The Neurovascular Anesthesiology rotation involves one month during the CA-2 level of training that offers a concentrated study of providing anesthesia for patients undergoing major neurological (intracranial or spinal) or vascular procedures. A CA-3 level rotation is available as an elective for one to two months duration. The CA-3 resident will be assigned to the most challenging neurological or vascular cases. The residents will gain experience in management of patients with a wide variety of neurological problems. Neurological physiology will be reviewed. After completion of this rotation the resident should have experience with providing care to patients with intracranial vascular and non-vascular lesions. The resident should also have gained experience in managing patients having open repairs of major vascular structures and with the management of patients having endovascular stent placement procedures. This concentrated period of study is to compliment the educational experience of the residents who may have provided anesthetic care to patients have major neurological or vascular procedures while they were assigned to the general operating room rotation.

CA-2 Level of training goals for Neurovascular Rotation:

• Learn the basic neurophysiology of cerebral blood flow, intracranial pressure and cerebral spinal fluid formation.
• Learn the basics of intracranial pressure monitoring.
• Learn the effects of anesthetics and various drugs on cerebral blood flow, cerebral metabolism and intracranial pressure.
• Learn the different methods of attempting cerebral protection during intracranial procedures.
• Learn the difference between focal and global ischemia.
• Learn different monitoring techniques for cerebral blood flow.
• Learn the differential diagnosis of venous air embolism.
• Learn the anesthetic management of a patient with a cerebral aneurysm.
• Learn the anesthetic management of a patient with an intracranial bleed.
• Learn the anesthetic management of the patient who has an intracranial mass lesion.
• Learn the effects of ventilation on cerebral blood flow.
• Learn the effects of anesthesia on cerebral auto-regulation.
• Learn the potential complications of positioning for neurological procedures.
• Learn the management of the patient with cervical spine injury.
• Understand the Glascow Coma Scale and its� importance in predicting outcomes in patients with cranial trauma.
• Learn the anesthetic considerations for a patient having an awake craniotomy.
• Learn the anesthetic management of a patient having major vascular procedures such as abdominal aortic aneurysm repair, carotid endarterectomy, thoracic aneurysm repair, thoraco-abdominal aortic aneurysm repair, femoral-femoral bypass, axillary-femoral bypass, femoral-popliteal bypass, fermoral-distal bypass.
• Learn the pathophysiology of aortic cross-clamping and unclamping.
• Learn strategies to preserve renal function.
• Learn the advantages and disadvantages of regional versus general anesthesia for patients having major vascular procedures.
• Learn the anesthetic management of the patient having endovascular stent placements.

CA-3 level of training goals for Neurovascular Rotation :

The CA-3 resident will be expected to further their knowledge in management of the patient having major neurological or vascular procedure as described in the learning goals of the CA-2 level of training resident.  The CA-3 resident will also gain exposure to and understanding of more advance monitoring techniques in neurological surgery and vascular surgery.

• Understand the basics of electrophysiology: anatomy, physiology and neural pathways as they apply to:
  • somatosensory evoked potentials.
  • brain stem auditory evoked potentials
  • electroencephalography
  • facial EMG monitoring
  • electrocorticography
  • Lower extremity EMG monitoring
  • Trigeminal facial reflex monitoring
  • Motor strip mapping
  • Cortical stimulation.
• Perform an pre-anesthetic evaluation and formulated an anesthetic management plan with minimal faculty assistance.
• Demonstrate to the faculty a detailed knowledge of fluid management for neurosurgical patients, including osmolarity, osmotherapy, and the side effects of each.
• Learn anesthetic management of patients with intractable seizure disorders.
• Learn the anesthetic management of patients with movement disorders having pallidotomy, thallamotomy or placement of deep brain stimulaor procedures.
• Learn the anesthetic considerations of providing anesthetic care to patient having procedures performed outside the operating room suite, i.e. neurointerventional radiological procedures, Magnetic resonance imaging.
• Learn the anesthetic management of patients having complex neurological procedures such as acoustic neuroma resection, trigeminal nerve decompression, Arnold-Chiari decompression CSF shunting, external carotid to internal carotid bypass, encephalodurosynagiosis, complex Arterio-venous malformation.
• Learn the management of patients undergoing various spine procedures including anterior and posterior instrumentation fixation.
• Learn the anesthetic considerations of management of the neonate undergoing procedures such as myelomeningocele repair, encephalocele repair or ventriculoperitoneal shunt procedures.
• Learn the anesthetic management of infants and children undergoing neurosurgical procedures including focal seizure foci resection, hemispherectomy, craniosynostosis repair, tethered cord release, craniofacial advancement procedures, Moya Moya repair, and all types of ventricular shunts.
• Learn the pathophysiology of lumbar cerbral spinal fluid pressure monitoring and drainage during thoracic and certain abdominal aortic artery repair procedures.
• Learn the special considerations for fiberoptic intubations in patients with a halo frame, leksell frame and in the lateral position.