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LETTER TO EDITOR
Year : 2002  |  Volume : 48  |  Issue : 3  |  Page : 240-1

Anaesthetic management of clip ligation of ruptured intracranial aneurysm associated with coarctation of aorta.




Correspondence Address:
R Sherke


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Source of Support: None, Conflict of Interest: None


PMID: 12432210

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Keywords: Adult, Anesthesia, General, methods,Aneurysm, Ruptured, complications,diagnosis,surgery,Aortic Coarctation, complications,diagnosis,surgery,Case Report, Cerebral Hemorrhage, complications,diagnosis,surgery,Follow-Up Studies, Human, Intracranial Aneurysm, complications,diagnosis,surgery,Intubation, Intratracheal, methods,Ligation, methods,Male, Risk Assessment, Treatment Outcome, Vascular Surgical Procedures, methods,


How to cite this article:
Sherke R, Yemala R, Srinivas M, Panigrahi M. Anaesthetic management of clip ligation of ruptured intracranial aneurysm associated with coarctation of aorta. J Postgrad Med 2002;48:240

How to cite this URL:
Sherke R, Yemala R, Srinivas M, Panigrahi M. Anaesthetic management of clip ligation of ruptured intracranial aneurysm associated with coarctation of aorta. J Postgrad Med [serial online] 2002 [cited 2019 Dec 15];48:240. Available from: http://www.jpgmonline.com/text.asp?2002/48/3/240/91


Sir,

Two male patients aged 23 years (patient A) and 42 years (patient B) presented with intracranial hemorrhage with Hunt and Hess grade of IV. In the patient A, coarctation of aorta was suspected due to failure to negotiate the catheter across the thoracic aorta and was confirmed by duplex doppler ultrasonography. In patient B, suspicion of coarctation of aorta on echocardiography was confirmed by aortography. Four-vessel cerebral angiography revealed aneurysm at bifurcation of right middle cerebral artery in patient A and direct puncture carotid angiogram demonstrated basilar artery aneurysm in patient B.

Anaesthetic management was similar in both the cases except for delay of 1 month in patient B which was necessitated by treatment for pulmonary infection subsequent to prolonged ventilatory support. Premedication included fentanyl 1 ?g/kg- and glycopyrolate 0.01 mg/kg. After pre-oxygenation, induction of anaesthesia was done with thiopentone 5 mg/kg. Tracheal intubation was done after adequate muscle relaxation with Vecuronium 0.1 mg/kg in patient A and tracheostomy was used in patient B. Anaesthesia was maintained with 60% nitrous oxide in oxygen, 0.25%-0.5% isoflurane and vecuronium. Besides routine intra-operative monitoring, invasive blood pressure measurement in radial and dorsalis pedis arteries with estimation of hourly urinary output were undertaken to assess and ensure adequate tissue perfusion beyond the stenosed segment of aorta. These were especially done during controlled hypotension for 20 minutes with continuous nitroglycerine infusion. Mean arterial pressure (MAP) was between 50 and 60 mm Hg in the lower limbs and between 70 and 80 mmHg in the upper limbs. Gradient in MAP between the upper and lower limbs had decreased from 38 mmHg to 11.3 mmHg in patient A and from 36.7 mmHg to 14 mmHg in patient B.

Controlled hypotension endangers the circulation of vital organs distal to coarctation of aorta during management of intracranial aneurysm. Various modalities used to ensure the adequate circulation include invasive and noninvasive blood pressure monitoring in the lower limbs, invasive cardiac function monitoring, spinal somatosensory evoked potential (SSEP) and spinal CSF fluid pressure.[1],[2] However, such an extensive, sophisticated and expensive monitoring may not be available at most of the centers in the developing countries. In addition, these provide only minimal advantage over more physiological monitoring such as invasive or noninvasive monitoring of blood pressure in the lower limbs combined with estimation of hourly urinary output. We used this simple monitoring tool based on the fact that the MAP more than 50-60 mm Hg is sufficient to maintain renal autoregulation, and adequate spinal cord circulation and cerebral perfusion.[3],[4],[5]

Maintenance of urinary flow more than 1 ml/min/Kg during the perioperative period while maintaining the MAP in the lower limbs above 50-60 mmHg, should ensure adequate circulation in the kidneys and other vital organs including spinal cord distal to coarctation. MAP in the upper torso is guided by the decrease that can be achieved in the MAP in the lower torso beyond the stenotic segment of aorta. Decrease in the gradient in the MAP between the upper and lower limbs during controlled hypotension allows greater reduction in blood pressure in the upper torso with considerably less reduction in the blood flow to the lower limbs, thus decreasing the risk of ischemia beyond coarctation of aorta.[2]

 
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1.Orsi P, Rosa G, Liberatori G, Lunardi PP, Ferrante L. Repair of two unruptured intracranial aneurysms in the presence of coarctation of aorta anaesthetic implications and management. J Neurosurg Anesthesiol 1993;5:48-51.  Back to cited text no. 1    
2.Goodie DB, Rigg DL. Controlled hypotension for cerebral aneurysm surgery in the presence of severe aortic coarctation. Br J Anaesth 1991;67:329-31.  Back to cited text no. 2    
3.Hughes RK, Reemtsma K. Correction of coarctation of aorta: Manometric determination of safety during test occlusion. J Thorac Cardiovasc Surg 1971;62:31-3.  Back to cited text no. 3    
4.Dworkin LD, Brenner BM. The Renal Circulation. In: Brenner BM, Rector FC Jr, editors. The Kidney, 4th ed. Philadelphia: WB Saunders Company; 1991. p. 164-204.  Back to cited text no. 4    
5.Zhang P, Wang B, Wang E, Chen X. Preliminary study on controlled hypotension induced by nimodipine in craniocerebral surgery. Chin Med J 1995;108:420-22.  Back to cited text no. 5    



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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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