Anaesthesia for intracranial aneurysm and AVM

Meet the patient

A 52-year-old woman arrives with the worst headache of her life — a thunderclap at rest, like being kicked in the back of the head. CT shows subarachnoid blood in the basal cisterns; CTA confirms an anterior communicating artery aneurysm. She is WFNS grade 2, day 1, listed for open clipping. Her ECG shows peaked T waves and a long QT — neurogenic stunned myocardium, not a primary cardiac event.[2]

The question that owns the next three hours is simple and lethal: how do you keep the aneurysm from blowing open before the surgeon places the clip? Every line of anaesthetic conduct answers that question until the neck is secured, and then the question flips — from preventing rupture to preventing hypoperfusion.[1]

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1. [1]Hindman BJ et al. No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial Anesthesiology, 2010.PMID 19952722
2. [2]Carney N et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition Neurosurgery, 2017.PMID 27654000
3. [3]Banik S et al. Effect of dexmedetomidine on dynamic cerebral autoregulation and carbon dioxide reactivity during sevoflurane anesthesia in healthy patients Korean J Anesthesiol, 2020.PMID 32209963