ANESTHETIC CONSIDERATI

ENDOVASCULAR REPA~~/OR
INTRACRANIAL ANEURYSMS
Alexander ZlotnikO 199

Epidemiology
Theincidence of intracranial aneurysms (IA) in th e general populatlO .
0.2to 9.9%. I h most cases of IA are sporadic ce tai d'
. A thoug
. . ,r n IS
aIn iseasestates
areassociated with the . development of lAs includinq poly cystiIC kIdney di-.
sease,neurofibromatosls type 1, Marfan syndrome
.' and Ehlers- DanIos syn-
drame type IV. Some people have a genetic predisposition to devel .
. ki . . f oplng
lAs,and the rrs IS increased In irst-deqree relatives. 20 to 30% of patients
diagnosedwith an aneurysm have more than one. Risk factors for multi-
pleaneurysms include cigarette smoking, female gender, and hypertension.
lAstypically exists at branch points in the cerebral vasculature, the most
commonsite being the junction of the anterior communicating artery and
mlddlecerebral artery.
IA rupture is a major cause of morbidity and mortality, though fortunate-
Iy,not aII aneurysms rupture. However, 85% of aii casesof subarachnoid he-
morrhage(SAH) result from a ruptured IA, which has a 25 to 50% mortality.
Manypeople that survive a SAH are severely debilitated. The most consistent
symptom of IA rupture is bad headache. Other presenting symptoms of lAs
l
arecaused by crarual nerve palsies, hydrocephalus, and cerebral compress -
an.Rarely, an IA can present with seizures. Most lAs does not rupture a~d
. d i dentally wlth uram
arecompletely asvmptomatlc: some are dlscovere inCI
, I upture rate of
nave an annua r

__ --
Irnagltlg lAs that are found incidentally
0,5-2%.
70-- . 1,.'/y Mrdiml Cr/lter fi
B 'parlment of Anesthesiology awd Critical Care, 5nrokll UIIWeTS .
en-Gurio/l Universiiy of the NFgelJ, Beer 'ihI'IJO, Israel

iltnişoara 20} }
 Interventional neuroradiology (INR) procedures are performed for a nUIll
ber of CNS pathologies, and endovascular treatrnent lAs IS an optlon fOr
many patients. The goal of endovascular reparr of lAs IS the occiuslOn of Iht
proximal feeding arterics or obliteration of thc nneurvsrnal sac. DeSlruCllon
of the sac while spannq the patent arterv can be difficult, and can lead 10
distal embolism and rup ture. Therefore, thc ancsthesioloqist must alwaVSbe ti
prepared for potential rupture.
O
Ruptured lAs can be safely treated with endovascular coilinq in the firSt
a
hours after rupture, with a low probabilitv of aneurvsrn perforation. SUCC~s
IS determined largely by the size and anatomy of the aneurysm. 57-85010 of
ruptured aneurysms less than 4mm in diarneter can be completely occluded
200 by endovascular coiling, while only 15-35% of aneurysms more than 41l1il1
can be successfully coiled.

Preoperative Considerations
The importance of pre-anesthetic assessment can be overstated. The
anesthesiologist must understand the patient's pathology and presentlng
symptoms. A careful neurological exam IS necessary for a comparison wlth
the patient's post-procedure state. As with aii anesthetic plans, pat,ents'
comorbid conditiFons, particularly relating to the patients' blood presSure,
renal function, and cardiovascular status, should be Investigated pnor to the
procedure. Because anti-coagulation is usually used, the presence of coagu-
lopathic conditions should be known, and evaluation of hemostatic funct,on
should be considered. Patients' allergies should be known, especially wrth
regards to contrast dye, protamlne, shellfish, and iodine. Previous expen-
ence with angiography should be inquired, as well as recent steroid use.
Patients who will undergo the procedure with mtravenous sedation shou'c
be capable of Iying supine an a hard, flat surface for a several hours, and risk
factors for aspiration should be Inquired. The possibihtv of pregnancy shOUld
oe investrqated in young female patients, In general pre-medication wlth
anxrolvt.cs should be avoided

Anesthetic Technique
Ihe choice of anesthetrc technique le; determined by the anesthesiolO-
gist, and there is little data to support that general anesthesia ar sedation
IS preferred. Most anestbcsroloqsrs and neuroradioloqrsts prefer a general
anesthetic for severa' reasons thts approach 15 more eomfortable for the
patient, there arrwav IS protected, the patient's rrnmobllitv wrll provlde 3
better Imagt' for the radiologist, and there IS tighter control of resp,ratory
and hemodynamic profile However, this must be weiqhed agalllst the rt~kS

----~----- --~-~ ,\cll/lllltari ;" ""t'slmt'

