Fundamentals of Pediatric Neuroanesthesia

Description

The book provides an excellent review of all the clinical aspects of neuroanesthesia in children, including neurosurgeries during fetal state to neonatal, infancy, toddler, and school-going age groups. To provide optimal anesthetic care in children undergoing neurosurgery, the care provider must have adequate knowledge on the developing brain and spinal cord, and the effect of anesthetics on the neuronal tissue, and the inherent issues pertaining to neurologic lesions. This book covers the diagnostic, imaging, surgical as well as anesthetic managements of all the neurosurgical problems in children. The chapters include a wide range of topics from basic neurophysiology to general concerns for pediatric neuroanesthesia, including fluid management, blood transfusion, temperature regulation, and surgical positioning, as well as specific issues such as anesthesia for brain tumor surgery, hydrocephalus, neural tube defects, cerebrovascular surgeries such as aneurysmal surgery, arteriovenous malformations (AVMs), Moyamoya disease, and vein of Galen malformation, functional neurosurgery, epilepsy surgery, neuroendoscopy, craniovertebral junction anomalies, spinal surgeries, neurotrauma, and brain abscess with congenital heart diseases. Interesting topics like neuroanesthesia in remote locations, regional anesthesia during neurosurgery, and anesthesia for children with neuromuscular disease are also discussed. Moreover, the book elaborates on advanced neuroanesthesia techniques during fetal neurosurgery and craniopagus separation surgery; and the postoperative intensive care management aspects in each chapter. It is supplemented with figures depicting surgical procedures and positioning, neuroimages, tables and illustrations for easy understanding. This book caters to neuroanesthesiologists, pediatric anesthesiologists, residents, and fellows of anesthesia or neuroanesthesia, practicing anesthesiologists, pediatric neurointensivists, nurse anesthetists, neurosurgeons, and pediatric neurosurgeons. It also serves as a reference book for the DM (neuroanesthesiology and neurocritical care), DNB-SS (neuroanesthesiology), and MD (anesthesiology) curriculums apart from anesthesia residency and pediatric anesthesia/ neurosurgery fellowship programs offered at various Institutions worldwide. Foreword Preface Acknowledgments Contents About the Editor Part I: General Considerations 1: Pediatric Neuroanesthesia: Evolution of a New Subspeciality 1.1 Introduction 1.2 Development of Neuroanesthesia Along with Neurosurgery 1.3 Development of Pediatric Neurosurgery as a Subspecialty 1.3.1 Neurosurgery: An Indian Perspective 1.4 Pediatric Neuroanesthesia: Not Just “Anesthesia” or “Neuroanesthesia” 1.5 Future Prospects as a Subspeciality 1.6 Conclusion References 2: Developmental Anatomy and Physiology of the Central Nervous System in Children 2.1 Introduction 2.2 Development of the Central and Autonomic Nervous Systems 2.2.1 Intrauterine Development 2.2.2 Development of the Brain 2.2.3 Development of the Spinal Cord 2.2.4 Autonomic Nervous System (ANS) 2.2.5 Neuronal and Cellular Proliferation 2.2.6 Myelination 2.3 Relevant Anatomy 2.3.1 Head Size, Suture, and Fontanelle 2.4 Cerebral Vascular Anatomy 2.4.1 Arterial Circulation 2.4.2 Venous Drainage 2.5 Cerebral Physiology 2.5.1 Cerebral Blood Flow (CBF) 2.5.1.1 Factors Affecting Cerebral Blood Flow Cerebrovascular Reactivity to Carbon Dioxide in Children 2.5.2 Cerebral Metabolic Rate (CMR) 2.5.3 Cerebral Autoregulation (CA) 2.5.3.1 Cerebral Autoregulation (CA) in Neonates 2.5.3.2 Cerebral Autoregulation (CA) in Small Children 2.5.4 Cerebral Spinal Fluid (CSF) Dynamics 2.5.5 Blood-Brain Barrier (BBB) 2.5.6 Intracranial Pressure (ICP) 2.5.7 Cerebral Compliance (Intracranial Pressure-Volume Relationship) 2.5.7.1 Intracranial Compliance 2.6 Spinal Cord Anatomy and Physiology 2.6.1 Spinal Cord Vascular Anatomy 2.7 Neurotoxicity in the Immature Human Brain 2.8 Epileptogenesis in the Developing Brain 2.9 Neuroprotection 2.9.1 General Measures 2.9.2 Anesthetic Agents 2.9.3 Temperature Control: Therapeutic Hypothermia 2.9.4 Hypoxic-Ischemic Preconditioning 2.9.5 Remote Ischemic Preconditioning 2.9.6 Erythropoietin (EPO) 2.9.7 Progesterone 2.9.8 Neurotrophic Factors 2.9.9 Stem Cell Treatment 2.10 Cerebral Physiology in Pathological States 2.11 Conclusion References 3: Effect of Sedatives and Anesthetics on Cerebral Physiology in Children 3.1 Introduction 3.2 Effect of Specific Anesthetic Agents 3.2.1 Inhaled Anesthetics 3.2.1.1 Nitrous Oxide 3.2.1.2 Halothane 3.2.1.3 Isoflurane 3.2.1.4 Sevoflurane 3.2.1.5 Desflurane 3.2.1.6 Xenon 3.2.2 Intravenous Anesthetics 3.2.2.1 Propofol 3.2.2.2 Thiopentone 3.2.2.3 Etomidate 3.2.2.4 Ketamine 3.2.3 Other Agents 3.2.3.1 Opioids 3.2.3.2 Benzodiazepines 3.2.3.3 Muscle Relaxants 3.2.3.4 Dexmedetomidine 3.3 Anesthetic Neuroprotection in Children 3.4 Conclusion References 4: Preoperative Evaluation and Preparation of Children Undergoing Neurosurgery 4.1 Introduction 4.2 History Taking in a Child Posted for Neurosurgery 4.3 Physical Examination 4.3.1 