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British Journal of Anaesthesia 99 (1): 102–18 (2007)

Aneurysmal subarachnoid haemorrhage and the anesthetist H.-J. Priebe Department of Anaesthesia, University Hospital, Hugstetter Str. 55, 79106 Freiburg, Germany. British Journal of Anaesthesia 99 (1): 102–18 (2007). Epidemiology and etiology. Incidence : 1 년에 100,000 명당 8~10 건 .

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British Journal of Anaesthesia 99 (1): 102–18 (2007)

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  1. Aneurysmal subarachnoid haemorrhage and the anesthetistH.-J. PriebeDepartment of Anaesthesia, University Hospital, Hugstetter Str. 55, 79106 Freiburg, Germany British Journal of Anaesthesia 99 (1): 102–18 (2007)

  2. Epidemiology and etiology Incidence : 1년에 100,000명당 8~10건. 주로 55세~60세에 호발 Stroke의 5~15%가 Ruptured intracranial An. 약 3/4 의 SAH는 ruptured cerebral An.에 의해 생긴다. Giant aneurysm : > 2 cm Cerebral An.의 발생 원인 1) genetically, hemodynamically, nicotine abuse- or alcohol abuse-induced structural defect 2) chronic hemodynamically-induced intravascular shear stress 의 복합적 요인 ( An. out-pouchings in the subarachnoid space at the base of the brain) 3) Infections or trauma. Aneurysms 호발 부위 : turbulent flow가 잘 발생하는 vascular bifurcations에 주로 위치 (80~90%) the anterior (carotid) circulation, the anterior and posterior communicating, and the middle cerebral artery (10~20%) posterior (vertebro-basilar) circulation.

  3. Pathophysiology An.의 Rupture시, intra-arterial and subarachnoid spaces사이에 free communication exists가 존재. The sudden increase in regional intracranial pressure (ICP) 의 갑작스러운 증가로 severe headache and (transient or permanent) loss of consciousness를 야기. Subarachnoid space로의 blood spread로 인해 headache, meningism, hydrocephalus를 야기한다. Recurrent episodes of bleeding, blood clots and adhesions으로 인해 subarachnoid space를 통한 spread of blood 방해로 인하여 Intracerebral hematomas형성. Subarachnoid space의 blood로 인해 cerebral vasospasm이 생긴다. Blood의 양과 위치가 incidence of cerebral vasospasm과 연관. ICP증가의 원인: 1)expanding mass effect of the hemorrhage 2) development of brain edema 3) obstructive hydrocephalus

  4. Autoregulation of cerebral blood flow (CBF) SAH는 CBF와 cerebral metabolic rate (CMR)의 감소가 동반된다. 자주, cerebral autoregulation의손상이 나타난다. 손상의 정도는 neurological condition과 연관되어있다. 이는 low blood pressure로 인해 Cerebral perfusion pressure (CPP)가 낮아져 neurological deficits정도가 높기 때문에 수술 중 혈압 낮추는 것은 논쟁의 여지가 있다. Cerebrovascular CO2 reactivity SAH 발생시, arterial carbon dioxide (CO2)의변화로 인해 cerebrovascular reactivity가 유지된다. CO2 reactivity가 손상되는 경우 poor neurological condition을 보인다. 대부분의 SAH시, hyperventilation이 increased ICP의 치료의 option으로 주어진다.

  5. Natural history SAH 의 사망률 : 50%. Aneurysmal SAH의 30 day mortality : 45%. 1/3 of survivors remain moderately to severely disabled. 약 10%의 SAH환자는 죽기 전에 많은 수가 comatose, severe neurological deficits를 갖는다. SAH발생 후, re-bleeding and cerebral vasospasm은 3주 내에 발생. Ruptured An.은 첫 24h동안에 2-4%에서, 첫2주안에 15–20% re-bleed 발생.

  6. Clinical presentation Symptoms : 1) sudden onset of severe headache 2) meningism 3) loss of consciousness (transient or persistent) 4) epileptic seizures 5) focal neurological deficits Neurological injury : 1) unconsciousness 2) depressed consciousness 3) focal neurological deficits 4) isolated cranial nerve palsy 감각의 둔화와 non-reactive small pupils가 특징적이다. 50%에서 hydrocephalus의 non-specific findings이 보여진다 Standardize clinical assessment and to estimate the prognosis 1) Clinical grading scales such as the one of Hunt and Hess 2) the World Federation of Neurological Surgeons

