In an 89-year-old man with transient ischemic attacks undergoing carotid endarterectomy under general anesthesia, which management is appropriate?

In an 89-year-old man with transient ischemic attacks undergoing carotid endarterectomy under general anesthesia, which management is appropriate?

• A. Hyperventilation to a PaCO2 of 30 mm Hg to reduce ICP
• B. Injection of local anesthetic around the carotid body to prevent bradycardia
• C. Initiation of deliberate hypotension after induction to reduce bleeding
• D. Induction of anesthesia with sodium thiopental

Answer: (D)

The concept being tested is protecting the brain during carotid endarterectomy by using an induction agent that lowers cerebral metabolic demand to tolerate temporary reductions in cerebral blood flow. Sodium thiopental reduces cerebral metabolic rate for oxygen and cerebral blood flow, and it lowers intracranial pressure, providing neuroprotection during the periods when the carotid is clamped and perfusion to parts of the brain may be reduced. This makes it a suitable choice for an elderly patient with TIAs undergoing carotid surgery under general anesthesia. Hyperventilating to a low CO2 level would constrict cerebral vessels and further decrease blood flow to an already at‑risk brain, increasing ischemia risk. Injecting local anesthetic around the carotid sinus or carotid body is not a standard protective strategy and carries unnecessary risk. Deliberate hypotension could reduce bleeding but would worsen cerebral perfusion in a patient with carotid stenosis and prior TIAs.

The concept being tested is protecting the brain during carotid endarterectomy by using an induction agent that lowers cerebral metabolic demand to tolerate temporary reductions in cerebral blood flow. Sodium thiopental reduces cerebral metabolic rate for oxygen and cerebral blood flow, and it lowers intracranial pressure, providing neuroprotection during the periods when the carotid is clamped and perfusion to parts of the brain may be reduced. This makes it a suitable choice for an elderly patient with TIAs undergoing carotid surgery under general anesthesia.

Hyperventilating to a low CO2 level would constrict cerebral vessels and further decrease blood flow to an already at‑risk brain, increasing ischemia risk. Injecting local anesthetic around the carotid sinus or carotid body is not a standard protective strategy and carries unnecessary risk. Deliberate hypotension could reduce bleeding but would worsen cerebral perfusion in a patient with carotid stenosis and prior TIAs.