General Examination 4.4 Neurologic Examination 4.5 Airway Assessment 4.6 Cardiovascular Examination 4.7 Respiratory Examination 4.8 Other Systemic Examinations 4.9 Preoperative Investigations 4.10 Risk Stratification 4.11 Other Considerations 4.11.1 The Child with Physical or Mental Handicap 4.11.2 Drug Abusing Child and Adolescent 4.12 Preoperative Preparation 4.12.1 Preoperative Visit 4.12.2 Informed Consent 4.12.3 Fasting Guidelines 4.12.4 Premedication and Review of Current Medications 4.13 Conclusion References 5: Airway Equipment and Difficult Airway Management During Pediatric Neurosurgery 5.1 Introduction 5.2 Infant Versus Adult Airway 5.3 Predicting Difficult Airway in Children 5.4 Planning and Investigations 5.5 Conducting the Anesthetic 5.6 Equipment for Airway Management in Children 5.6.1 Pediatric Masks 5.6.2 Pediatric Laryngoscopes 5.6.3 Airway Adjuncts 5.6.4 Tracheal Tube Exchangers 5.6.5 Cuffed Endotracheal Tubes in Pediatric Patients 5.6.6 Reinforced Endotracheal Tubes in Pediatric Patients 5.6.7 Frova Intubating Introducer 5.6.8 Laryngeal Mask Airways (LMAs) and Other Supraglottic Airway Devices (SADs) 5.6.9 Video Laryngoscope 5.6.10 Fiberoptic Bronchoscope 5.6.11 Pediatric Anesthetic Circuit During Neurosurgery 5.7 Pediatric Neurosurgical Patients with Difficult Airway 5.7.1 Rapid Sequence Induction 5.7.2 Difficulty Securing the Airway 5.7.3 Difficulty in Maintaining the Airway 5.7.4 Difficult Extubation 5.8 The Pediatric Emergency Difficult Airway Cart 5.9 Escape Route for Cannot Intubate, Cannot Oxygenate (CICO) Scenarios 5.10 Pediatric Tracheostomy 5.11 Conclusion References 6: Anesthetizing Pediatric Neurosurgical Patients: A Practical Approach 6.1 Introduction 6.2 Preoperative Preparation 6.2.1 Preoperative Checks 6.2.1.1 Preoperative Assessment 6.2.1.2 Fasting and Consent 6.2.1.3 Radiology and Labs 6.2.1.4 Checklist 6.2.1.5 Anxiolysis on Day of Surgery 6.2.2 Operating Room Preparation 6.3 Intraoperative Management 6.3.1 Vascular Access 6.3.2 Induction of Anesthesia 6.3.3 Intubation (Airway Management) 6.3.4 Maintenance of Anesthesia 6.3.5 Monitoring 6.3.5.1 Hemodynamic Monitoring 6.3.5.2 Neurophysiologic Monitoring 6.3.6 Positioning 6.3.7 Fluid and Blood Component Therapy 6.3.8 Glucose Homeostasis 6.3.9 Temperature Regulation 6.3.10 Intraoperative Complications 6.3.11 Emergence 6.4 Postoperative Care 6.4.1 PACU Considerations 6.4.1.1 Organization of PACU 6.4.1.2 Transport and Handover 6.4.2 Specific Entities in PACU 6.4.2.1 Emergence Delirium 6.4.2.2 Pain Management Opioids Non-opioids 6.4.2.3 Adverse Respiratory Events and Mechanical Ventilation 6.4.2.4 ICP Monitoring and Management 6.4.2.5 Fluid and Electrolyte Disturbances 6.5 Conclusion References 7: Positioning Children During Neurosurgery 7.1 Introduction 7.2 Historical Aspects 7.3 General Principles Common to all Pediatric Positions 7.3.1 Transport and Handling 7.3.2 Equipment 7.3.2.1 The Surgical Table 7.3.2.2 Accessories 7.3.2.3 Head Immobilization Devices 7.3.3 Protective Padding 7.3.4 Physiology of Patient Positioning 7.3.4.1 Respiratory Physiology 7.3.4.2 Circulation 7.3.4.3 Temperature Regulation 7.3.5 Head Position 7.3.6 Repositioning During Anesthesia 7.4 Basic Positions in Neurosurgery 7.4.1 Supine Position 7.4.2 Lateral Position 7.4.3 Park Bench Position 7.4.4 Prone Position 7.4.5 Head-Elevated Prone or Concorde Position 7.4.6 Sea Lion Prone or Sphinx Position 7.4.7 Sitting Position 7.5 Conclusion References 8: Monitoring Children Undergoing Neurosurgery 8.1 Introduction 8.2 Basic Monitoring 8.3 Special Monitoring 8.4 Monitoring the Nervous System 8.4.1 Monitoring Intracranial Pressure and Cerebral Blood Flow 8.4.1.1 Intracranial Pressure (ICP) Direct Methods Indirect Methods 8.4.2 Monitoring Metabolism and Oxygenation 8.4.2.1 Near-Infrared Spectroscopy 8.4.2.2 Brain Tissue Oxygen (PbtO2) Monitoring 8.4.2.3 Jugular Venous Oximetry 8.4.2.4 Cerebral Microdialysis 8.4.3 Transcranial Doppler (TCD) Ultrasonography 8.4.4 Monitoring of Function 8.4.4.1 Somatosensory Evoked Potentials (SSEPs) 8.4.4.2 Motor Evoked Potentials (MEPs) 8.4.4.3 Electromyography (EMG) 8.4.4.4 Visual Evoked Potentials (VEPs) 8.4.4.5 Brainstem Auditory Evoked Responses (BAERs) 8.4.4.6 Electroencephalography 8.5 Conclusion References 9: Perioperative Thermoregulation in Children and Temperature Monitoring 9.1 Introduction 9.2 Physiology of Thermoregulation 9.2.1 Thermoregulation in Newborn 9.3 Effects of Anesthesia on Thermoregulation 9.4 Perioperative Hypothermia 9.4.1 Adverse Effects of Hypothermia 9.5 Perioperative Thermal Manipulations 9.6 Temperature Monitoring 9.7 Perioperative Hyperthermia 9.8 Malignant Hyperthermia in Children 9.9 Targeted Temperature Management in Pediatric Neurointensive Care 9.10 Conclusion References 10: Fluid and Electrolytes Management in Children Undergoing Neurosurgery 10.1 Introduction 10.2 General Considerations 10.3 Choice of Fluid During Pediatric Neurosurgery 10.3.1 Fluid Considerations Before Surgery 10.3.2 Assessment and Correction of Fluid Deficit 10.3.3 Maintenance Fluid Requirements 10.3.4 Management of Other Losses During Surgery 10.3.5 Postoperative Fluid