to-pial collateral or leptomeningeal pathways&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The extent to which the blood pressure has to be raised depends on the condition of the patient and the nature of the disease&#46; Typically&#44; during deliberate hypertension the systemic blood pressure is raised by 30&#8211;40&#37; above the baseline in the absence of some direct outcome measure&#44; such as resolution of ischemic symptoms or imaging evidence of improved perfusion&#46; Phenylephrine is usually the first line agent for deliberate hypertension and is titrated to achieve the desired level of blood pressure&#46; The EKG and ST segment monitor should be carefully inspected for signs of myocardial ischemia&#46; Other pressors may be appropriate with excessive reflex bradycardia or baseline chronotropic medication or conduction delays&#46; The effects of catecholamines on the cerebral circulation are not predictable&#44; but in general&#44; all of them are acceptable to achieve the target of adequate systemic pressure in the context of brain injury&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The risk of causing hemorrhage into an ischemic area or rupturing an aneurysm must be weighed against the benefits of improving perfusion&#44; but augmentation of blood pressure in the face of acute cerebral ischemia to promote collateral blood supply is probably protective in most settings&#46; Clear communication with the interventional team is certainly crucial to determine the appropriate blood pressure goal and to monitor the effects of manipulation of cerebral perfusion&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Deliberate hypotension</span><p id="par0095" class="elsevierStylePara elsevierViewall">The two primary indications for induced hypotension are&#58; &#40;1&#41; to test cerebrovascular reserve in patients undergoing carotid occlusion&#59; and &#40;2&#41; to slow flow in a feeding artery of brain arterio-venous malformations before glue injection &#40;sometimes termed &#8220;flow arrest&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">14</span></a> The most important factor in choosing a hypotensive agent is the ability to safely and expeditiously achieve the desired reduction in blood pressure while maintaining the patient physiologically stable&#44; and if awake&#44; not interfere with neurological assessment&#46; It is important to realize that the population average lower limit of autoregulation is closer to 70<span class="elsevierStyleHsp" style=""></span>mmHg than the 50<span class="elsevierStyleHsp" style=""></span>mmHg frequently shown in text books&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">15</span></a> This may have important implications for use of deliberate hypotension&#44; since ensuring adequate cerebral perfusion is critical for patient safety&#44; especially if general anesthesia is used&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Management of neurological and procedural crises</span><p id="par0100" class="elsevierStylePara elsevierViewall">A well thought-out plan&#44; coupled with rapid and effective communication between the anesthesia and radiology teams&#44; is critical for good outcomes&#46; The primary responsibility of the anesthesia team is to preserve gas exchange and&#44; if needed&#44; secure the airway and support systemic circulation&#46; The anesthesiologist should communicate with the INR team and determine whether the problem is hemorrhagic or occlusive&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the setting of vascular occlusion&#44; the goal is to increase distal perfusion by blood pressure augmentation with or without direct thrombolysis&#46; If the problem is hemorrhagic&#44; immediate cessation of heparin and reversal with protamine is indicated&#44; after discussion with the interventional team&#46; As an emergency reversal dose&#44; 1<span class="elsevierStyleHsp" style=""></span>mg protamine can be given for each 100<span class="elsevierStyleHsp" style=""></span>units of initial heparin dosage that resulted in therapeutic anticoagulation&#46; The ACT can then be used to fine-tune the final protamine dose&#46; Complications of protamine administration include hypotension&#44; true anaphylaxis and pulmonary hypertension&#46; In the anesthetized or comatose patient&#44; the sudden onset of bradycardia and hypertension &#40;Cushing response&#41; or the endovascular therapist&#39;s diagnosis of extravasation of contrast may be the only clues to a developing hemorrhage&#46; Most cases of vascular rupture can be managed in the angiography suite&#46; The INR team can attempt to seal the rupture site endovascularly and abort the procedure&#59; a ventriculostomy catheter may be placed emergently in the angiography suite&#46; Patients with suspected rupture will require emergent CT scan&#44; but emergent craniotomy is usually not indicated&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Post-operative management</span><p id="par0110" class="elsevierStylePara elsevierViewall">Endovascular surgery patients pass the immediate post-operative period in a monitored setting such as a high dependency unit or intensive care unit to watch for signs of hemodynamic instability or neurologic deterioration&#46; Control of blood pressure may be necessary during transport and post-operative recovery&#44; e&#46;g&#46;&#44; induced hypertension&#44; if indicated&#46; In particular&#44; patients undergoing treatment of extracranial carotid disease are prone to postprocedural hemodynamic instability&#44; similar to post carotid endartectomy patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">16</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Abrupt restoration of normal systemic pressure to a chronically hypotensive &#40;ischemic&#41; vascular bed may overwhelm autoregulatory capacity and result in hemorrhage or swelling &#40;normal perfusion pressure breakthrough&#44; NPPB&#41;&#46; The mechanism is unclear&#44; but it is probably not simply a hemodynamic effect&#46; Nonetheless&#44; cerebral hyperemia is probably exacerbated by uncontrolled increases in systemic arterial blood pressure&#46; In the absence of collateral perfusion pressure inadequacy&#44; fastidious attention to preventing hypertension is warranted&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">None</p></span></span>"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Pre-operative planning and patient preparation"
