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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intracranial aneurysms
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
Surgical considerations
  • Clipping confers benefit when aneurysm exceeds 10 mm
  • Initial 72 hr window
  • Beyond delayed 10-14 days- risk of vasospasm
anesthetic considerations
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
Induction
  • Avoid acute increases in blood pressure while preserving CPP
  • Consider awake A-line, lidocaine, beta blockers, narcotics
  • Avoid aggressive hyperventilation and hypocapnia
slide6

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
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
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
slide9
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
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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