Anesthesia for Cerebral Aneurysm Surgery

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.

Hyponatremia in a pediatric stroke patient: syndrome of inappropriate antidiuretic hormone secretion or cerebral salt wasting?

OBJECTIVE

To determine the potential role of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in the pathogenesis of cerebral salt wasting.

DESIGN

Clinical case report.

SETTING

Regional pediatric intensive care unit.

PATIENT

A 3-yr-old boy with a cerebral infarct secondary to traumatic carotid artery dissection who developed hyponatremia associated with weight loss and excessive renal sodium excretion on the sixth day after hospitalization.

MEASUREMENTS AND MAIN RESULTS

Plasma concentrations of ANP, BNP, antidiuretic hormone, and renin were determined serially and compared with concentrations measured in a group of eight healthy children undergoing elective surgical procedures. Compared with controls, ANP and BNP plasma concentrations on the eighth day after hospitalization were increased 1.9-fold and 7.7-fold, respectively. Thereafter, the course of ANP and BNP paralleled that of sodium and H2O excretion and remained elevated until the 14th (BNP) and 16th (ANP) days after hospitalization. Serum antidiuretic hormone and renin concentrations were within normal ranges during the entire observation period.

CONCLUSION

Cerebral salt wasting is associated with elevated plasma concentrations of ANP and BNP. Natriuretic peptides may play a role in the pathogenesis of this syndrome.

Anesthesia for cerebral aneurysms: a comparison between interventional neuroradiology and surgery

PURPOSE

To review the anesthetic management of patients with cerebral aneurysms during treatment in the interventional neuroradiology (INR) suite compared with in the operating room.

METHODS

This was a retrospective chart review of 100 consecutive patients treated by endovascular coiling compared with 100 patients treated by surgical clipping of a cerebral aneurysm. Information compared and analyzed included demographics, pre-procedure medical history, neurological status including location and size of aneurysm, anesthetic management, complications and patient outcome. P < 0.05 was considered significant.

RESULTS

Patients in the INR group were older (54 +/- 15 vs 49 +/- 12 yr), had a greater incidence of pre-procedure cardiorespiratory problems (55 vs 34 patients) and had more aneurysms located in the posterior fossa (68 vs 11) (P < 0.05). General anesthesia was used in all except seven INR patients who received conscious sedation. There were some differences in the anesthetic agents and techniques. There was less monitoring of INR patients; temperature (33 vs 99 patients), intraarterial catheter (22 vs 100), central venous catheter (4 vs 78), and evoked potential monitoring (0 vs 100). There were no differences in the incidence of documented complications or in patient outcome.

CONCLUSION

There were some differences in the anesthetic management of patients undergoing endovascular treatment of a cerebral aneurysm compared with treatment in the operating room. The patients in the INR suite were sicker and somewhat older and they received less invasive monitoring, but the complication rate and outcome did not differ.