Necessary Harmony Between Anesthesia and Neurosurgery During Extracranial–Intracranial Bypass: A Review of Neuroanesthesia Strategies and Perioperative Insights

The extracranial–intracranial (EC–IC) bypass is a complex neurosurgical procedure performed for cerebral flow augmentation or flow replacement. Anesthetic management of these patients poses significant challenges due to the delicate balance required to maintain cerebral perfusion, often complicated by extensive cardiovascular comorbidities. Despite the complexity of these cases, current literature offers limited guidance on optimal anesthetic strategies. At our high-volume academic institution, we developed a standardized multimodal anesthetic protocol aimed at achieving intraoperative hemodynamic stability and facilitating timely postoperative emergence. A dedicated team of neuroanesthesiologists manages these cases in constant communication with the surgical team, ensuring real-time adjustments aligned with surgical needs and patient physiology. Our experience highlights the importance of individualized anesthetic planning and interdisciplinary coordination. Given the scarcity of published data and the specialized nature of EC–IC bypass procedures, we believe our institutional approach may serve as a useful reference for other centers, particularly those with limited exposure to this complex patient population, and lay the foundation for future prospective trials on optimal anesthetic care for this patient population.