Management and Monitoring of Fluid Therapy 10.4 General Principles for Electrolytes Management 10.5 Sodium Disturbances 10.5.1 Hyponatremia 10.5.2 Hypernatremia 10.5.3 Diabetes Insipidus (DI) 10.5.4 Hyperkalemia 10.5.5 Hypokalemia 10.5.6 Hypocalcemia 10.5.7 Hypercalcemia 10.5.8 Hypophosphatemia 10.5.9 Hyperphosphatemia 10.5.10 Hypomagnesemia 10.5.11 Hypermagnesemia 10.6 Conclusions References 11: Blood Loss and Transfusion in Children Undergoing Neurosurgery 11.1 Introduction 11.2 Blood Volume Calculation 11.3 Conditions Prone to Intraoperative Bleeding 11.4 Blood Transfusion Goals [12] 11.5 Perioperative Monitoring of Blood Loss 11.5.1 Perfusion of Vital Organs Monitoring 11.5.2 Noninvasive Hemoglobin Monitoring 11.5.3 Intraoperative Blood Loss Estimation 11.5.4 Coagulation Monitoring [20] 11.5.5 Point-of-Care (POC) Coagulation Tests 11.6 Blood and Component Transfusion [23–25] 11.6.1 Red Blood Cell (RBC) Transfusion [24, 25] 11.6.2 Platelet Transfusion [23, 29] 11.6.3 Fresh Frozen Plasma [23, 29, 30] 11.6.4 Cryoprecipitate 11.7 Massive Transfusion (MT) and Massive Transfusion Protocol (MTP) 11.8 Consequences of Blood Transfusion 11.8.1 Allergic and Febrile Non-hemolytic Reactions 11.8.2 Hemolytic Transfusion Reactions and Other Immunologic Considerations 11.8.3 Risk of Infectious Disease Transmission 11.8.4 Metabolic Repercussions 11.8.4.1 Hypocalcemia 11.8.4.2 Hyperkalemia 11.8.4.3 Hypomagnesemia 11.8.4.4 Acid-Base Changes 11.8.4.5 Hypothermia 11.8.4.6 Transfusion-Associated Circulatory Overload (TACO) 11.8.4.7 Transfusion-Related Acute Lung Injury (TRALI) 11.8.4.8 Transfusion-Related Immunomodulation (TRIM) 11.8.4.9 Blood Transfusion and Postoperative Morbidity in Children 11.8.4.10 Clinical Effect of Aging of Stored RBC 11.9 Perioperative Blood Conservation Strategies 11.10 Conclusion References Part II: Anesthetic Management of Specific Problems 12: Hydrocephalus and CSF Diversion Procedures for Pediatric Neurosurgical Patients 12.1 Introduction 12.2 CSF Dynamics and Pathophysiology of Hydrocephalus 12.3 Classification 12.3.1 Communicating Vs. Non-communicating Hydrocephalus 12.3.2 Syndromic Vs. Non-syndromic Hydrocephalus 12.3.3 Congenital Vs. Acquired Hydrocephalus (Table 12.2) 12.3.3.1 Congenital Hydrocephalus 12.3.3.2 Acquired Hydrocephalus 12.4 Clinical Presentations 12.5 Diagnosis of Hydrocephalus 12.6 Management with CSF Diversion Procedures 12.6.1 CSF Shunts Used for Diversion Procedures 12.7 Endoscopic Third Ventriculostomy 12.8 Hydrocephalus Outcome 12.9 Anesthetic Management for CSF Diversion Procedures 12.9.1 Preoperative Assessment 12.9.2 Anesthetic Considerations 12.9.3 Postoperative Management 12.10 Shunt Complications 12.10.1 Shunt Blockage/Under-Shunting 12.10.2 Shunt Infection 12.10.3 Over-Shunting 12.10.4 Miscellaneous Complications 12.11 Special Anesthetic Considerations 12.11.1 Shunted Patient for Incidental (Laparoscopy) Surgery 12.11.2 Shunted Patient for MRI 12.11.3 Shunted Patient for Neuraxial Block 12.12 Conclusion References 13: Neural Tube Defects: Meningocele and Encephalocele 13.1 Introduction 13.2 Embryology and Pathogenesis 13.2.1 Primary Prevention 13.3 Spinal Dysraphism 13.3.1 Meningomyelocele 13.3.1.1 Pathophysiology 13.3.1.2 Clinical Presentation 13.3.1.3 Diagnosis 13.3.1.4 Management 13.3.1.5 Preanesthetic Preparation 13.3.1.6 Anesthetic Management 13.3.1.7 Latex Allergy 13.4 Occult Spinal Dysraphism 13.4.1 Tethered Cord Syndrome 13.5 Cranial Dysraphism 13.5.1 Encephalocele 13.6 Conclusion References 14: Anesthesia for Fetal Neurosurgery 14.1 Introduction 14.2 Fetal Surgeries in General 14.3 Fetal Neurosurgery 14.4 Ventriculo-Amniotic Shunt for Hydrocephalus 14.5 Meningomyelocele Repair 14.5.1 Open Approach 14.5.2 Fetoscopic Approach 14.5.3 Maternal and Fetal Physiology 14.6 Anesthetic Management 14.6.1 Preoperative Preparation 14.6.2 Maternal Evaluation 14.6.3 Fetal Evaluation 14.6.4 Operating Room Setup and Monitoring 14.6.5 Fetal Supplies 14.6.6 Medications 14.6.7 Intraoperative Anesthetic Management 14.6.8 Uterine Relaxation 14.6.9 Fetal Anesthesia and Analgesia 14.6.10 Postoperative Anesthetic Management 14.7 Outcome and Future Directions 14.8 Ethical and Legal Considerations 14.9 Conclusion References 15: Perioperative Management of Children with Chiari Malformation 15.1 Introduction 15.2 Posterior Cranial Fossa and Cervicomedullary Junction 15.3 Pathophysiology of Chiari Malformation 15.4 Types of Chiari Malformation 15.5 Clinical Presentation 15.6 Diagnosis of Chiari Malformations 15.7 Treatment Options 15.8 Anesthetic Management 15.8.1 Preoperative Evaluation 15.8.2 Premedication 15.8.3 Monitoring 15.8.4 Induction of Anesthesia 15.8.5 Maintenance of Anesthesia 15.8.6 Awakening and Extubation 15.8.7 Postoperative Management 15.9 Conclusion References 16: Anesthesia for Craniovertebral Junction Anomalies in Pediatric Patients 16.1 Introduction 16.2 Anatomy of the Craniovertebral Junction (CVJ) 16.2.1 Embryological Basis of CVJ Anomalies 16.2.2 Osseo-ligamentous Anatomy 16.2.3 Neurovascular Structures of the CVJ 16.3 Classification of CVJ Anomalies 16.4 Syndromic Associations with CVJ Anomalies 16.5 