  7. Hunt and Hess grading scale for SAH Grade Clinical description ------------------------------------------------------------- I Asymptomatic or minimal headache and slight nuchal rigidity II Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy III Drowsiness, confusion, or mild focal deficit IV Stupor, moderate to severe hemiparesis, and possibly early decerebrate rigidity and vegetative disturbances V Deep coma, decerebrate rigidity, and moribund appearance

  8. World Federation of Neurological Surgeons Grading Scale for aneurysmal SAH . Grade GCS score Motor deficit . I 15 Absent I I 13 or 14 Absent III 13 or 14 Present IV 7–12 Present or absent V 3–6 Present or absent * GCS : Glasgow Coma Scale. Higher clinical grade의 의미: cerebral vasospasm, elevated ICP, impaired cerebral autoregulation, impaired vascular CO2 reactivity, cardiac arrhythmias and dysfunction, hypovolemia, and hyponatremia.

  9. Diagnosis SAH는 여러 복합적인 증상을 갖기 때문에 severe headache, lasting for longer than an hour with no alternative explanation 환자의 경우 SAH를 r/o 해야 한다 Initial diagnostic tool of choice : Unenhanced cranial CT SAH발생시 10일안에 재 흡수되기 때문에 sudden severe headache and immediately impaired consciousness 발생시 즉각적으로 CT를 촬영 해야 한다. The amount of blood on unenhanced CT can be described by the Fisher four-point scale. CT상 blood의 위치와 분포는 SAH의 원인을 알아내는데 도움이 된다. Additional investigations : Lumbar puncture, Multi-slice CT angiography, Four-vessel catheter angiography, spinal catheter angiography, MRI SAH의 진단 후, 다음 단계는 An.의 rupture여부

  10. Fisher grading scale of cranial computerized tomography (CCT) Grade Findings on CCT . 1 No subarachnoid blood detected 2 Diffuse or vertical layers <1 mm 3 Localized clot and/or vertical layer >1 mm 4 Intracerebral or intraventricular clot with diffuse or no subarachnoid haemorrhage * the best predictor of cerebral vasospasm and overall patient outcome.

  11. Major complications of SAH Re-bleeding, cerebral vasospasm leading to immediate and delayed cerebral ischemia, hydrocephalus, cardiopulmonary dysfunction,electrolyte disturbances. Non-neurological complications of SAH (e.g. anemia, hypertension, hypotension, hyperglycemia, electrolyte disorders, cardiac insufficiency, and arrhythmias)

  12. Complications of aneurysmal SAH. Re-bleeding On day 1: 15% By 1 month: 40% After 6 months: 3% per year Cerebral ischemia Immediate onset (increased ICP resulting in decreased CPP) Delayed onset (peaks 4–14 days after SAH) Seizures Hydrocephalus (in 15–20% of cases) Cardiac dysfunction (reflected by echocardiographic abnormalities and by increases in serum concentration of cardiac troponin) Hyponatraemia, hypomagnesaemia or both (because of salt wasting)

  13. Cerebral vasospasm Cerebral vasospasm : 60–70%정도 발생, 3–12일 후에 나타나며 2주정도 지속. Cerebral vasospasm -> cerebral ischemia : major cause of morbidity and mortality after SAH. Severe cerebral vasospasm은 infarction and death를 야기 (SAH환자의1/3) Dx.: angiographly ICP증가와 hypovolaemia는 cerebral vasospasm을 증가시킨다. Cerebral vasospasm은 또 ICP를 증가시킨다 Cardiac dysfunction marked systemic and pulmonary hypertension, cardiac arrhythmias, myocardial dysfunction and injury, and neurogenic pulmonary edema를 동반. ECG abnormalities : QTc prolongation, repolarization abnormalities Cardiac injury and dysfunction은 직접적으로 morbidity and mortality Electrolyte disturbances Hyponatraemia, hypokalaemia, hypocalcaemia, hypomagnesaemia

  14. Prophylaxis and therapy of cerebral vasospasm Nimodipine Mild sedation Positive fluid balance Avoidance of hypotensive episodes Hyponatremia. Symptomatic treatment of cerebral vasospasm Triple-H therapy Balloon angioplasty Intra-arterial papaverine.

