PERIOPERATIVE MANAGEMENT OF INTRACRANIAL VASCULAR SURGERY

Abstract

Perioperative management of intracranial anemysm requires understanding of the blood supply to the brain , the physiologic background of cerebral dynamic and the pathology and pathophysiology of intracranial anemysms .

Rupture of intracranial anemysm results in injection of blood into the subarachnoid space and increase in the intracranial pressure .complications include cerebral edema , diffuse cerebral ischemia , cerebral arterial vasospasm , hydrocephalus and rebleeding .

The aim of premedication is to provide adequate sedation and prevent catastrophic fluctuation in blood pressure that might lead to anemysmal rupture during surgery , however , profound hypotension should be avoided as lower limit of autoregulation to induce cerebral ischemia or infraction . Hence drugs that do not change cerebral blood flow during aneurysm surgery should be used to induce hypotension .

Current prophylaxis for vasospasm is the preoperative administration of nirnodipine which requires attention to fluid and electrolyte balance .

Induction of anesthesia is carried out with pentothal or propofol , fentanyl or sufentanial , muscle relaxant ( vecuronium or atracurium ) and I 00% oxygen . Maintenance is based on - air oxygen or nitrous oxide-oxygen , fentanyl or sufentanil and muscle relaxant with or without low doses Of isoflurane .

lntraoprative precise control of blood pressure is essential induced hyotension may be used to facilitate surgical conditions .

Alternatively , may neurosurgeons prefer the use of temporary proximal occlusion of the parent vessel . Cerebral protection therapy may be instituted against focal cerebral ischemia when prolonged intracranial vessel occlusion is encountered .

The anesthesiologist's responsibility should extend to the intensive care unit, management of recovery problems , continued monitoring for detection , prevention and management of complications that may occur in the postoperative period.