Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage

Sandeep Kundra, Vidhi Mahendru, Vishnu Gupta, Ashwani Kumar Choudhary, Sandeep Kundra, Vidhi Mahendru, Vishnu Gupta, Ashwani Kumar Choudhary

Abstract

Aneurysmal subarachnoid hemorrhage is associated with high mortality. Understanding of the underlying pathophysiology is important as early intervention can improve outcome. Increasing age, altered sensorium and poor Hunt and Hess grade are independent predictors of adverse outcome. Early operative interventions imposes an onus on anesthesiologists to provide brain relaxation. Coiling and clipping are the two treatment options with increasing trends toward coiling. Intraoperatively, tight control of blood pressure and adequate brain relaxation is desirable, so that accidental aneurysm rupture can be averted. Patients with poor grades tolerate higher blood pressures, but are prone to ischemia whereas patients with lower grades tolerate lower blood pressure, but are prone to aneurysm rupture if blood pressure increases. Patients with Hunt and Hess Grade I or II with uneventful intraoperative course are extubated in operation theater, whereas, higher grades are kept electively ventilated. Postoperative management includes attention toward fluid status and early management of vasospasm.

Keywords: Aneurysm; neuroanesthesia; sub-arachnoid hemorrhage.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1
Figure 1
Transmural pressure = Mean arterial blood pressure (MAP) — intracranial pressure (ICP); cerebral perfusion pressure = MAP — ICP