Pathophysiology of CVJ Anomalies 16.6 Clinical Features of CVJ Anomalies 16.7 Diagnosis of CVJ Anomaly 16.7.1 Imaging Studies 16.7.2 Acquired CVJ Pathologies 16.8 Management of CVJ Anomalies 16.9 Surgical Procedures 16.10 Anesthetic Management 16.10.1 Preoperative Evaluation and Optimization 16.10.2 Monitoring 16.10.3 Induction of Anesthesia and Endotracheal Intubation 16.10.4 Maintenance of Anesthesia 16.10.5 Intraoperative Complications 16.10.6 Electrophysiological Monitoring 16.10.7 Extubation 16.11 Postoperative Management 16.11.1 Tracheostomy 16.11.2 Post-discharge Care 16.12 Conclusion References 17: Anesthetic Concerns During Pediatric Spine Surgery 17.1 Introduction 17.2 Overview of Anesthetic Management 17.2.1 Preoperative Evaluation and Preparation 17.2.2 Patient Positioning 17.2.3 Intraoperative Neurophysiological Monitoring (IONM) 17.2.3.1 Anesthetic Management for IONM During Pediatric Spine Surgery 17.3 Tethered Cord Syndrome (TCS) 17.4 Spina Bifida and Latex Allergy 17.5 Myelomeningocele (MMC) 17.6 Spinal Lipoma 17.7 Spinal Deformity 17.7.1 Congenital Spinal Deformity 17.7.2 Idiopathic Scoliosis 17.8 Spinal Tumor Surgeries 17.9 Spinal Vascular Malformations 17.10 Spinal Surgery for Neurofibromatosis 17.11 Conclusion References 18: Craniosynostosis and Anesthetic Concerns 18.1 Introduction 18.2 Embryology and Anatomical Variations of Craniosynostosis 18.3 Classification of Craniosynostosis 18.4 Diagnosis of Craniosynostosis 18.5 Surgical Management of Craniosynostosis 18.5.1 Indications for Surgery 18.5.2 Surgical Options 18.5.3 Timing of Surgery 18.6 Anesthetic Management 18.6.1 Preoperative Concerns 18.6.2 Intraoperative Management of Craniosynostosis 18.6.3 Postoperative Concerns 18.7 Conclusion References 19: Anesthesia for Craniopagus Separation Surgery 19.1 Introduction 19.2 Historical Aspects of Conjoined Twins 19.3 Classification of Craniopagus Twins 19.4 Shared Vascular System in Craniopagus Twins 19.5 Management of Craniopagus Twins 19.5.1 Staged vs. Non-staged Separation 19.6 Preoperative Evaluation and Preparation 19.6.1 Multidisciplinary Team (MDT) 19.6.2 Neuroradiology and Imaging 19.7 Anesthetic Management 19.7.1 Anesthesia for Neuroimaging Procedures 19.7.2 Anesthesia for the Separation Surgery 19.8 Postoperative Intensive Care 19.9 Legal and Ethical Concerns 19.10 Conclusion References 20: Anesthesia for Minimally Invasive Neurosurgical Procedures in Children 20.1 Introduction 20.2 Technology Aids to Minimally Invasive Neurosurgery 20.2.1 Neuroendoscopy 20.2.1.1 Neuroendoscopy for CSF Pathway Obstruction 20.2.1.2 Surgical Technique of ETV 20.2.1.3 Advantages of ETV 20.2.1.4 Disadvantages of ETV 20.2.1.5 Anesthetic Challenges for ETV 20.2.1.6 Choice of Irrigating Fluid 20.2.1.7 Hemodynamic and Biochemical Changes During ETV 20.2.1.8 Pressure Inside the Neuroendoscope (PIN) and CPP 20.2.1.9 Complications During the ETV 20.2.2 Image-Guided Neurosurgery 20.2.3 Minimally Invasive Robotic Neurosurgery 20.2.4 Specific Neurosurgical Procedures 20.2.4.1 Craniosynostosis 20.2.4.2 Endoscopic Strip Craniectomy 20.2.4.3 Spring-Assisted Cranioplasty 20.2.4.4 Intraoperative Monitoring and Anesthetic Management 20.2.4.5 Sellar and Suprasellar Tumors 20.2.4.6 Anesthetic Management 20.2.4.7 Minimally Invasive Epilepsy Surgery 20.2.4.8 Movement Disorders 20.2.5 Minimally Invasive Spine (MIS) Surgery 20.2.5.1 Indications for MIS 20.2.5.2 Surgical Approach 20.2.5.3 Anesthetic Management 20.2.5.4 Video-Assisted Thoracoscopic Surgery (VATS) 20.2.5.5 Indications for VATS 20.2.5.6 Contraindications for VATS 20.2.5.7 Perioperative Management of VATS 20.2.5.8 Vertebroplasty and Kyphoplasty 20.3 Conclusion References 21: Anesthetic Concerns During Surgical Excision of Intracranial Arteriovenous Malformations 21.1 Introduction 21.2 Epidemiology 21.3 Etiopathogenesis 21.4 Criteria for Classification 21.4.1 Applications of the Grading Scheme 21.5 Clinical Presentations 21.6 Diagnosis 21.7 Treatment of AVM 21.8 Anesthetic Management 21.8.1 Anesthetic Management for Diagnostic Interventions 21.8.2 Anesthetic Management for Emergency Craniotomy 21.8.3 Anesthetic Management for Microsurgical Resection of AVM 21.8.4 Anesthetic Management for Endovascular Procedures 21.8.5 Anesthetic Management for Stereotactic Radiosurgery 21.9 Conclusion References 22: Anesthetic Management of Cerebral Aneurysm Surgery in Children 22.1 Introduction 22.2 Etiopathogenesis 22.3 Types and Location 22.4 Clinical Presentation 22.5 Diagnosis 22.6 Clinical Grading 22.7 Complications of Aneurysmal SAH 22.7.1 Rebleeding 22.7.2 Vasospasm and Delayed Cerebral Ischemia 22.7.2.1 Diagnosis of Vasospasm 22.7.2.2 Treatment of Vasospasm and Delayed Cerebral Ischemia 22.7.3 Hydrocephalus 22.7.4 Seizures 22.7.5 Fluid and Electrolyte Disturbances 22.7.6 Pulmonary and Cardiac Complications 22.8 Treatment of Cerebral Aneurysm in Children 22.8.1 Surgical Treatment 22.8.2 Anesthetic Consideration During Surgical Clipping 22.8.2.1 Induction of Anesthesia 22.8.2.2 Monitoring 22.8.2.3 Maintenance of Anesthesia 22.8.2.4 Recovery and Extubation 22.8.3 Endovascular Treatment 22.8.3.1 Anesthetic Considerations