**2.1 Preoperative anesthetic evaluation and premedication**

Preoperative anesthetic assessment is paramount in reducing the complications associated with MMD and improving the surgical outcome. It must include detailed general medical, surgical history, physical exam, and assessment for signs and symptoms associated with MMD and coexisting comorbidities. Patients with MMD may have a significant preexisting neurologic deficit. Depending on the mode of presentation, hypertension can occur as a result of cerebral vascular incompetency. Inadequate treatment of hypertension may lead to perioperative cerebral infarction or stroke. History of frequent preoperative transient ischemic attacks indicates compromised cerebral collateral circulation and is a significant risk factor for perioperative complications [21–23]. Chronic cerebral ischemia may lead to neurologic deficits such as motor deficit, epilepsy, and mental retardation. MMD is linked to other medical conditions, including cardiovascular and renal systems, which have a direct impact on anesthetic management and postoperative outcomes. A multidisciplinary strategy is vital to improve the perioperative outcome and avoid complications, necessitating a high level of collaboration and communication with the surgeon. Suggested criteria in the selection of adult MMD patients for cerebral revascularization [17] (see **Table 4**). Thus, preoperative assessment allows early recognition of highrisk patients and reciprocal identification of the potential perioperative issues, and adequate preparation to deal with the challenges. In summary, the goal of preoperative anesthesia assessment involves recognizing risk factors for cerebral ischemia, pre-existing neurological deficits, degree of hemodynamic failure, adequacy of collateral circulation and vascular risk factors (diabetes, cardiovascular disease, hypertension), and optimize the patient's condition before surgery.


### **Table 4.**

*Suggested criteria for revascularization surgery.*
