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; cardiopulmonary dysfunction and electrolyte disturbance are recognised SAH complications in the neuroanaesthesia review scope.^[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.^[2]

References9ShowHide

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]Priebe HJ Aneurysmal subarachnoid haemorrhage and the anaesthetist. Br J Anaesth, 2007.PMID 17525049
3. [3]Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ, 1989.PMID 2496789
4. [4]Intarakhao P, Thiarawat P, Tewaritrueangsri A, et al. Low-dose adenosine-induced transient asystole during intracranial aneurysm surgery. Surg Neurol Int, 2020.PMID 32874738
5. [5]Seo H, Kim E, Jung H, et al. A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection. J Neurosurg, 2017.PMID 27540904
6. [6]Chyatte D Normal pressure perfusion breakthrough after resection of arteriovenous malformation. J Stroke Cerebrovasc Dis, 1997.PMID 17894984
7. [7]Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke, 2012.PMID 22556195
8. [8]Banik S, Rath GP, Lamsal R, Bithal PK Effect of dexmedetomidine on dynamic cerebral autoregulation and carbon dioxide reactivity during sevoflurane anesthesia in healthy patients. Korean J Anesthesiol, 2020.PMID 32209963
9. [9]Meling TR, Romundstad L, Niemi G, et al. Adenosine-assisted clipping of intracranial aneurysms. Neurosurg Rev, 2018.PMID 28819885