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        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Anesthetic technique"
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              "identificador" => "sec0020"
              "titulo" => "Choice of anesthetic technique"
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              "titulo" => "Intravenous sedation"
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          "identificador" => "sec0035"
          "titulo" => "Anticoagulation"
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          "identificador" => "sec0040"
          "titulo" => "Deliberate hypertension"
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          "identificador" => "sec0045"
          "titulo" => "Deliberate hypotension"
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          "identificador" => "sec0050"
          "titulo" => "Management of neurological and procedural crises"
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          "titulo" => "Post-operative management"
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            0 => "Neurosurgical procedures"
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            3 => "Endovascular procedures"
            4 => "Central nervous system vascular malformations"
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            0 => "Procedimientos Neuroquir&#250;rgicos"
            1 => "Hemodin&#225;mica"
            2 => "Anestesia"
            3 => "Procedimientos Endovasculares"
            4 => "Malformaciones Vasculares del Sistema Nervioso Centra"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Interventional Neuroradiology</span> &#40;INR&#41; is firmly established in the management of cerebrovascular diseases&#46; The aim of this manuscript is to present the author&#39;s critical review of the literature and interpretation emphasizing perioperative and anesthetic management strategies to prevent complications and minimize their effects if they occur&#46; Planning the anesthetic and perioperative management is predicated on understanding the goals of the therapeutic intervention and anticipating potential problems&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La <span class="elsevierStyleItalic">Neuroradiolog&#237;a Intervencionista</span> &#40;NRI&#41; est&#225; firmemente establecida en el manejo de la patolog&#237;a cerebrovascular&#46; El objetivo del presente manuscrito es presentar una revisi&#243;n cr&#237;tica de la literatura e interpretaci&#243;n por parte del autor&#44; enfatizando las estrategias perioperatorias y anest&#233;sicas para prevenir complicaciones y minimizar sus efectos en caso de que estas se presenten&#46; La planeaci&#243;n de la gesti&#243;n anest&#233;sica y perioperatoria se fundamenta en comprender las metas de la intervenci&#243;n terap&#233;utica y anticiparse a los problemas potenciales&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Lee CZ&#46; Anestesia en neuroradiolog&#237;a intervencionista&#46; Rev Colomb Anestesiol&#46; 2015&#59;43&#58;151&#8211;155&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Possible anesthetic considerations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Therapeutic embolization of vascular malformation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intracranial AVMs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deliberate hypotension&#44; post-procedure NPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dural AVM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Existence of venous hypertension&#59; deliberate hypercapnia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extracranial AVMs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deliberate hypercapnia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Carotid cavernous fistula &#40;CCF&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deliberate hypercapnia&#44; post-procedure NPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cerebral aneurysms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aneurysmal rupture&#44; blood pressure control<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Ethanol sclerotherapy of arteriovenous or venous malformations</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brain swelling&#44; airway swelling&#44; hypoxemia&#44; hypoglycemia&#44; intoxication from ethanol&#44; cardiorespiratory arrest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Balloon angioplasty &#38; stenting of occlusive cerebrovascular disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cerebral ischemia&#44; deliberate hypertension&#44; concomitant coronary artery disease&#44; bradycadia&#44; hypotension&#44; NPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Balloon angioplasty or pharmacological treatment of cerebral vasospasm secondary to aneurysmal SAH</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cerebral ischemia&#44; blood pressure control<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Therapeutic carotid occlusion for giant aneurysms and skull base tumors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cerebral ischemia&#44; blood pressure control<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Thrombolysis of acute thromboembolic stroke</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Post-procedure ICH &#40;NPPB&#41;&#44; concomitant coronary artery disease&#44; blood pressure control<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Interventional neuroradiologic procedures and primary anesthetic considerations&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#8211;11</span></a></p>"
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                          "etal" => false
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                            0 => "W&#46;L&#46; Young"
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                            0 => "Z&#46;H&#46; Anastasian"
                            1 => "D&#46; Strozyk"
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                      "doi" => "10.1097/ALN.0b013e31820c2b81"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos