Anesthetic goals for cerebral aneurysm
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Anesthetic Goals for cerebral aneurysm. Lindsay Attaway MD. Intracranial aneurysms. Arise in Circle of Willis Mostly in anterior circulation Rupture and SAH greatest concern Account for 75-80% of SAH 1/3 die from initial bleed 1/3 severe disability/delayed death

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Anesthetic Goals for cerebral aneurysm

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Anesthetic Goals for cerebral aneurysm

Lindsay Attaway MD


Intracranial aneurysms

  • Arise in Circle of Willis

  • Mostly in anterior circulation

  • Rupture and SAH greatest concern

  • Account for 75-80% of SAH

  • 1/3 die from initial bleed

  • 1/3 severe disability/delayed death

  • 1/3 with acceptable outcome


Surgical considerations

  • Clipping confers benefit when aneurysm exceeds 10 mm

  • Initial 72 hr window

  • Beyond delayed 10-14 days- risk of vasospasm


Anesthetic considerations

  • Primary concern- prevent rupture

  • Mortality of rupture on induction exceeds 75%

  • Likelihood of rupture depends on size, prior rupture, wall strength and transmural pressure

  • Transmural pressure

    • CPP= MAP – ICP

  • Critical periods: induction, dura/arachnoid exposure, hematoma evac, dissection


Induction

  • Avoid acute increases in blood pressure while preserving CPP

  • Consider awake A-line, lidocaine, beta blockers, narcotics

  • Avoid aggressive hyperventilation and hypocapnia


A 45 yo female is experiencing progressive mental deterioration over a 6 hr period, 5 days out from emergent Sah evacuation and aneurysm clipping. Most likely cause is:

  • A: Cerebral edema

  • B: Hyponatremia

  • C: Recurrent cerebral hemorrhage

  • D: Vasospasm

  • E: Improper placement of the aneurysm clip


Vasospasm

  • Subarachnoid bleeders at risk for vasospasm and further ischemia

    • Rare in day 1-3

    • Peaks at day 7

    • Resolves around day 10-14

  • Symptoms may include:

    • Change in mentation

    • New neurologic deficit

    • Respiratory changes

  • Diagnosis by angiography and transcranial Doppler


Therapy that is useful in the treatment of cerebral vasospasm includes all of the following except:

  • A: Blood pressure elevation

  • B: Hemodilution

  • C: Diuretics

  • D: Calcium channel blockers

  • E: Avoiding hyperglycemia


HHH

  • HEMODILUTION, HYPERTENSION, HYPERVOLEMIA

  • Strategy to augment CBF past strictures by CPP and IV volume

  • Keep MAP normal prior to clipping, High/Normal after clipping

  • Not indicated for elective aneurysm clipping


Other Considerations

  • Blood pressure control during pinning and positioning

  • Surgeon desires cerebral relaxation

    • Gentle hyperventilation

    • Osmotic diuretics

  • Surgeon prefers isoelectric EEG

    • Bolus and infusion of propofol or etomidate

    • Increase MAP after deployment

  • Wake up

    • Avoid straining, coughing, bucking, and HD liability


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