A venous air embolism (VAE) is a potentially life-threatening event caused by air in the vascular system. The entrainment of air from an operative site into the venous vasculature produces a wide array of systemic effects. This chapter presents a case study of a 37-year-old female with a right-sided acoustic neuroma presenting for a suboccipital approach to tumor resection. VAE was historically most often associated with craniotomies performed in the sitting position. Clinical presentation depends on the severity of the air embolus. There are several monitors that are capable of detecting venous air emboli. The most sensitive is transesophageal echocardiography (TEE). The presence of TEE also enables direct visualization of air aspiration through a central catheter if a VAE should occur. Monitors for high-risk cases should be chosen depending on the expertise of the anesthesiologist, the surgery being performed, and the position of the patient.

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.