During Endovascular Treatment 22.8.3.2 Choice of Anesthesia 22.8.3.3 Maintenance of Anesthesia 22.8.3.4 Recovery and Extubation 22.9 Conclusion References 23: Anesthetic Management of Vein of Galen Malformations 23.1 Introduction 23.2 Anatomy and Embryology of VOGM 23.3 Pathophysiology 23.4 Clinical Manifestations 23.5 Diagnosis 23.6 Differential Diagnosis 23.7 Classification VOGM 23.8 Medical Management 23.8.1 Management of Pulmonary Hypertension [36–40] 23.9 Definitive Treatment 23.9.1 Endovascular Embolization 23.9.1.1 Route of Embolization 23.9.1.2 Embolic Agents 23.9.2 Stereotactic Radiosurgery 23.10 Anesthetic Considerations in Vein of Galen Malformations 23.10.1 Preoperative Evaluation 23.10.2 Induction 23.10.3 Monitoring 23.10.4 Concerns During the Procedure 23.10.4.1 Fluid Management 23.10.4.2 Other Concerns 23.10.5 Complications 23.11 Post-Procedure Management 23.12 Brain Melting Phenomenon and Hydrocephalus 23.13 Prognosis 23.14 Conclusion References 24: Anesthetic Concerns in Children with Brain Abscess and Congenital Heart Disease 24.1 Introduction 24.2 Etiopathogenesis of Brain Abscess in Children with Cardiac Disease 24.3 Clinical Presentation and Management of Brain Abscess 24.3.1 Clinical Presentation 24.4 Management Options 24.5 Anesthetic Considerations 24.6 Preoperative Evaluation 24.7 Preoperative Optimization 24.7.1 Dehydration and Electrolyte Abnormality 24.7.2 Coagulation Abnormality 24.7.3 Hyperviscosity Syndrome 24.7.4 Cyanotic Spell 24.7.5 Oxygen Therapy 24.7.6 Antibiotic Prophylaxis 24.8 Preoperative Preparation 24.9 Anesthetic Techniques 24.10 Conclusion References 25: Anesthesia for Moyamoya Disease in Children 25.1 Introduction 25.1.1 Moyamoya Disease Versus Moyamoya Syndrome 25.2 Pathophysiology of Moyamoya Disease 25.3 Clinical Presentation 25.4 Diagnosis 25.5 Electroencephalography 25.6 Other Diagnostics 25.6.1 Cerebrovascular Reserve 25.7 Medical Management 25.8 Surgical Treatment: Direct Versus Indirect Bypass 25.9 Preoperative Management 25.9.1 Dehydration 25.9.2 Review of Medications 25.9.3 Premedication 25.9.4 Induction of Anesthesia 25.10 Intraoperative Anesthetic Management 25.10.1 Monitoring 25.10.2 Partial Pressure of Arterial Carbon Dioxide (PaCO2) 25.10.3 Blood Pressure 25.10.4 Cerebral Oximetry (Near-Infrared Spectroscopy) 25.10.5 Anesthetic Agents 25.10.6 Emergence Delirium 25.11 Postoperative Management 25.11.1 Postoperative Ischemic Complications 25.11.2 Cerebral Hyperperfusion 25.11.3 Pain Control 25.12 Conclusion References 26: Anesthesia for Pediatric Deep Brain Stimulation Surgery 26.1 Introduction 26.2 Dystonias 26.3 Deep Brain Stimulation (DBS) 26.4 Anesthetic Challenges 26.5 Preanesthetic Preparation 26.6 Monitoring 26.7 Anesthetic Techniques 26.7.1 Local Anesthesia/Awake Craniotomy 26.7.2 Monitored Anesthesia Care 26.7.3 General Anesthesia (GA): Induction and Maintenance 26.8 Complications 26.9 Postoperative Care 26.10 Patient with DBS Implant for Non-DBS Surgery 26.11 Conclusion References 27: Awake Craniotomy in Children 27.1 Introduction 27.2 History of Awake Craniotomy 27.3 Age and Awake Craniotomy 27.4 Indications and Contra-indications for Awake Craniotomy in Children 27.5 Preoperative Preparation of the Child 27.5.1 Preoperative Team Visit 27.5.2 Preoperative Workup 27.5.3 Premedication 27.5.4 Operating Room Setup 27.5.5 Positioning of the Child 27.5.6 Anesthesia Techniques 27.5.6.1 Asleep-Awake-Asleep (AAA) Technique 27.5.6.2 Monitored Anesthesia Care (MAC) or Conscious Sedation (CS) 27.5.6.3 Regional Scalp Block 27.5.7 Choice of Sedatives and Anesthetics 27.5.8 Routine Monitoring 27.5.9 Neurophysiologic Monitoring 27.5.9.1 Motor Mapping 27.5.9.2 Language Mapping 27.5.9.3 Mapping of Visual Function 27.5.9.4 Electrocorticography (ECoG) 27.5.10 Management of Complications 27.6 Postoperative Care 27.7 Conclusion References 28: Anesthesia for Epilepsy Surgery in Children 28.1 Introduction 28.2 Epileptic Seizure 28.3 Drug Refractory Epilepsy 28.4 Resolution of Epilepsy 28.5 Seizure Semiology 28.6 Medical Management of Epilepsy 28.7 Evaluation of Patients with Refractory Seizures 28.8 Electroencephalography (EEG) 28.9 Ictal EEG with Video 28.10 Extra-Operative Invasive EEG Monitoring 28.11 Magnetic Resonance Imaging (MRI) 28.12 Functional MRI (fMRI) 28.13 Magnetoencephalography (MEG) 28.14 Single-Photon Emission Computed Tomography (SPECT) 28.15 Positron Emission Tomography (PET) 28.16 Wada Test 28.17 Role of Anesthesiologist during Preoperative Workup 28.18 Choice and Types of Epilepsy Surgery 28.19 Preoperative Anesthetic Evaluation and Preparation 28.20 Intraoperative Anesthetic Technique 28.21 Intraoperative Monitoring 28.21.1 Anesthesia Monitoring 28.21.2 Neuromonitoring 28.21.2.1 Electrocorticography (ECoG) Role of Anesthetic Agents on ECoG 28.21.2.2 Cortical Stimulation under General Anesthesia 28.21.3 Awake Craniotomy and Excision for Epilepsy 28.21.4 Emergence and Awakening 28.21.5 Complications in the Perioperative Period 28.22 Conclusion References 29: Anesthetic Considerations for Supratentorial Space-Occupying Lesions in Children 29.1 Introduction 29.2 Classification of