nial pressure (ICP). Ketamine, in the spontaneously breathing patient, produces increased cerebral blood flow (CBF) and ICP, but may also have cerebral protective effects as an N-methyl-D-aspartate (NMDA) receptor inhibitor [1].

Unlike the intravenous agents, inhalational agents are all cerebral vasodilators that can be offset by hyperventilation to hypocarbia. They also decrease cerebral metabolism, leading to a coupled decrease in CBF. The overall effect on CBF depends on a balance between the concentration of the inhalational agent and the degree of hyperventilation [2,3]. In addition, nitrous oxide is frequently used in anesthesia of all types as an adjunct to other agents, allowing them to be used in lower doses. Its use in neuroanesthesia is controversial because it increases CBF and may increase ICP in susceptible patients [4]. This effect can also be offset by hyperventilation. Thus, while nitrous oxide has been extensively used in neuroanesthesia without apparent detrimental effect, it is probably prudent to avoid its use in the presence of decreased intracranial compliance.

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