  15. Nimodipine Calcium channel blocker Improves outcome after SAH Thrombophlebitis발생가능( peripherally투여시) : 반드시 central venous catheter로. Infusion system : protected from light. Triple-H therapy Triple-H therapy : hypertension, hypervolaemia, and haemodilution Ix. 1) Transcranial Doppler velocities (as a reflection of cerebral vasospasm)이 증가된 환자 2) the development of neurological deficits인 환자에서 시행 Therapeutic goal of triple-H therapy Increase CBF, Increase CPP 120–150 mm Hg in unclipped 160–200 mm Hg in clipped aneurysms ; CVP: 8–12 mm Hg정도로 유지 Hematocrit 0.3–0.35 Complications of triple-H therapy 1) pulmonary edema 2) myocardial ischemia 3) respiratory insufficiency 4) hyponatremia 5) indwelling catheter-associated morbidity

  16. Balloon angioplasty Ix. medical tx.에 반응하지 않은 상태로 새로운 신경학적 손상이 있을 경우 Cx. dissection, rupture, and thrombosis of the cerebral artery with subsequent cerebral infarction or hemorrhage. Intra-arterial papaverine Vasospasm이 more distal vessel segments에 있을 경우, intra-arterial administration of papaverine may be more effective (maximally 300 mg per hemisphere). Relatively short acting, 가끔은 반복적인 치료를 필요로 한다. Neurotoxic하여 seizures, coma, blindness, irreversible brain injury가능성 Radiography상 항상 향상되어지지는 않으며 triple-H therapy보다 많은 효과적인지도 의문.

  17. Occlusion therapy of cerebral aneurysm surgically (‘clipping’) or endovascularly by detachable coils (‘coiling’). IX. Based on patient age, World Federation of Neurological Surgeons grade Co-morbidity, SAH onset time, and the anatomy of the aneurysm. Rationale for early intervention prevention of re-bleeding Reduction in the incidence of cerebral vasospasm by the removal of blood from the subarachnoid space. All ruptured aneurysms in patients with Hunt and Hess grades I–IV are generally treated within 72 h. Controversy exists as how to proceed in patients with grade V.

  18. Procedural risks Clipping Procedural morbidity (4.0–10.9%) & mortality (1.0–3.0%) Intraoperative leak and frank rupture of aneurysms 발생률 : 6-13%. Coiling Procedural morbidity (3.7–5.3%) & mortality (1.1–1.5%) Major Cx. : arterial dissection, parent artery occlusion thromboembolism, rupture of the aneurysm Minor CX. : Reaction to contrast material, groin haematoma, infection, pseudo-aneurysm. Limitations of coiling Large aneurysms or aneurysms with wider necks, Occlusion of the aneurysm with coiling상태 Clipping vs coiling Coiling : Minimally invasive Tx., more safer,lower perioperative risk. Complete occlusion 비율 : surgically group VS endovascular group (82 vs 66%) Re-bleeding occurrence : surgically group VS endovascular group (41 vs 52%)

  19. Perioperative anaesthetic management

  20. Perioperative anaesthetic management Preoperative evaluation & Premedication Preoperative evaluation 고려 해야 할 점 > 1) Electrolyte disturbances로 인한 ECG변화 가능성 (prolonged QT-interval, abnormal T-wave, and arrhythmias) 2) Myocardial injury ( ST-segment elevation or depression, Q-waves, and arrhythmia) ->적절한 진단과 치료가 필요 SAH환자의 경우 ECG의변화는 cardiac origin이기 보다는 neurological damage완 연관된 neurogenic origin이다 SAH 환자중 cardiac troponin의 증가가 보일 경우 myocardial cell injury를 나타내며 예후는 나쁘다 Underlying cardiac impairment가 있는 경우 coiling이 선호 Premedication No drug can be considered the drug of choice in all situations Anxiety로 인한 투여의 경우 respiratory depression을 야기 (causing an increase in PaCO2 followed by an increase in ICP

  21. Perioperative anaesthetic managementMonitoring & ICP monitoring Monitoring Standard monitoring 1) 5-lead ECG, continuous 2) Intra-arterial pressure 3) Pulse oximetry 4) Capnography 5) Urinary output 6) Body temperature 7) Neuromuscularblock. * Insert a central venous catheter : (1) Guidance of intravascular volume (2) For the injection of potent cardiovascular drugs (3) For administration of mannitol (smaller peripheral vein으로 투여 시 local inflammation가능성이 있다.) ICP monitoring Poor clinical grade or hydrocephalus한 경우

  22. Perioperative anaesthetic managementNeurophysiological monitoring & Jugular venous bulb monitoring Neurophysiological monitoring Cerebral function의 monitoring 1) Cortical somatosensory-evoked potential (SSEP) : Both ant. or post. cerebral circulation수술 시 2) Brainstem auditory-evoked potential (BAEP) : vertebral-basilar circulation수술 시 Combined SSEP and BAEP monitoring 은 false-positive & false-negative를 낮춘다 Detection of cerebral ischemia by evoked potential monitoring (removal or replacement of a vascular clip시 측정) Evoked potential monitoring : High-dose barbiturates사용시 억제 specificity가 낮다 이러한 제한 점으로 인해 routine monitoring 은 아니다 neurophysiological monitoring사용시 i.v. anaesthesia가 choice Jugular venous bulb monitoring Cerebral venous oxygen saturation의 monitoring Cerebral ischaemia의 the early recognition Temporary occlusion시 artery feeding과 collateral perfusion여부 확인