. "f
,II
J/r IlIlrn1tl,1
era]
 ntial hypertension and subsequent incre d :
f pote ' t b t' aSe Intracr '
o 'response to In u a Ion and extubation Adu'" anlal pressure
[Iep) In technique prevents the ability to asses~th Itlonally, a general an-
thetl c e patlent's '
e~ 109lcaistatus, Intraoperative
neuro I ' ,
eneral anest resta, propofol IS of ten lhe age t f '
For g be achi n o cholce f '
Maintenance can e achieved wrth either sev fi or Induc-
tlOn ' d ' o urane or isofl
Desfiuranebas been associate with increased cerebral blood fi urane,
oregulation, and more cerebral vasodilation in an' I OW, loss of
au t id d ' una studles, Nitr
ideis generally aVOI e because of risk of enlargement f mi ous
il OX ,,' f ", o micro air bub-
If esduringInJectlon o contrast
, ( or rrnqation fluid, For airw ay management
bl
d eI'thera laryngeal
, mask airwav LMA) or endotracheal tube (En) ,Intubatlon "
'Il isappropnate, 201
If conscious sedation is used, the patient should be comfortabl ',
fi' fusi ( y positi-
onedon the ta b Ie. A propo o In usron 10-20 Ilg/kg/min) is preferred b
manyanesthesiologists because it offe:s some degree of control when raPi~
le returnto consclousness and neuroloqical assessment is needed. The relati-
Ig velylllgh rate of upper airway obstruction with propofol use, hawever, must
:h beconsldered and a nasopharyngeal airway should be immediately availa-
s' bie,Alternatively, other agents, including dexmedetomidine, fentanyl, and
e, midazolam,can be administered and titrated to effect. Oxygen should be
le administeredcontinuously via nasal cannula, and oxygen saturation shauld
J- becontinuously monitored.
In TheINR suite should be prepared like any operating room, and should be
equippedfor general anesthesia and intubation, Emergency equipment far
cardmpulmonarv resuscltatron should be immediately available.

Intraoperative Monitoring and Considerations ,

Regardlessof the anesthetic technique used, the monitors used In the
INRsuite are the same as those used in the operating roorn. ,In, addltlo-
" b fui in achlev1t1gtlght
naI to standard monitors an arterial line can e use , d
h "d an osmotlc load an
emodynamlc control. Contrast medlum can pro uce 'd fluid
'cdd ta diuresis thus bladder catheterization is generally used to gUI eh Id
'li' C body temperature 5 ou
~nagement as well as for patient comfort. ore lded This is especially
le closely monitored, and hypothermla should be avolde, uIts In imaging
~portant when conscious sedation is used, as shlvenng resd xtension tu-
aegrad
, at'Ion, lntravascular access shou Id b e establ1shed '\ an nesthesiologist
e
een
Olngshould be used to maxirnize the distanCe betw t le 8
3nd the fluoroscopy unit t;lin an ~deqlla-
Thc ' rr is ta mam ' sure
t h goal of anesthesia In endovascular IA repa I erfllsion pres ,
e emod in cer rbra P
ynamlc profile and avoid decreases
Tm1 --~----
)O/lrl/2(J1J ~-
 · . I essure (Iep), and hemodyna .
Cerebral isehemia, inereased ,"traeran~h p; blood pressure should be momle
instability are intraoperatlve co~eerns. us, cologie control. ni.
tared closely and maintained wlth tlght pharma
After the initial angiogram is obtained via ihe femoral artery, a ?aseline
n
activated clotting time (ACT) is obtained and hepan (70 unlts/kg) IS admi.
nistered intravenously for a target ACT of two to three umes the baseline
level. Before embolization. the anatomy of t~e aneurysm sac IS carefully
examined with advanced 3-dimensional imag.lng, and decisions are made
with regards to the safety and feasibility of coll109 the aneurysm.

Intraoperative Complications . .
202 The two most frequent and devastating compllcatlons that occur dunng
endovascular treatment of lAs is hemorrhage (2.40f0) and thromboembollsm
to distant vessels (3.5%). The anesthesiologist's first priority should be Im·
mediate securlng of the airway and communication wlth the interventional
radiologist. If the problem is hemorrhage, heparin must be immediately dis-
contlOued and reversal with protamine should be administered intraveno-
usly (1 mg protarnme for each 100 units of heparin used, with an ACT after-
ward used for fine-tuning the dose). A ventriculostomy is usually performed
to decrease ICP. In the setting of vascular occlusion, the anesthesiologlst's
goal is to IOcrease perfusion by augmenting blood pressure with or without
thrombolysis.

Post-operative Care
Postoperatively, patients with successful embolization should be mou-
tored for neuroloqical cornplications and hemodynamic instability. Prompt
recoqrutron of SAH and neurological complications are vital in provlding
.mrnediate intervention and preventing additional morbiditv. Only rarelyan
eme-qent craniotomy IS necessary.
Recanalization of coiled aneurvsms is a siqruficant oostoperauve problem
Surface active and bioactive coils have been developed, but their efficaC'l
has yet to be determmed. Thus, follow-up angiography is recommendedfor
<lll coiled aneurvsms, usually at 6 months ano 2 years.