Perioperative Management of Aneurysmal Subarachnoid Hemorrhage

Abstract

Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)

“…These recommendations, in addition to the reversal of anticoagulant drugs, are in accordance with previous recommendations [21,22]. In addition, any physician involved in the management of these should be aware of the strategies regarding the reversal of anticoagulation, also considering the increase in the utilization of novel oral anticoagulants (NOACs) [18,21]. The utilization of point-of-care (POC) tests (i.e., thromboelastometry (TEG) and rotational thromboelastography (ROTEM)), although not easily available (especially in peripheral hospital), can be useful to guide the reversal of these drugs [23].…”

“…Important ABP fluctuations can be dangerous after SAH. High values of ABP can increase the risk of rebleeding (by increasing transmural pressure), and low values can exacerbate secondary brain injury reducing CPP especially in case of intracranial hypertension [6,18,19]. Moreover, it is important to keep in mind that in case of chronic arterial hypertension, the cerebral autoregulation curve is shifted to the right [20], and these patients are more likely to experience cerebral hypoperfusion, especially in case of elevated ICP [10,20].…”

“…Coagulopathy can promote rebleeding [21]. Moreover, some SAH patients may be in therapy with antithrombotic and anticoagulant drugs for preexisting pathologies [18,21]. In this case, a PLT count greater than 100,000/ mm 3 (especially in patients needing neurosurgical intervention) as well as a PT/aPTT value < 1.5 the normal control seems to be reasonable to prevent complications.…”

The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery—a systematic review

“…[13,21] Nonetheless, supplemental medications to induce burst suppression may be advantageous in patients with inadequate collaterals and prolonged temporary clipping (longer than 10 min), provided hypotension from the bolus drug can be avoided. [69]…”

Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2020

“…28 A large multidisciplinary, international panel have recently presented a consensus statement of recommendations on determination of brain death and death by neurological criteria (the World Brain Death project). 29 Other reviews of interest include an excellent narrative review on the perioperative management of aneurysmal subarachnoid hemorrhage by Sharma 30 and a narrative review on the anesthesia and critical care providers' roles in the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic management for mechanical thrombectomy. 31 There is a recent update on the Guidelines for the Management of Severe Traumatic Brain Injury.…”