Anesthesia for intracranial aneurysm surgery

Predictors of aneurysmal rebleed before definitive surgical or endovascular management

BACKGROUND

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

METHOD

A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

RESULTS

Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002).

CONCLUSIONS

Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm

Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.

Aneurysmal rebleeding : factors associated with clinical outcome in the rebleeding patients

OBJECTIVE

Aneurysmal rebleeding is a major cause of death and disability. The aim of this study is to investigate the incidence of rebleeding, and the factors related with patient's outcome.

METHODS

During a period of 12 years, from September 1995 to August 2007, 492 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) underwent surgery at our institution. We reviewed the patient's clinical records, radiologic findings, and possible factors inducing rebleeding. Also, we statistically analyzed various factors between favorable outcome group (FG) and unfavorable outcome group (UG) in the rebleeding patients.

RESULTS

Rebleeding occurred in 38 (7.7%) of 492 patients. Male gender, location of aneurysm (anterior communicating artery) were statistically significant between rebleeding group and non-rebleeding group (p = 0.01 and p = 0.04, respectively). Rebleeding occurred in 26 patients (74.3%) within 2 hours from initial attack. There were no statistically significant factors between FG and UG. However, time interval between initial SAH to rebleeding was shorter in the UG compared to FG (FG = 28.71 hrs, UG = 2.9 hrs).

CONCLUSION

Rebleeding occurs more frequently in the earlier period after initial SAH. Thus, careful management in the earlier period after SAH and early obliteration of aneurysm will be necessary.

Adverse effects of limited hypotensive anesthesia on the outcome of patients with subarachnoid hemorrhage

OBJECT

This study was aimed at clarifying the effect of intraoperative hypotensive anesthesia on the outcome of early surgery in patients with subarachnoid hemorrhage (SAH) caused by saccular cerebral aneurysms. Other factors were also screened for possible effects on the outcome.

METHODS

Hospital charts in 84 consecutive patients with SAH who underwent aneurysm clipping by Day 4 were examined. Possible factors affecting the outcome were analyzed using multiple logistic regression with the dichotomous Glasgow Outcome Scale score as the outcome variable. The relationship between the intraoperative hypotension and the occurrence and severity of vasospasm was studied using both single- and multivariate analyses.

CONCLUSIONS

Intraoperative hypotension had a significantly adverse effect on the outcome of SAH. Hypotension was also related to more frequent and severe manifestations of vasospasm. A long-lasting effect of brain retraction is possibly the cause of this phenomenon. The data contained in this study preclude the use of intraoperative hypotension even in a limited form.

Timing of operation for ruptured cerebral aneurysm and long-term recovery of cognitive functions

Advantage and disadvantages of early and late operation for ruptured cerebral aneurysm are controversially evaluated with regard to peri-operative operation outcome and long-term cognitive recovery. In this retrospective analysis 22 patients with early surgery (ES) within three days after subarachnoid haemorrhage (SAH) and 22 patients with late surgery (LS) at least 14 days after SAH were studied. Patients were pair-wise matched by degree of SAH localisation of aneurysm and age at SAH. On average three years after SAH both groups were examined individually with a comprehensive neuropsychological test battery including tests of premorbid intelligence, concept formation, memory, visuomotor speed, aphasia screening, and mood. ES and LS patients were well comparable in terms of years of education and level of premorbid intelligence. There was a clear influence of patients age on fluid intelligence tests, indicating a general change-sensitivity of tests. No influence of degree of SAH and localisation of aneurysm could be detected. There were also no differences between ES and LS patients in neuropsychological tests sensitive to brain damage, suggesting that the decision for early or late surgery for ruptured cerebral aneurysm can be based upon surgical reasons at the time of the SAH.