References

    1. Pong RP, Lam AM. Anaesthetic management of cerebral aneurysm surgery. In: Cotrell JE, Young WL, editors. Neuroanaesthesia. 5th ed. Missouri: Mosby Elsevier; 2010. pp. 218–46.
    1. Macmillan CS, Grant IS, Andrews PJ. Pulmonary and cardiac sequelae of subarachnoid haemorrhage: Time for active management? Intensive Care Med. 2002;28:1012–23.
    1. Passier PE, Visser-Meily JM, van Zandvoort MJ, Post MW, Rinkel GJ, van Heugten C. Prevalence and determinants of cognitive complaints after aneurysmal subarachnoid hemorrhage. Cerebrovasc Dis. 2010;29:557–63.
    1. Al-Shahi R, White PM, Davenport RJ, Lindsay KW. Subarachnoid haemorrhage. BMJ. 2006;333:235–40.
    1. de Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A. Timing of aneurysm surgery in subarachnoid hemorrhage: A systematic review of the literature. Neurosurgery. 2002;50:336–40.
    1. Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: A systematic review. Lancet Neurol. 2009;8:355–69.
    1. Kotapka MJ, Flamm ES. Cerebral aneurysms: Surgical considerations. In: Cotrell JE, Smith DS, editors. Anaesthesia and Neurosurgery. 4th ed. St.Louis: Mosby; 2001. pp. 353–65.
    1. Feigin VL, Rinkel GJ, Lawes CM, Algra A, Bennett DA, van Gijn J, et al. Risk factors for subarachnoid hemorrhage: An updated systematic review of epidemiological studies. Stroke. 2005;36:2773–80.
    1. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14–20.
    1. Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg. 1988;68:985–6.
    1. Kothavale A, Banki NM, Kopelnik A, Yarlagadda S, Lawton MT, Ko N, et al. Predictors of left ventricular regional wall motion abnormalities after subarachnoid hemorrhage. Neurocrit Care. 2006;4:199–205.
    1. Diringer MN, Lim JS, Kirsch JR, Hanley DF. Suprasellar and intraventricular blood predict elevated plasma atrial natriuretic factor in subarachnoid hemorrhage. Stroke. 1991;22:577–81.
    1. Nelson RJ, Roberts J, Rubin C, Walker V, Ackery DM, Pickard JD. Association of hypovolemia after subarachnoid hemorrhage with computed tomographic scan evidence of raised intracranial pressure. Neurosurgery. 1991;29:178–82.
    1. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6:1–9.
    1. Macrea LM, Tramèr MR, Walder B. Spontaneous subarachnoid hemorrhage and serious cardiopulmonary dysfunction: A systematic review. Resuscitation. 2005;65:139–48.
    1. Kassell NF, Torner JC, Haley EC, Jr, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg. 1990;73:18–36.
    1. Haley EC, Jr, Kassell NF, Torner JC. The International Cooperative Study on the Timing of Aneurysm Surgery. The North American experience. Stroke. 1992;23:205–14.
    1. Gaberel T, Magheru C, Emery E, Derlon JM. Antifibrinolytic therapy in the management of aneurismal subarachnoid hemorrhage revisited. A meta-analysis. Acta Neurochir (Wien) 2012;154:1–9.
    1. Roos YB, Rinkel GJ, Vermeulen M, Algra A, van Gijn J. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2003;2:CD001245.
    1. Demirgil BT, Tugcu B, Postalci L, Guclu G, Dalgic A, Oral Z. Factors leading to hydrocephalus after aneurysmal subarachnoid hemorrhage. Minim Invasive Neurosurg. 2003;46:344–8.
    1. Harrod CG, Bendok BR, Batjer HH. Prediction of cerebral vasospasm in patients presenting with aneurysmal subarachnoid hemorrhage: A review. Neurosurgery. 2005;56:633–54.
    1. Zetterling M, Hallberg L, Hillered L, Karlsson T, Enblad P, Ronne Engström E. Brain energy metabolism in patients with spontaneous subarachnoid hemorrhage and global cerebral edema. Neurosurgery. 2010;66:1102–10.
    1. Carrera E, Schmidt JM, Oddo M, Fernandez L, Claassen J, Seder D, et al. Transcranial Doppler for predicting delayed cerebral ischemia after subarachnoid hemorrhage. Neurosurgery. 2009;65:316–23.
    1. Dhawan V, DeGeorgia M. Neurointensive care biophysiological monitoring. J Neurointerv Surg. 2012;4:407–13.
    1. Dorhout Mees SM, Rinkel GJ, Feigin VL, Algra A, van den Bergh WM, Vermeulen M, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007;18:CD000277.
    1. Suarez JI. Participants in the International Multidisciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Magnesium sulfate administration in subarachnoid hemorrhage. Neurocrit Care. 2011;15:302–7.
    1. Wong GK, Poon WS, Chan MT, Boet R, Gin T, Ng SC, et al. Plasma magnesium concentrations and clinical outcomes in aneurysmal subarachnoid hemorrhage patients: Post hoc analysis of intravenous magnesium sulphate for aneurysmal subarachnoid hemorrhage trial. Stroke. 2010;41:1841–4.
    1. Vergouwen MD, de Haan RJ, Vermeulen M, Roos YB. Effect of statin treatment on vasospasm, delayed cerebral ischemia, and functional outcome in patients with aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis update. Stroke. 2010;41:e47–52.
    1. Tseng MY. Participants in the International Multidisciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Summary of evidence on immediate statins therapy following aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;15:298–301.
    1. Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KT. Delayed cerebral ischaemia after subarachnoid haemorrhage: Looking beyond vasospasm. Br J Anaesth. 2012;109:315–29.
    1. Naval NS, Stevens RD, Mirski MA, Bhardwaj A. Controversies in the management of aneurysmal subarachnoid hemorrhage. Crit Care Med. 2006;34:511–24.
    1. Treggiari MM. Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Hemodynamic management of subarachnoid hemorrhage. Neurocrit Care. 2011;15:329–35.
    1. Diringer MN, Bleck TP, Claude Hemphill J, 3 rd, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: Recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15:211–40.
    1. Dankbaar JW, Slooter AJ, Rinkel GJ, Schaaf IC. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: A systematic review. Crit Care. 2010;14:R23.
    1. Rosenwasser RH, Armonda RA, Thomas JE, Benitez RP, Gannon PM, Harrop J. Therapeutic modalities for the management of cerebral vasospasm: Timing of endovascular options. Neurosurgery. 1999;44:975–9.
