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Pituitary adenomas are benign lesions commonly encountered in clinical practice. Functioning adenomas often result in symptoms related to hormone excess, whereas nonfunctioning adenomas often present later with symptoms secondary to mass effect of the tumor. Diagnosis is done by way of laboratory testing and magnetic resonance imaging (MRI). Transsphenoidal pituitary resection (TPR) is the mainstay of treatment for pituitary adenomas and poses unique challenges as it involves the principles and practices of both endocrine and neurosurgical management. Airway management may be difficult in patients with acromegaly or Cushing disease. The anesthetic management for pituitary surgery requires comprehensive preoperative assessment of hormonal function and airway anatomy. Intraoperative management revolves around facilitating surgical exposure while providing hemodynamic stability and allowing for rapid emergence. Postoperative disorders of sodium balance and pituitary hormone deficiency are common after pituitary surgery.

A vascular air embolism (VAE) is the entrainment of gas or exogenous air from the operative field in the arterial or venous vasculature. The incidence of VAE varies from 10% to 97% depending on the surgical procedure, being more common in neurosurgery, orthopedic shoulder surgery, and gynecological procedures. The two most important factors determining the morbidity and mortality are the volume of air and the rate of accumulation. Small amounts of air have subclinical presentation, as most is absorbed in the circulation; moderate amounts can cause pulmonary hypertension; large amounts can cause right-side heart obstruction, ventricular collapse, and death. The clinical manifestations include arrhythmias, hypotension, cardiogenic shock, dyspnea, decreased end-tidal CO2, increased end-tidal nitrogen, seizures, and altered mental status. The main goals of treatment consist of preventing further air entry, reduction of air entrained, and hemodynamic support. The anesthetic considerations consist of proper assessment in the preoperative period, as well as optimization of patient positioning. In the operating room, a precordial Doppler is the most sensitive and least invasive monitor; other diagnostic methods include end-tidal nitrogen and drop of end-tidal CO2. During the postoperative period, the patient should continue to be monitored in an intensive care unit.

Interventional neuroradiology (INR) is a rapidly evolving field with an expanding variety of indications and techniques. It encompasses the diagnosis and treatment of many neurovascular and spine conditions, including but not limited to cerebral aneurysm, arteriovenous malformations, cerebral vasospasm, and stroke management. To facilitate the close teamwork required between interventionists and anesthesiologists necessary for the successful outcome, it is important to have full understanding of cerebral protection strategies and the potential pitfalls of each procedure. Under normal circumstances, anesthesia goals revolve around maintaining patient immobility, avoiding hemodynamic alterations, and ensuring rapid recovery to facilitate postprocedure neurological evaluation. Interventional radiology suites pose challenges in anesthetic care due to their “off-site” location, remote from the main operating room area, which necessitates special preparations.