New Age Neurosurgery: Avoiding Complications in Interventional NeuroradiologyWilliam L. Young, M.D. San Francisco, California
311Page 1This talk will outline the roles of the Anesthesiologist in the
Interventional Neuroradiology
(INR) suite with anemphasis on management strategies to prevent complications and minimize their effects if they occur. We willdiscuss fundamental management principles of affording "protection," of which direct pharmacological protection is perhaps the least important. Planning the anesthetic and perioperative management is predicated on understandingthe goals of the therapeutic intervention and anticipating potential problems. Endovascular neurosurgery / INR isfirmly established in the management of cerebrovascular disease, most notably in the management of intracranialaneurysms.
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For the overall management approach to the patient with cerebrovascular disease, there is acceleratinginterest and discussion in appropriate management of asymptomatic or unruptured lesions.
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There are several anesthetic concerns that are particularly important for INR procedures, including: (1) maintainingimmobility during the procedure to facilitate imaging; (2) rapid recovery from anesthesia at the end of the case tofacilitate neurological examination and monitoring, or provide for intermittent evaluation of neurological functionduring the procedure; (3) managing anticoagulation; (4) treating and managing sudden unexpected procedure-specific complications during the procedure, i.e., hemorrhage or vascular occlusion, which may involvemanipulating systemic or regional blood pressures; (5) guiding the medical management of critical care patientsduring transport to and from the radiology suites; (6) self-protection issues related to radiation safety.
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PRE-OPERATIVE PLANNING AND PATIENT PREPARATION
Baseline blood pressure and cardiovascular reserve should be assessed carefully. This almost axiomatic statement is particularly important for several reasons. Blood pressure manipulation is commonly required and treatment-related perturbations should be anticipated. Therefore, a clear sense of “where the patient lives” needs to be established.One must keep in mind that “autoregulation” as presented in the textbooks is a description of a population;individual patients are likely to vary considerably, a concept based on the historical observations that underlie our modern notions of autoregulatory behavior.
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In those cases where intra-arterial catheters are used, the concordance between blood pressure cuff and intra-arterial readings needs to be considered; pre-operative blood pressure rangeis likely to be known through blood pressure cuff values.Pre-operative calcium channel blockers for prophylaxis for cerebral ischemia may be used and can affecthemodynamic management. In addition, these agents or trans-dermal nitroglycerin are sometimes used to lessen theincidence of catheter-induced vasospasm.For cases managed with an unsecured airway, routine evaluation of the potential ease of laryngoscopy in anemergent situation should take into account that direct access to the airway may be limited by table or roomlogistics. Recent pterional craniotomy can sometimes result in impaired tempomandicular joint mobility.For i.v. sedation cases, careful padding of pressure points and working with the patient to obtain final comfortable positioning may assist in the patient’s ability to tolerate a long period of lying supine and motionless, decreasing therequirement for sedation, anxiolysis, and analgesia. The possibility of pregnancy in female patients and a history of adverse reactions to radiographic contrast agents should be explored.Secure intravenous (iv) access should be available with adequate extension tubing to allow drug and fluidadministration at maximal distance from the image intensifier during fluoroscopy. Access to intravenous or arterialcatheters can be difficult when the patient is draped and the arms are restrained at the sides; connections should besecure. Infusions of anticoagulant, primary anesthetics or vasoactive agents should be through proximal ports withminimal dead space.In addition to standard monitors, capnography sampling via the sampling port of nasal cannula is useful for i.v.sedation cases. A pulse oximeter probe can be placed on the great toe of the leg that will receive the femoralintroducer sheath to provide an early warning of femoral artery obstruction or distal thromboembolism.For intracranial procedures and post-operative care, beat-to-beat arterial pressure monitoring and blood samplingcan be facilitated by an arterial line. A side port of the femoral artery introducer sheath can be used, but the sheathis usually removed immediately after the procedure. In a patient who requires continuous blood pressure monitoring post-operatively or frequent blood sampling, it is convenient to have a separate radial arterial blood pressurecatheter. Using a co-axial or tri-axial catheter system, arterial pressure at the carotid artery, vertebral artery, and the
