Concerns and challenges during anesthetic management of aneurysmal subarachnoid hemorrhage

Abstract

Anesthetic management of patients with aneurysmal subarachnoid hemorrhage is challenging because of the emergency nature of the presentation, complex pathology, varied intracranial and systemic manifestations and need for special requirements during the course of management. Successful perioperative outcome depends on overcoming these challenges by thorough understanding of pathophysiology of Subarachnoid hemorrhage, knowledge about associated complications, preoperative optimization, choice of definitive therapy, a good anesthetic and surgical technique, vigilant monitoring and optimal postoperative care. Guidelines based on randomized studies and provided by various societies are helpful in the routine management of these patients and wherever there is a lack of high quality evidence, the available data is provided for practical management.

Anesthetic Management of Left Ventricular Assist Device Exchange in a Patient with Intracranial Hemorrhage

“…In patients with intracranial hemorrhage, major precautions that need to be taken include soft intubation, avoidance of hyper/hypotension, mild hyperventilation, head elevation, and avoidance of high concentrations of inhalation agents and nitrous oxide in order not to increase intracranial pressure. 5 We preferred ECMO support to maintain low intracranial pressure in our patient by preventing hypoventilation and hypercarbia, treated his hypotension with inotropic agents, and performed soft intubation. Additionally, we administered an osmotic diuretic agent (2 mg/kg of 20% mannitol intravenously) to increase the intracranial pressure reduction.…”

“…The monitorization of the bispectral index helps to protect cerebral autoregulation by allowing adjustment for adequate blood pressure and anesthetic drug titration. 5 We, therefore, opted for midazolam and ketamine in our patient for the induction and maintenance of anesthesia to ensure adequate anesthesia depth (bispectral index value = 40–50) and to avoid hemodynamic lability. We also tried to reduce the intracranial pressure-enhancing effect of ketamine by providing low-dose use with anesthesia depth control and the combination with midazolam and fentanyl.…”

“…Although there is no clinically relevant evidence, pharmacological protective agents (thiopental and etomidate) are recommended in ischemia. 5 Hence, we aimed to use thiopental for cerebral protection, especially in the period when our patient’s NIRS values were reduced. We also administered corticosteroids during the prolonged hypotension periods as is suggested in the literature.…”

“…We also administered corticosteroids during the prolonged hypotension periods as is suggested in the literature. 5 It is known that steroids have many adverse effects including hyperglycemia, but they decrease the proinflammatory response, act as an antioxidant in the ischemic tissue, and allow the regulation of serum sodium and plasma osmolarity. 7 …”

Aneurysmal Subarachnoid Hemorrhage

“…These ECG changes may be attributed to a primary cardiac problem rather than an underlying acute SAH when the patient is initially seen in the emergency room, and there is thus a danger that the diagnosis of SAH will be overlooked (15, 16, e24). Excessively elevated catecholamine secretion after acute SAH can also cause pulmonary hypertension and pulmonary edema, leading to increased mortality (14)(15)(16).…”