The increasing use of coronary artery angioplasty with deployment of stents for treatment of coronary artery disease poses several dilemmas for perioperative management. These conflicting requirements are manifested most acutely in the management of patients with neurovascular disease. This chapter presents a case study of a 51-year-old female with a past medical history of ischemic heart disease, hypertension, and undifferentiated autoimmune disease with interstitial lung involvement, as an example. The presence of coronary stents in patients undergoing neurosurgical procedures warrants specific consideration prior to anesthesia. It is necessary to balance the risks of stent thrombosis, and the subsequent risk of myocardial infarction, arrhythmia, or cardiac arrest, against the risks of hemorrhage during or after a neurosurgical procedure. There is currently an irresolvable conflict between the risks of with holding and continuing antiplatelet agents in the perioperative period.