311Page 2distal cerebral circulation can be measured. Pressures in these distal cathethers usually underestimate systolic andoverestimates diastolic pressure; however, mean pressures are reliable. Bladder catheters assist in fluid managementas well as patient comfort. A significant volume of heparinized flush solution and radiographic contrast is may beused.Radiation Safety is a critical part of pre-operative planning. It is probably reasonable to assume that the x-raymachine is always on. There are three sources of radiation in the INR suite:
direct
radiation from the X-ray tube,
leakage
(through the collimators' protective shielding), and
scattered
(reflected from the patients and the areasurrounding the body part to be imaged). A fundamental knowledge of radiation safety is essential for all staff members working in an INR suite. The amount of exposure decreases proportionally to the inverse of the square of the distance from the source of radiation (inverse square law). Digital subtraction angiography (DSA) deliversconsiderably more radiation than fluoroscopy.Optimal protection would dictate that all personnel should wear lead aprons, thyroid shields, and radiation exposure badges. The lead aprons should be periodically evaluated for any cracks in the lead lining that may allow accidentalradiation exposure. Movable lead glass screens may provide additional protection for the anesthesia team. Clear communication between the INR and anesthesia teams is also crucial for limiting radiation exposure. With proper precautions the anesthesia team should be exposed to far less than the annual recommended limit for health careworkers (see URL http://pdg.lbl.gov/).
ANESTHETIC TECHNIQUEChoice of Anesthetic Technique
Most centers routinely involved use general endotracheal anesthesia for aneurysm coiling and endovascular treatment of vasospasm. Choice of anesthetic technique varies between centers with no clear superior method.
General Anesthesia
A primary reason for employing general anesthesia is to minimize motion artifacts and to improve the quality of image. Relative normocapnia or modest hypocapnia consistent with the safe conduct of positive pressure ventilationshould be maintained unless intracranial pressure is a concern. The specific choice of anesthesia may be guided primarily by other cardio- and cerebrovascular considerations. Total intravenous anesthetic techniques, or combinations of inhalational and intravenous methods, may optimize rapid emergence. To date, pharmacological protection against ischemic injury during neurosurgical procedures has not been proven. A theoretical argumentcould be made for eschewing the use of N2O because of the possibility of introducing air emboli into the cerebralcirculation and reports that it worsens outcome after experimental brain injury.
Intravenous Sedation
Intravenous sedation in aneurysm management is used most often for patients coming for interim follow-upangiography to assess the necessity for retreatment after primary coiling. If further treatment is indicated, thetechnique can be converted to a general anesthetic. Goals of anesthetic choice for intravenous sedation are toalleviate pain, anxiety, and discomfort, provide patient immobility and allow rapid recovery. There may be adiscomfort associated with injection of contrast into the cerebral arteries (burning) and with distention or traction onthem (headache). A long period of lying can cause significant discomfort.A variety of sedation regimens are available, and specific choices are based on the experience of the practitioner andthe goals of anesthetic management. Common to all intravenous sedation techniques is the potential for upper airway obstruction. Placement of nasopharyngeal airways may cause troublesome bleeding in anticoagulated patients and is generally avoided.Dexmetetomidine is a new agent that may have applicability in the setting of INR. It is a potent, selective alpha
2
-agonist with sedative, anxiolytic, and analgesic properties, with recent regulatory approval for sedation.Dexmedetomidine is especially noteworthy for its ability to produce a state of patient tranquility without depressingrespiration. However, there are two caveats to consider. First, there are still unclear effects on cerebral perfusion.
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More importantly, there is a tendency for patients managed with dexmedetomidine to have relatively low blood pressure in the post-anesthesia recovery period.
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Because patients with aneurismal subarachnoid hemorrhage may be critically dependent on adequate collateral perfusion pressure, use of regimens that may result in blood pressuredecreases should be used with great caution.