Pediatric Supratentorial Tumors 29.3 Common Pediatric Supratentorial Tumors 29.3.1 Low- or High-Grade Glioma 29.3.1.1 Subependymal Giant Cell Astrocytoma (SEGA) 29.3.1.2 Supratentorial Ependymomas 29.3.1.3 Primitive Neuroectodermal Tumor (PNET) 29.3.1.4 Dysembryoplastic Neuroepithelial Tumor (DNET) 29.3.1.5 Intraventricular Tumors 29.3.1.6 Choroid Plexus Tumors 29.3.1.7 Craniopharyngiomas 29.3.1.8 Pineal Tumors 29.3.1.9 Supratentorial Meningioma 29.3.1.10 Hypothalamic Astrocytomas or Optic Pathway Glioma 29.4 Pathophysiology of Supratentorial Tumors 29.5 Clinical Presentation 29.6 Anesthetic Management 29.6.1 Preoperative Evaluation, Optimization, and Premedication 29.7 Intraoperative Management 29.7.1 Vascular Access 29.7.2 Induction of Anesthesia 29.7.3 Airway Management 29.8 Pharmacology of Anesthetic Agents in Children 29.9 Maintenance of Anesthesia 29.10 Intraoperative Monitoring 29.11 Positioning 29.12 Fluid Management 29.13 Hyperosmolar Therapy and Optimization of Surgical Field 29.14 Intraoperative Crisis Management 29.14.1 Intraoperative “Brain Bulge” or “Tight Brain” 29.14.2 Severe Blood Loss 29.14.3 Intraoperative Hypothermia 29.14.4 Electrolyte Imbalance 29.14.5 Intraoperative Seizure Prophylaxis 29.14.6 Emergence from Anesthesia 29.15 Early Vs. Delayed Emergence and Extubation 29.16 Postoperative Management 29.16.1 Post-Craniotomy Pain Management in Children 29.16.2 Postoperative Nausea and Vomiting (PONV) 29.16.3 Stereotactic Radiosurgery in Children 29.16.4 Awake Craniotomy in Children 29.17 Conclusion References 30: Anesthetic Management of Posterior Fossa Surgery in Children 30.1 Introduction 30.2 Anatomy of Posterior Fossa 30.3 Clinical Manifestations 30.4 Preoperative Evaluation of Lesions 30.5 Management of Posterior Fossa Lesions 30.5.1 Medical Management 30.5.2 Surgical Management 30.5.3 Anesthetic Management 30.5.3.1 Pre-Anesthesia Checkup 30.5.3.2 Preoperative Preparation of the Child 30.5.3.3 Induction of Anesthesia 30.5.3.4 Intraoperative Monitoring 30.5.3.5 Positioning the Child during Posterior Fossa Surgery 30.5.3.6 Maintenance of Anesthesia 30.5.3.7 Fluid Management 30.5.3.8 Blood Loss and Transfusion Trigger 30.5.3.9 Temperature Regulation 30.5.3.10 Emergence from Anesthesia 30.5.3.11 Postoperative Care 30.5.4 Complications of Posterior Fossa Surgery 30.5.4.1 Brainstem and Cranial Nerve Stimulation (Trigemino-Cardiac Reflex, Glossopharyngeal-Vagal Reflex) 30.5.4.2 Endotracheal Tube Kinking and Accidental Extubation 30.5.4.3 Venous Air Embolism (VAE) 30.5.4.4 Hydrocephalus 30.5.4.5 Pneumocephalus 30.5.4.6 Quadriplegia (Mid-Cervical Flexion Myelopathy) 30.5.4.7 Postoperative Cranial Nerve Dysfunction/Brainstem Swelling/Compression 30.5.4.8 Macroglossia 30.5.4.9 Airway and Swallowing Difficulties 30.5.4.10 Posterior Fossa Syndrome (PFS) 30.5.4.11 Re-Exploration 30.5.4.12 Reintubation 30.5.4.13 Seizures 30.5.4.14 CSF Leakage/Pseudo-Meningocele 30.5.4.15 Meningitis 30.5.4.16 Dyselectrolytemia 30.5.4.17 Pulmonary Infection/Sepsis 30.6 Conclusion References 31: Perioperative Management of Children with Traumatic Brain Injury 31.1 Introduction 31.2 Prehospital Care 31.3 Pathophysiology 31.4 Neuroimaging 31.5 Surgical Indications and Interventions 31.6 Preoperative Evaluation and Consent 31.7 Intravenous Access 31.8 Airway Management 31.9 Anesthetic Drugs 31.9.1 Induction Agents 31.9.2 Neuromuscular Blocking Drugs 31.10 Oxygenation and Ventilation 31.11 Cerebral Perfusion Pressure and Hemodynamic Targets 31.12 Fluid and Blood Component Administration 31.13 Glycemic Control 31.14 Positioning 31.15 Temperature Management 31.16 Management of Intracranial Hypertension 31.16.1 Hyperosmolar Solutions 31.16.2 Barbiturate Coma 31.16.3 Decompressive Craniectomy 31.17 Perioperative Steroids 31.18 Seizure Prophylaxis 31.19 Antibiotic Prophylaxis 31.20 Postoperative Intensive Care 31.21 Miscellaneous Conditions 31.22 Conclusion References 32: Perioperative Management of Pediatric Spine Injury 32.1 Introduction 32.2 Epidemiology 32.3 Anatomy of Pediatric Spine 32.4 Radiology 32.5 Management 32.5.1 Initial Management 32.5.1.1 Immobilization of Cervical Spine 32.5.1.2 Tracheal Intubation 32.5.1.3 Management of Systemic Effects of Spine Injury 32.5.2 Medical and Surgical Management of Spine Injury 32.5.2.1 Cervical Spine Injuries Conservative Management Surgical Management 32.5.2.2 Thoracolumbar Spine Injuries Compression Fractures Burst Fractures Flexion-Distraction Injuries Spinous Process/Transverse Process Fractures 32.5.3 Perioperative Anesthetic Management 32.5.3.1 Preoperative Evaluation 32.5.3.2 Intraoperative Anesthetic Management Induction of Anesthesia Maintenance of Anesthesia Intraoperative Monitoring Recovery and Tracheal Extubation Intraoperative Neuromonitoring Wake-Up Test Somatosensory Evoked Potentials (SSEP) Motor Evoked Potentials (MEP) Specific Intraoperative Considerations Positioning Spinal Cord Blood Flow (SCBF) Blood Conservation Strategies Intraoperative Complications and New Neurological Deficits 32.5.3.3 Postoperative Management Postoperative Pain Management Management of Complications Deep Venous Thrombosis (DVT) Anterior