The perioperative pain management for craniotomies can be extremely challenging. This chapter presents a common clinical scenario and offers options for perioperative pain management. It presents a case study of a 52-year-old female American Society of Anesthesiologists class 3 patient presented for clipping of a cerebral aneurysm. The case described is a common example of the complexity frequently associated with neurosurgical patients. The combined regimen provided for analgesia and hemodynamic control, while allowing for an adequate neurologic examination. In addition, opioids were limited, thereby decreasing the risk of postoperative nausea and vomiting. Opioids are a key component of intraoperative and postoperative pain management for craniotomies. Morphine can cause histamine release, which can lead to venodilation and subsequent hypotension. A combination of intravenous analgesics and regional anesthesia can provide excellent pain relief and decrease the wide hemodynamic changes that can accompany anesthesia and surgery.

Perioperative acute ischemic stroke (AIS) is a feared complication of surgery that is associated with increased in-hospital mortality, length of hospital stay, disability, and discharge to long-term care facilities. This chapter presents a case study of a 70-year-old female with a past medical history of hypertension, hypercholesterolemia, myocardial infarction, and morbid obesity. Since treatment with intravenous tissue plasminogen activator (tPa) is contraindicated after major surgical procedures, the patient was taken to the interventional radiology suite and endovascular mechanical thrombolysis was performed. The main risk factors for perioperative stroke include (1) female sex, (2) advanced age, (3) atrial fibrillation, (4) cardiac valvular disease, (5) congestive heart failure, (6) history of previous transient ischemic attack (TIA) or stroke, (7) renal disease, (8) diabetes mellitus, (9) hypertension, and (10) general anesthesia. Preoperative evaluation of patients should focus on identifying and correcting potentially modifiable risk factors to reduce the risk of this devastating complication.