  23. Perioperative anaesthetic management Brain relaxation & Mannitol Brain relaxation 목적> Adequate CPP Avoid hypotension and hypertension, Maintaining normoventilation Adequate oxygenation Mannitol Peak effect of mannitol on ICP and brain bulk : 약30–45 min Clinical effect의 판정 : (urine output의 측정보다) ICP에의 반응여부 Early reduction in ICP는 preserved autoregulation을 나타냄 Rapid infusion : transient hypotension 야기 Slow infusion : 혈압은 20%이상 올라가지 않는다. Mannitol은 renal Insufficiency 환자의 경우 일시적으로 hematocrit의 감소, serum osmolality의 증가되어 hyponatraemia, hyperkalaemia, and metabolic acidosis가 생길수 있다. Recommended dose : 0.25 ~ 2 g/ kg(Usually,0.5–1.0g/ kg) Dose and speed of infusion은 underlying clinical circumstances를 보고 판단

  24. Perioperative anaesthetic managementFurosemide & Drainage of CSF Furosemide Alternative to mannitol. Dose : alone at high dose or Combination with mannitol at lower dose ICP감소 & brain water content감소 Mannitol투여 전 furosemide의 투여는 mannitol으로 인한 초기 ICP상승을 둔화 Combination하는 것이 각각의 약을 따로 쓰는 것 보다 ICP와 brain bulk에의 therapeutic effect가 넓다. Drainage of CSF 성인의 CSF양은 약150 ml Lumbar subarachnoid or ventriculostomy catheter Catheter거치 후 acute drainage of a large volume of CSF를 피해야 한다 : abrupt decrease in ICP and brain ‘sagging’. aneurysm의 re-bleed, and intracerebral haematoma reflex hypertension, bradycardia등이 생길 수 있다. CIx. intracerebral haematoma환자( risk of brainstem herniation) 이론적으로, CSF drainage는 dura를 열기 전에 투여되면 안 된다. 그러나 임상적으로 신경외과 의사는 dura 열기 전에 상태를 좋게 하기 위해 CSF drainage를 시도한다.

  25. Perioperative anaesthetic management Miscellaneous interventions Miscellaneous interventions 1) Adequate ventilation & oxygenation 2) CPP and acid–base status 3) Unobstructed cerebral venous return (check the patient’s head position) 4) Drainage of CSF Mild hyperventilation : PaCO2 30–35 mm Hg before opening the dura PaCO2 25–30 mm Hg during opening the dura Bolus dose of thiopentone (approximately 2–3 mg /kg) for its cerebrovasoconstrictive property. 효과가 있다면, continuous infusion of thiopentone (4–5 mg/kg/h)투여 그러나 awakening이 delay될 수 있다.

  26. Perioperative anaesthetic management General principles of anesthesia General principles of anesthesia (1) Control of the TMPG (transmural pressure gradient) of the aneurysm (2) Preservation of adequate CPP and oxygen delivery (3) Avoidance of large and sudden swings in ICP (4) Providing conditions that allow optimal surgical exposure with least brain retraction (5) Allowing rapid awakening of the patient Risk of rupture of aneurysm : By dangerous increase in the TMPG of the aneurysm (1) Laryngoscopy , Tracheal intubation (2) positioning of the patient placement of the pin head-holder (3) raising of the bone flap Prophylactic administration of bolus doses : 자극에 대한 반응을 둔화시켜 hypertensive response의 가능성을 낮춘다 (1) anesthetic drugs (e.g. propofol or thiopentone before placement of the pin head-holder) (2) cardiovascular depressant drugs (e.g. esmolol or labetalol before laryngoscopy and tracheal intubation). *ultra-short-acting opioid, remifentanil의 사용으로 potent stimulation를 낮춘다.