Spinal Artery Syndrome Postoperative Visual Loss (POVL) Cerebrospinal Fluid (CSF) Leak Epidural Hematoma 32.5.4 Intensive Care Management 32.5.4.1 Hemodynamic Management 32.5.4.2 Respiratory Management 32.5.4.3 Management of Autonomic Dysfunctions 32.5.4.4 Prophylaxis of Deep Vein Thrombosis (DVT) 32.5.4.5 Bowel and Bladder Dysfunctions 32.5.4.6 Thermo-Dysregulation 32.5.4.7 Nutritional Care 32.5.4.8 Prevention of Decubitus Ulcers 32.6 Rehabilitation 32.7 Conclusion References 33: Anesthesia for Interventional Neuroradiologic Procedures in Children 33.1 Introduction 33.2 Relevant Neuroanatomy 33.3 Pre-Procedural Preparation of the Child 33.4 History 33.5 Physical Examination 33.6 Investigation 33.7 Preprocedural Checklist 33.8 The Procedure of Neurointervention 33.9 Anesthesia Technique 33.10 Commonly Performed Neurointerventional Procedures 33.10.1 Digital Subtraction Angiography (DSA) 33.10.2 Intracranial Aneurysm 33.10.3 Cerebral Arteriovenous Fistula (AVF) and Arteriovenous Malformation (AVM) 33.10.3.1 Cerebral Arteriovenous Fistula (AVF) 33.10.3.2 Arteriovenous Malformation (AVM) 33.10.3.3 Vein of Galen Malformation (VOGM) 33.10.3.4 Retinoblastoma and Intra-Arterial Chemotherapy 33.10.4 Spinal DSA and Vascular Interventions 33.11 Iodinated Contrast Media (ICM) 33.12 Allergic Reactions 33.13 Radiation Hazards 33.14 Conclusion References 34: Neuroanesthesia at Remote Locations 34.1 Introduction 34.2 Challenges 34.3 Pre-Procedural Assessment and Preparation 34.4 Preparation of Patient 34.5 Premedication 34.6 Preparation of Anesthesia Location 34.7 Anesthetic Techniques 34.8 Complications 34.9 Post-Procedural Care 34.10 Magnetic Resonance Imaging 34.11 MRI Scanner Design [10, 11] 34.12 Anesthetic Considerations for MRI 34.13 Management of Emergencies during MRI 34.14 Computed Tomographic Scan 34.15 Neuroradiologic Procedures 34.16 Gamma Knife Radiosurgery 34.17 Positron Emission Tomography and Single-Photon Emission Computed Tomography 34.18 Electroconvulsive Therapy (ECT) 34.19 Conclusion References 35: Anesthesia for Children with Neuromuscular Diseases 35.1 Introduction 35.2 Classification of Neuromuscular Diseases in Children 35.2.1 Myasthenic Syndromes 35.2.2 Channelopathies 35.2.3 Muscular Dystrophies 35.2.4 Myotonic Syndromes 35.2.5 Mitochondrial Myopathies 35.2.6 Spinal Muscular Atrophy (SMA) 35.3 Anesthetic Considerations 35.3.1 Anesthetic Considerations for Diagnosed NMDs 35.3.1.1 General Considerations 35.3.1.2 Disease-Specific Anesthetic Considerations 35.3.2 Disorders with Clinical Manifestations Similar to NMDs 35.3.2.1 Cerebral Palsy 35.3.2.2 Brachial Plexopathy 35.3.3 When to Suspect NMDs in Asymptomatic or Mildly Symptomatic Children 35.3.4 Considerations for Children with Suspected Myopathy for Muscle Biopsy (or Emergency Surgery) 35.4 Chronic Pain Management in Children with NMD 35.5 Stem Cell Therapy 35.6 Conclusion References 36: Regional Anesthesia for Neurosurgery in Children 36.1 Introduction 36.2 Neurosurgical Indications in Children 36.3 Regional Anesthesia for Awake Craniotomy: Scalp Block 36.3.1 Equipment 36.3.2 Technique 36.4 Regional Anesthesia for Craniofacial Surgery 36.5 Regional Anesthesia for Vagal Nerve Stimulator Implantation: Neck Block 36.5.1 Anatomy and Technique 36.6 Regional Techniques and Preexisting Neurologic Disease 36.7 Neural Tube Defects 36.8 Brain Tumors, Aneurysms, and Arteriovenous Malformations 36.9 Epilepsy 36.10 Neurosurgical Complications After Regional Techniques 36.11 Epidural and Spinal Anesthesia After Major Spine Surgeries 36.12 Conditions Mimicking Spinal Canal Stenosis in Children 36.13 Neuraxial Blocks in Patients with Preexisting Baclofen Pumps 36.14 Local Anesthesia Toxicity 36.15 Conclusion References Part III: Postoperative Care and Miscellaneous Topics 37: Recovery and Postoperative Care in Children Undergoing Neurosurgery 37.1 Introduction 37.2 Physiological Changes During Recovery After Neurosurgery 37.3 Enhanced Recovery After Surgery (ERAS) Pathways 37.4 Implications of Poor Recovery in Children 37.5 Impact of Anesthetic Management on Postoperative Recovery 37.6 Assessment of Recovery 37.7 Desired Recovery Profile 37.8 Dilemmas in Decision-Making 37.8.1 Early Versus Delayed Recovery 37.8.2 Awake Versus Deep Extubation 37.8.3 Postoperative ICU Versus Ward Care 37.9 Common Issues and Their Management During Recovery 37.9.1 Unintended Delayed Recovery 37.9.2 Emergence Agitation 37.9.3 Delirium 37.9.4 Hemodynamic Complications 37.9.5 Respiratory Complications 37.9.6 Pain Management 37.9.7 Postoperative Nausea and Vomiting 37.9.8 Hypothermia 37.9.9 Seizures 37.10 Specific Conditions and Postoperative Issues 37.10.1 Tumor Surgery 37.10.2 Epilepsy and Functional Surgery 37.10.3 Neurovascular Surgery 37.10.4 CSF Diversion Procedures 37.10.5 Craniosynostosis 37.10.6 Cranio-Vertebral Junction Anomalies 37.10.7 Spine Surgery 37.10.8 Brain Trauma Surgery 37.10.9 Neuroendoscopy 37.10.10 Surgery for Neuro-infections 37.10.11 Neuroradiologic Interventions 37.10.12 Neurosurgery in Children with Syndromic Associations 37.11 Discharge from PACU 37.12 Conclusion References 38: Postoperative Pain