Anesthesia for intracranial neurovascular procedures in adults
- Laurel E Moore, MD
Laurel E Moore, MD
- Clinical Associate Professor of Anesthesiology
- University of Michigan School of Medicine
- Magnus K Teig, BMedSc (Hons.), MBChB, MRCP, FRCA, EDIC, FFICM
Magnus K Teig, BMedSc (Hons.), MBChB, MRCP, FRCA, EDIC, FFICM
- Clinical Assistant Professor
- University of Michigan Department of Anesthesiology
- Vijaykumar Tarnal, MD, FRCA
Vijaykumar Tarnal, MD, FRCA
- Clinical Assistant Professor of Anesthesiology
- The University of Michigan School of Medicine
Intracranial vascular lesions are relatively common abnormalities that may require elective or emergent intervention. This topic will discuss anesthetic management for craniotomy for unruptured and ruptured intracranial aneurysm clipping, resection of arteriovenous malformations, extracranial-to-intracranial bypass procedures, and interventional radiologic treatment of intracranial neurovascular lesions.
Epidemiology, evaluation, and management of subarachnoid hemorrhage and the diagnosis and management of unruptured aneurysms and brain atriovenous malformations (AVMs) are discussed separately. (See "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage" and "Unruptured intracranial aneurysms" and "Brain arteriovenous malformations" and "Treatment of cerebral aneurysms".)
Intracranial aneurysms may be treated with clipping via craniotomy, endovascular intervention, or with a combination of surgical and endovascular techniques. (See "Treatment of cerebral aneurysms".)
Anesthesia for craniotomy is discussed more fully separately. (See "Anesthesia for craniotomy".)
The anesthetic concerns specific to craniotomy for aneurysm clipping are discussed here.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Sampson TR, Dhar R, Diringer MN. Factors associated with the development of anemia after subarachnoid hemorrhage. Neurocrit Care 2010; 12:4.
- Naidech AM, Drescher J, Ault ML, et al. Higher hemoglobin is associated with less cerebral infarction, poor outcome, and death after subarachnoid hemorrhage. Neurosurgery 2006; 59:775.
- Naidech AM, Shaibani A, Garg RK, et al. Prospective, randomized trial of higher goal hemoglobin after subarachnoid hemorrhage. Neurocrit Care 2010; 13:313.
- Diringer MN, Bleck TP, Claude Hemphill J 3rd, 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.
- Woertgen C, Rothoerl RD, Albert R, et al. Effects of temporary clipping during aneurysm surgery. Neurol Res 2008; 30:542.
- Hindman BJ, Bayman EO, Pfisterer WK, et al. No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial. Anesthesiology 2010; 112:86.
- Bebawy JF, Zeeni C, Sharma S, et al. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation does not worsen neurologic outcome. Anesth Analg 2013; 117:1205.
- Bendok BR, Gupta DK, Rahme RJ, et al. Adenosine for temporary flow arrest during intracranial aneurysm surgery: a single-center retrospective review. Neurosurgery 2011; 69:815.
- Guinn NR, McDonagh DL, Borel CO, et al. Adenosine-induced transient asystole for intracranial aneurysm surgery: a retrospective review. J Neurosurg Anesthesiol 2011; 23:35.
- Bebawy JF, Gupta DK, Bendok BR, et al. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile. Anesth Analg 2010; 110:1406.
- Luostarinen T, Takala RS, Niemi TT, et al. Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture. World Neurosurg 2010; 73:79.
- Kahn RA, Moskowitz DM, Marin ML, et al. Safety and efficacy of high-dose adenosine-induced asystole during endovascular AAA repair. J Endovasc Ther 2000; 7:292.
- Todd MM, Hindman BJ, Clarke WR, et al. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 2005; 352:135.
- Batjer H, Samson D. Intraoperative aneurysmal rupture: incidence, outcome, and suggestions for surgical management. Neurosurgery 1986; 18:701.
- Beatty RA. Intraoperative aneurysms rupture during the predissection stage. J Neurol Neurosurg Psychiatry 1990; 53:711.
- Tsementzis SA, Hitchcock ER. Outcome from "rescue clipping" of ruptured intracranial aneurysms during induction anaesthesia and endotracheal intubation. J Neurol Neurosurg Psychiatry 1985; 48:160.
- Taylor CL, Yuan Z, Selman WR, et al. Cerebral arterial aneurysm formation and rupture in 20,767 elderly patients: hypertension and other risk factors. J Neurosurg 1995; 83:812.
- Nahed BV, DiLuna ML, Morgan T, et al. Hypertension, age, and location predict rupture of small intracranial aneurysms. Neurosurgery 2005; 57:676.
- Elijovich L, Higashida RT, Lawton MT, et al. Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study. Stroke 2008; 39:1501.
- Tummala RP, Chu RM, Madison MT, et al. Outcomes after aneurysm rupture during endovascular coil embolization. Neurosurgery 2001; 49:1059.
- Miller C, Mirski M. Anesthesia considerations and intraoperative monitoring during surgery for arteriovenous malformations and dural arteriovenous fistulas. Neurosurg Clin N Am 2012; 23:153.
- Rangel-Castilla 2015
- Asouhidou I, Katsaridis V, Meng L, et al. Desaturation during Onyx embolization. Br J Anaesth 2010; 105:385.
- Wang H, Lv X, Jiang C, et al. Onyx migration in the endovascular management of intracranial dural arteriovenous fistulas. Interv Neuroradiol 2009; 15:301.
- Naik SS, Sudhir V, Arvinda HR, et al. Embolisation of pulmonary vasculature during endovascular therapy—a case report. Childs Nerv Syst 2015; 31:1607.
- Hashimoto T, Young WL, Aagaard BD, et al. Adenosine-induced ventricular asystole to induce transient profound systemic hypotension in patients undergoing endovascular therapy. Dose-response characteristics. Anesthesiology 2000; 93:998.
- van Rooij WJ, Sluzewski M, Beute GN. Brain AVM embolization with Onyx. AJNR Am J Neuroradiol 2007; 28:172.
- INTRACRANIAL ANEURYSMS
- Planning the anesthetic
- Anesthetic management for craniotomy for aneurysm
- - Preparation for anesthesia
- Preoperative evaluation
- Vasoactive medications
- Venous access
- Blood pressure goals
- - Premedication
- - Induction of anesthesia
- - Maintenance of anesthesia
- Stages of surgery
- - Skull pinning and incision
- - Dissection
- - Temporary clipping
- - Adenosine-induced temporary flow arrest
- - Post-aneurysm clip
- Glycemic management
- Temperature management
- Patient immobility
- Indocyanine green
- - Intraoperative aneurysm rupture
- Rupture with aneurysm exposed
- Rupture prior to aneurysm exposure
- - Emergence and postoperative care
- Endovascular therapy for intracranial aneurysm
- - Preparation for anesthesia
- - Induction and maintenance for endovascular therapy
- Anesthesia for vasospasm treatment
- BRAIN ARTERIOVENOUS MALFORMATIONS
- Normal perfusion pressure breakthrough
- Embolization for brain arteriovenous malformation
- EXTRACRANIAL-INTRACRANIAL BYPASS
- Extracranial-intracranial bypass procedures
- Anesthesia for extracranial-intracranial bypass
- SUMMARY AND RECOMMENDATIONS