**4.3 Anesthetic consideration for MMD patients going for non-revascularization surgery**

## *4.3.1 Laparoscopic surgery*

Laparoscopic surgery has gained tremendous popularity in recent years. The key element in laparoscopic surgery is the creation of pneumoperitoneum with carbon dioxide insufflation. The physiological changes especially cardiopulmonary alterations during laparoscopic surgery occur mainly due to the creation of pneumoperitoneum and positioning of the patient. Similarly, cerebral hemodynamic changes (including changes in cerebral perfusion and intracranial pressure) also occur during the creation of pneumoperitoneum and positioning of the patient. Anesthesia goals for MMD patients undergoing laparoscopic surgery are to allow physiological changes during surgery with minimal effects on the body's vital organs and rapid and smooth recovery. Induction of anesthesia should be carried out with careful titration of anesthetic drugs to avoid hemodynamic fluctuations. Airway manipulation should be minimized to avoid sympathetic surge. Nakanishi et al. used Laryngeal mask airway ProSeal successfully in a MMD patient who underwent laparoscopic cholecystectomy [74]. The author proposes the use of LMA ProSeal as an effective alternative with minimal hemodynamic change, compared with tracheal intubation [75]. Moreover, Lee et al. reported a case of intracranial hemorrhage during laparoscopic cholecystectomy due to unrecognized MMD [76]. Hence, rigorous ventilatory management utilizing End-tidal CO2 and arterial CO2 during pneumoperitoneum and arterial blood pressure for continuous monitoring of hemodynamic changes is mandatory. The intraoperative aim is to maintain blood pressure, oxygen saturation, ventilation, and smooth emergence from anesthesia.

### *4.3.2 Cardiac surgery*

Patients with MMD undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) pose considerable anesthetic challenges. CPB is a technique in which a machine temporarily takes over the function of the heart and lung.

*Perioperative Considerations for Revascularization and Non-Revascularization Surgeries… DOI: http://dx.doi.org/10.5772/intechopen.96564*

CPB in moyamoya patients has a high risk of decreasing cerebral perfusion pressure due to the perfusion pressure variability in the initial stages of CPB and non-pulsatile flow. Moreover, the risk of hypocapnic cerebral vasoconstriction and hypercapnic cerebral steal is a well-recognized phenomenon. Preserving the autoregulation of the cerebral blood flow is key to prevent cerebral ischemia. Case report proposes the use of an Intra-aortic balloon pump (IABP) that produces pulsatile flow which facilitates maintaining a higher perfusion pressure (mean arterial pressure > 80 mm Hg) and reduces the vasoconstrictors' requirement [77–79]. Regional cerebral oxygen saturation (rSO2) monitoring for cerebral blood flow; is a useful tool and provides real-time cerebral blood flow; the goal is to keep cerebral saturation at 80% of the baseline value. The key strategy is to keep the blood pressure, PaCO2, hematocrit, and body temperature to normal and should be adjusted rigorously intraoperatively. Off-pump coronary artery bypass (OPCAB) is a safe procedure that avoids the risk of CPB related hypotensive brain ischemia, for multi-vessel coronary patients with moyamoya disease [80, 81].