Management of Pediatric Neurosurgical Patients 38.1 Introduction 38.2 Pain Pathophysiology in Neurosurgery 38.3 Pain Assessment in Children 38.4 Multimodal Analgesia After Neurosurgery/Spine Surgery 38.4.1 Opioids 38.4.2 Patient-Controlled Analgesia 38.4.3 Acetaminophen 38.4.4 Non-steroidal Anti-inflammatory Drugs 38.4.5 Antidepressants 38.4.6 Gabapentinoids 38.4.7 Muscle Relaxants 38.4.8 Alpha-2 Agonists 38.4.9 Corticosteroids 38.4.10 NMDA Antagonists 38.4.11 Non-pharmacologic Therapy 38.4.12 Nerve Blocks 38.4.13 Preemptive Analgesia 38.4.14 Special Considerations 38.5 Chronic Postsurgical Pain and Persistent Post-craniotomy Pain 38.6 Role of Genetic Factors and Epigenetics for Postoperative Pain 38.6.1 Opioid Pharmacogenomics 38.7 Conclusion References 39: Postoperative Respiratory Complications and Ventilatory Strategies in Pediatric Neurosurgical Patients 39.1 Introduction 39.2 Postoperative Respiratory Complications in Non-ventilated Children 39.3 Postoperative Respiratory Complications in Ventilated Children 39.3.1 Indications for Ventilation 39.3.2 Common Respiratory Pathologies in Ventilated Patients 39.3.3 Ventilatory Management in Pediatric Neurosurgical Patients 39.3.3.1 Monitoring Ventilator Settings 39.3.4 Respiratory Care of Pediatric Neurosurgical Patient on Mechanical Ventilation 39.3.5 Weaning and Extubation 39.3.6 Role of Tracheostomy in Pediatric Neurocritical Care 39.4 Conclusion References 40: Brain Death and Organ Donation in Children 40.1 Introduction 40.2 Definition of Brain Death 40.3 Epidemiology of Brain Death in Children 40.4 Etiology of Brain Death 40.5 Brain Death Determination in Children 40.6 Neurological Examination 40.6.1 Prerequisites of Neurologic Evaluation 40.6.2 Coma 40.6.3 Assessment of Brainstem Reflexes 40.6.4 Apnea Test 40.7 Number of Examinations and the Observation Period 40.8 Brain Death Determination in Preterm Neonates 40.9 Number of Physicians Required for Diagnosing Brain Death 40.10 Ancillary Tests 40.11 Physiological Changes Following Brain Death 40.11.1 Management of Brain-Dead Organ Donor 40.11.2 Sympathetic Storm 40.11.3 Hypotension 40.11.4 Arrhythmias 40.11.5 Fluid and Electrolyte Disturbances 40.11.6 Diabetes Insipidus 40.11.7 Hypothermia 40.11.8 Coagulation Abnormalities 40.11.9 Oliguria 40.11.10 Hormone Replacement Therapy 40.11.11 Management of the Lung 40.11.12 Glucose Metabolism 40.12 Conclusion References 41: Developing Brain and Anesthetic Neurotoxicity 41.1 Introduction 41.2 Human Brain Development 41.2.1 Embryonic Period (Conception—Week 8) 41.2.2 Fetal Period (Week 9—Birth) 41.2.3 Postnatal Life 41.3 Anesthesia-Induced Neurotoxicity in Preclinical Animal Models 41.3.1 Mechanisms of Anesthesia-Induced Neurodegeneration 41.3.2 Risk Factors for Anesthesia-Induced Neurotoxicity 41.3.3 Limitations of Preclinical Studies 41.4 Clinical Evidence in Pediatric Anesthetic Neurotoxicity 41.4.1 Surgical Condition and Preoperative Risk Factors 41.4.2 Developmental Age of Exposure and Timing of the Surgical Procedure 41.4.3 Number and Duration of Exposure 41.4.4 Anesthesia-Related Confounders 41.4.5 Demographics 41.4.6 Migration and Loss to Follow-up 41.4.7 Outcome Variable Selection 41.4.8 Timing of Assessment 41.5 Pharmacological Neuroprotection Strategies 41.6 Future Prospects 41.7 Conclusion References 42: Anesthesia for Radiation Therapy in Children 42.1 Introduction 42.2 Pediatric Neurological Tumors and Indications for Radiotherapy 42.3 Technology and Types of Radiotherapy 42.4 Preparation for Radiotherapy 42.5 Role of Anesthesiologist 42.6 Anesthesia Technique 42.7 Radiation-Induced Toxicity and Complications 42.7.1 Mechanism of Toxicity 42.7.2 Acute and Early Delayed Toxicities of Cranial Irradiation 42.7.3 Fatigue 42.7.4 Alopecia and Radiation Dermatitis 42.7.5 Late Delayed Toxicities of Cranial Irradiation 42.8 Effects of Repetitive Anesthesia and Radiotherapy on Neurologic System 42.9 Special Concerns: Pain, Psychological Impact on Child and Parents 42.10 Conclusion References 43: Neurological Perspectives in Pediatric Cardiac Surgery 43.1 Introduction 43.2 Pediatric Cardiac Surgery and Neurologic Involvement 43.3 Neurodevelopmental Abnormalities After Cardiac Surgery 43.4 Mechanisms of Neurological Injury After Cardiac Surgery 43.4.1 Focal or Multifocal Hypoxic-Ischemic Injury 43.4.2 Global Hypoxic-Ischemic Injury 43.4.3 Pulsatile vs. Nonpulsatile Flow 43.4.4 Regional Cerebral Perfusion (RCP) vs. Deep Hypothermic Circulatory Arrest (DHCA) 43.4.5 CPB-Related Inflammatory Response 43.4.6 pH Stat vs. Alpha Stat 43.4.7 Hematocrit and Transfusion Management 43.5 Neurological Monitoring During Pediatric Cardiac Surgery 43.6 Neurological Abnormalities Before Cardiac Surgery 43.7 Neurological Complications After Pediatric Cardiac Surgery 43.8 Neurosurgical Procedures After Pediatric Cardiac Surgery 43.8.1 Preparation of a Pediatric Patient for Neurosurgery After Cardiac Surgery 43.8.2 Reversal of Anticoagulation 43.8.3 Measures to Reduce ICP 43.8.4 Optimization of the Child 43.8.5 Intraoperative Management 43.9 Complications During Surgery 43.10 Postoperative Management 43.11 Conclusion References