    1. Santillan A, Knopman J, Zink W, Patsalides A, Gobin YP. Transluminal balloon angioplasty for symptomatic distal vasospasm refractory to medical therapy in patients with aneurysmal subarachnoid hemorrhage. Neurosurgery. 2011;69:95–101.
    1. Qureshi AI, Suri MF, Khan J, Kim SH, Fessler RD, Ringer AJ, et al. Endovascular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients: Safety and feasibility. J Neurosurg. 2001;94:880–5.
    1. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366:809–17.
    1. van Rooij WJ, Sluzewski M, Beute GN, Nijssen PC. Procedural complications of coiling of ruptured intracranial aneurysms: Incidence and risk factors in a consecutive series of 681 patients. AJNR Am J Neuroradiol. 2006;27:1498–501.
    1. Derdeyn CP, Barr JD, Berenstein A, Connors JJ, Dion JE, Duckwiler GR, et al. The International Subarachnoid Aneurysm Trial (ISAT): A position statement from the Executive Committee of the American Society of Interventional and Therapeutic Neuroradiology and the American Society of Neuroradiology. AJNR Am J Neuroradiol. 2003;24:1404–8.
    1. Harbaugh RE, Heros RC, Hadley MN. Position statement on the International Subarachnoid Aneurysm Trial (ISAT) [Last accessed on 2006 Dec 30]. Available from: .
    1. Pong RP, Lam AM. Anesthetic management of cerebral aneurysm surgery. In: Cottrell JE, Oung WL, editors. Cottrell's and Young's Neuroanesthesia. 5th ed. Philadelphia: Mosby Elsevier; 2010. pp. 218–46.
    1. Dorairaj IL, Hancock SM. Anaesthesia for interventional neuroradiology. Contin Educ Anaesth Crit Care Pain. 2008;8:86–9.
    1. Voldby B, Enevoldsen EM, Jensen FT. Cerebrovascular reactivity in patients with ruptured intracranial aneurysms. J Neurosurg. 1985;62:59–67.
    1. Priebe HJ. Aneurysmal subarachnoid haemorrhage and the anaesthetist. Br J Anaesth. 2007;99:102–18.
    1. Torre-Healy A, Marko NF, Weil RJ. Hyperosmolar therapy for intracranial hypertension. Neurocrit Care. 2012;17:117–30.
    1. Gruber A, Dorfer C, Standhardt H, Bavinzski G, Knosp E. Prospective comparison of intraoperative vascular monitoring technologies during cerebral aneurysm surgery. Neurosurgery. 2011;68:657–73.
    1. Saito S, Kadoi Y, Nara T, Sudo M, Obata H, Morita T, et al. The comparative effects of propofol versus thiopental on middle cerebral artery blood flow velocity during electroconvulsive therapy. Anesth Analg. 2000;91:1531–6.
    1. Woods AW, Allam S. Tracheal intubation without the use of neuromuscular blocking agents. Br J Anaesth. 2005;94:150–8.
    1. Lanier WL, Milde JH, Michenfelder JD. Cerebral stimulation following succinylcholine in dogs. Anesthesiology. 1986;64:551–9.
    1. Kovarik WD, Mayberg TS, Lam AM, Mathisen TL, Winn HR. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg. 1994;78:469–73.
    1. Petersen KD, Landsfeldt U, Cold GE, Petersen CB, Mau S, Hauerberg J, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: A randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003;98:329–36.
    1. Miura Y, Kamiya K, Kanazawa K, Okada M, Nakane M, Kumasaka A, et al. Superior recovery profiles of propofol-based regimen as compared to isoflurane-based regimen in patients undergoing craniotomy for primary brain tumor excision: A retrospective study. J Anesth. 2012;26:721–7.
    1. Dinsmore J. Anaesthesia for elective neurosurgery. Br J Anaesth. 2007;99:68–74.
    1. Gupta S, Heath K, Matta BF. Effect of incremental doses of sevoflurane on cerebral pressure autoregulation in humans. Br J Anaesth. 1997;79:469–72.
    1. Sankhyan N, Vykunta Raju KN, Sharma S, Gulati S. Management of raised intracranial pressure. Indian J Pediatr. 2010;77:1409–16.
    1. Todd MM, Cutkomp J, Brian JE. Influence of mannitol and furosemide, alone and in combination, on brain water content after fluid percussion injury. Anesthesiology. 2006;105:1176–81.
    1. Rozet I, Tontisirin N, Muangman S, Vavilala MS, Souter MJ, Lee LA, et al. Effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance. Anesthesiology. 2007;107:697–704.
    1. Choi JW, Kim TS, Joo SP, Lee JK, Kim JH, Kim SH. Effect of temporary clipping on the cerebral infarction in middle cerebral artery aneurysm surgery. Korean J Cerebrovasc Surg. 2006;8:248–53.
    1. Romero Kräuchi O, Verger Bennasar AM. Protective measures against cerebral ischemia following subarachnoid hemorrhage: Part 1. Rev Esp Anestesiol Reanim. 2011;58:230–5.
    1. Baughman VL. Brain protection during neurosurgery. Anesthesiol Clin North America. 2002;20:315–27. vi.
    1. Ogilvy CS, Chu D, Kaplan S. Mild hypothermia, hypertension, and mannitol are protective against infarction during experimental intracranial temporary vessel occlusion. Neurosurgery. 1996;38:1202–9.
    1. McConkey PP, Kien ND. Cerebral protection with thiopentone during combined carotid endarterectomy and clipping of intracranial aneurysm. Anaesth Intensive Care. 2002;30:219–22.
    1. El Beheiry H. Protecting the brain during neurosurgical procedures: Strategies that can work. Curr Opin Anaesthesiol. 2012;25:548–55.
    1. Bao L, Xu F. Fundamental research progress of mild hypothermia in cerebral protection. Springerplus. 2013;2:306.
    1. Nguyen HP, Zaroff JG, Bayman EO, Gelb AW, Todd MM, Hindman BJ, et al. Perioperative hypothermia (33 degrees C) does not increase the occurrence of cardiovascular events in patients undergoing cerebral aneurysm surgery: Findings from the intraoperative hypothermia for aneurysm surgery trial. Anesthesiology. 2010;113:327–42.
    1. Zhao ZX, Wu C, He M. A systematic review of clinical outcomes, perioperative data and selective adverse events related to mild hypothermia in intracranial aneurysm surgery. Clin Neurol Neurosurg. 2012;114:827–32.
    1. Chan MT, Boet R, Ng SC, Poon WS, Gin T. Magnesium sulfate for brain protection during temporary cerebral artery occlusion. Acta Neurochir Suppl. 2005;95:107–11.

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