  27. Perioperative anaesthetic management Choice of anesthetic drug Choice of anaesthetic drug * Avoid hypertensive episodes and ensure adequate CPP physiological ICP and optimal brain relaxation을 유지 Volatile anesthetics : direct cerebral vasodilatory effects 1 MAC까지 CBF를 비교적 유지 (metabolic rate의 감소로 CBF감소) Opioids는 일시적으로 ICP를 증가시킨다. Etomidate : least cardiovascular side-effects compared with other drugs (decrease ICP while preserving CPP) sensory-evoked potential 측정 시에는 total i.v. anesthetic가 선호

  28. Perioperative anaesthetic management Management of CPP and TMPG of the aneurysm Management of CPP and TMPG of the aneurysm CPP and TMPG of the aneurysm. CPP = MAP – ICP TMPG of the aneurysm : MAP – ICP (the pressure within the aneurysm (equal to MAP) - the pressure outside the aneurysm (equal to ICP)) TMPG가 작을수록 risk of aneurysm rupture가 감소한다. CPP가 높을수록 cerebral oxygenation이 유지된다. Risk of inadequate cerebral perfusion과 rupture of the aneurysm가능성의 균형을 맞추는 딜레마가 생긴다. 이상적으로는, 거의 얻기는 힘들지만, CPP와 TMPG of the aneurysm은 preoperative baseline values를유지하는 것 이다.

  29. Perioperative anaesthetic management Induction of anaesthesia Induction of anaesthesia goals (1) prevention of rupture of the aneurysm, (2) preservation of cerebral oxygenation (3) prevention of an increase in ICP * Blunt the hypertensive response to laryngoscopy and tracheal intubation (e.g. esmolol, labetalol, and i.v. lidocaine) * Deep level of anesthesia ( high doses of anesthetic drugs or monitoring of depth of anesthesia) * Continuous infusion of a vasopressor (phenylephrine or norepinephrine)

  30. Perioperative anaesthetic management Respiratory management & Induced hypotension Respiratory management Normoventilation이 목표 가능하면 N2O를 제외하고, CO2의 cerebrovascular reactivity를 유지 Prolonged hyperventilation -> cerebral ischemia발생 가능 Transient and moderate hyperventilation는 ICP가 증가된 경우에만 고려 Induced hypotension Systemic arterial pressure의 감소는 TMPG of the An.와 wall stress of the An.을 감소시킨다. 이는 clipping of the An. & rupture of An.시 bleeding control에 도움을 준다 Induced systemic hypotension은 특히 hypovolemia일 경우 cerebral perfusion을 악화 시킬 수 있고 higher incidence of severe cerebral vasospasm이 생길 수 있다. Duration of temporary occlusion : 15–20 min이 넘지 않도록 (decrease in brain PO2 and an increase in brain PCO2)

  31. Perioperative anaesthetic management Induced hypothermia & Pharmacological brain protection Induced hypothermia 임상적으로 약간의 hypothermia를 유지한다. 이는 beneficial effect는 가지지 못한다. Giant An. (>2 cm)는 (특히 brainstem가까이에 있을 경우) Cardiopulmonary bypass를 이용하여 complete circulatory arrest와 profound hypothermia를 일으킨다. Pharmacological brain protection barbiturate or propofol :prophylactically administration EEG burst suppression

  32. Perioperative anaesthetic management Prophylaxis of cerebral vasospasm Prophylaxis of cerebral vasospasm Fluid management 수술 전 cerebral vasospasm이 없고 good clinical grade면, normovolaemia를 유지 약간 baseline MAP보다 높은 것도 postoperative cerebral vasospasm을 줄이는데 도움이 된다. 수술 전 cerebral vasospasm이 있는 경우, volume loading시 invasive monitoring하는 것이 낫다 (transoesophageal,echocardiographic monitoring) 수술전 hypertension이 있던 환자는 MAP를 comparable level로 유지하고, intraoperatively induced hypotension은 relatively contraindication이다. Papaverine After clipping of the An. & before closure of the dura : preventing cerebral vasospasm. Cx. : mydriasis facial nerve palsy, signs and Sx. resembling malignant hyperthermia bradycardia and hypotension cerebral vasospasm(rarely)

  33. Perioperative anaesthetic management Recovery Recovery 술 후, 환자는 여러 진단과 치료의 접근이 가능하게 구두 명령에 반응하여 빠른 신경학적 평가가 가능하게 해야 한다. Rapid and smooth awakening을 필요로 한다. Emergence시간이 지체되거나 새로운 신경학적 장애가 발견되면, CT or angiography를 통해 intracerebral haematoma or occlusion of a blood vessel여부를 r/o해야한다. 수술전보다 술 후 혈압이 20–30%정도 올라가면 intracranial hemorrhage나 edema의 가능성이 있다. HTN의 예방을 위한 약제 투여 : analgesic, anti-emetic, anti-shivering or anti-hypertensive drugs Hunt and Hess grades III or IV or intraoperative complications인 경우 : 수술 후 즉각적인 extubation을 피해야 한다 Critically ill patients : 술 후 intensive cardiopulmonary and general supportive care가 필요 Stupor or comatose 환자의 경우 초기에 tracheotomy하는 것도 고려

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