Intracranial aneurysms larger than 25 mm in diameter are conventionally classified as a giant aneurysm and these comprise 2~5% of all intracranial aneurysms. During the perioperative management, the role of anesthesilolgists should minimize hemodynamic stress to prevent the aneurysmal rupture and maintain the optimal condition for the operation using vasoactive drugs and/or its adjuvants.
CASE: A 50-year-old woman was admitted to neurosurgical ward because of severe headache, dysarthria and left hemiparesis. Preoperative four-vessel angiography and computed tomography(CT) scan revealed a giant aneurysm (3.1 2.3 2.5 cm) located in the bifurcation of the righr middle cerebral artery(MCA). Premedication was performed with glycopyrrolate 1 hour before anesthesia. Midazolam was given intravenousely before placement of arterial and central venous catheters. Anesthesia was induced with lidocaine and fentanyl followed by propofol. Vecuronium was administered in order to obtain muscle relaxation. Mask ventilation to normocarbia(assessd by PETCO2) was started and then trachea was intubated with no blood pressure(BP) changes. Anesthesia was maintained by isoflurane N2O O2. Heart rate, pulse oxymetry, capnography and invasive arterial blood pressure were monitored. When the craniectomy was finished, mannitol was started and PaCO2 was gradually reduced to 30mmHg. After middle cerebral artery was identified, the concentration of isoflurane was increased to reduce the mean aretrial BP. When temporary clip was placed on the MCA, a first volus(3.0 mg/kg) of thiopental sodium was administered intravenously and then second bolus(100~200 mg) were given before multiple clipping of giant aneurysm. After aneurysm was clipped, isofurane concentration was reduced and hetastarch and isotonis saline solution were given to increase BP. No more anesthetics were given during closure, but esmolol was used to maintain a systolic BP of<140 mmHg. Postoperative investigations, which included CT scan of the brain and electroencephalography, did not demonstrate any abnormality. On the 25th postoperative day the patient was discharged from hospital with consciousness, stable hemodynamics and without neurological sequelae.
SUMMARY: Multiple neck clippinng is often effective in the management of giant aneurysm, but occasionally cause a catastrophic aneurysmal rupture and subarachnoid hemorrhage. Therefore anesthesiologists should maintain the hemodynamic stability to prevent the aneurysmal rupture perioperatively by using optimal vasoactive drugs.
|