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ANTICOAGULATIONHeparin:
Careful management of coagulation is required to prevent thromboembolic complications during and after the procedure. Generally, after a baseline activated clotting time (ACT) is obtained, intravenous heparin (70 units/kg) isgiven to a target prolongation of 2 ~ 3 times of baseline. Then heparin can be given continuously or as anintermittent bolus with hourly monitoring of ACT. Occasionally, a patient may be refractory to attempts to obtainadequate anticoagulation. Switching from bovine to porcine heparin or vice versa should be considered. If antithrombin III deficiency is suspected, administration of fresh frozen plasma may be necessary.
Direct Thrombin Inhibitors:
Heparin-induced thrombocytopenia (HIT) is a potentially devastating prothrombotic syndrome caused by heparindependent antibodies after exposure. Direct thrombin inhibitors may be used in patients with or at risk of HIT,although they entail their own risks, including a small risk of anaphylaxis. They inhibit thrombin both in the freeform or bound to the clot. Monitoring of action is done by measuring the aPTT, or ACT. Lepirudin is FDA-approved for anticoagulation in patients with HIT. The half-life of lepirudin is 40 to 120 minutes, and it undergoesrenal elimination. For HIT patients with renal impairment, Argatroban, predominantly metabolized in the liver, may be preferrable. Bivalirudin, a synthetic derivative of lepirudin, has a short half-life of about 25 minutes. Since bivalirudin is partially renally eliminated, dose adjustments may be needed in patients with renal dysfunction. Arecent report described bivalirudin as a potential alternative during INR procedures to heparin for intravenousanticoagulation and intra-arterial thrombolysis.
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Antiplatelet agents:
Antiplatelet agents (aspirin, the glycoprotein IIb/IIIa receptor antagonists and the thienopyridine derivatives) areincreasingly being used for cerebrovascular disease management, as well as rescue from thromboemboliccomplications.
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Activation of the platelet membrane glycoprotein (GP) IIb/IIIa leads to fibrinogen binding and isa final common pathway for platelet aggregation. Abciximab, eptifibatide and tirofiban are glycoprotein IIb/IIIareceptor antagonists. The long duration and potent effect of Abciximab also increase the likelihood of major bleeding. The smaller molecule agents, eptifibatide and tirofiban, are competitive blockers and have a shorter half-life (about 2 hours). Thienopyridine derivatives (ticlopidine and clopidogrel) bind to the platelet’s ADP receptorsand permanently alter the receptor; therefore, the duration of action is the life span of the platelet. The addition of clopidogrel to the antiplatelet regimen is used when stent-assisted coiling is anticipated, and also for management of unruptured aneurysms.
Reversal of Anticoagulation:
At the end of the procedure or at occurrence of hemorrhagic complication, heparin may be reversed with protamine.Since there is no specific antidote for the direct thrombin inhibitors or the antiplatelet agents, the biological half-lifeis one of the major considerations in drug choice and platelet transfusion is a non-specific therapy, should reversal be indicated. There is no currently available accurate test to measure platelet function in patients taking the newer antiplatelet drugs. Desmopressin (DDAVP) has been reported to shorten the prolonged bleeding time of individualstaking antiplatelet agents such as aspirin and ticlopidine. There are also increasing recent reports on using specificclotting factors, including recombinant factor VIIa and factor IX complex, to rescue severe life-threatening bleeding,including intracranial hemorrhage uncontrolled by standard transfusion therapy. The safety and efficacy of thesecoagulation factors remain to be investigated.
DELIBERATE HYPERTENSION
During acute arterial occlusion or vasospasm, the only practical way to increase collateral blood flow may be anaugmentation of the collateral perfusion pressure by raising the systemic blood pressure. The Circle of Willis is a primary collateral pathway in cerebral circulation. However, in as many as 21% of otherwise normal subjects, thecircle may not be complete. There are also secondary collateral channels that bridge adjacent major vascular territories, most importantly for the long circumferential arteries that supply the hemispheric convexities. These pathways are known as the pial-to-pial collateral or leptomeningeal pathways.The extent to which the blood pressure has to be raised depends on the condition of the patient and the nature of thedisease. Typically, during deliberate hypertension the systemic blood pressure is raised by 30-40% above the baseline, in the absence of some direct outcome measure such as resolution of ischemic symptoms or imagingevidence of improved perfusion. Phenylephrine is usually the first line agent for deliberate hypertension and is
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