Craniotomy for intracranial aneurysm
Anesthesia type

General

Airway

ETT

Lines and access

PIV x2
Art line
±Central line

Monitors

Standard ASA
5-lead EKG
Core temp
UOP
ABG
±CVP
Neuromonitoring

Primary anesthetic considerations
Preoperative

Characterize neurologic deficits
Controlled hypotension

Intraoperative

Smooth induction
Controlled hypotension
Have adenosine available
Decrease CRMO2
Manage ICP

Postoperative

PONV

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A craniotomy for an intracranial aneurysm is a procedure performed to surgically treat intracranial aneurysms to prevent or manage rupture, which can be life-threatening.

Overview

Background

  • Intracranial aneurysms are defects of arterial walls which can occur at any of the major bifurcations of the Circle of Willis.
  • Most are treated endovascularly
  • The Hess and Hunt scale provides prognostic value based upon neuro exam findings:
Hunt-Hess Grading System for Aneurysmal Subarachnoid Hemorrhage[1]
Grade Description Mortality
I Asymptomatic, mild headache, slight neck stiffness 2%
II Moderate-to-severe headache, neck stiffness, no neurologic deficit (other than cranial nerve palsy) 5%
III Drowsiness, confusion, mild focal neurologic deficit 15-20%
IV Stupor, moderate-to-severe hemiparesis 30-40%
V Coma, decerebrate posturing 50-80%

Indications

  • Complex aneurysms which cannot be definitively treated endovascularly

Surgical procedure

  • The procedure is performed through a craniotomy
  • For cerebral aneurysms, approach is typically through the sylvian fissure to expose the circle of Willis
  • Aneurysms are treated using microsurgical clip ligation, which attempts to isolate defective aneurysmal wall and preserve flow through the vessel[1]

Preoperative management

Patient evaluation

System Considerations
Airway If acute, consider RSI
Neurologic Distinguish whether aneurysm has ruptured or not

Identify any neurologic deficits

Cardiovascular Evaluate baseline blood pressure

If ruptured:

  • May be treated with vasodilator to maintain controlled hypotension
  • May present with ST and T-wave changes, wall motion abnormalities, and elevated troponin[2]
    • Neurogenic stunned myocardium from catecholamines
    • May be misdiagnosed as ACS

Labs and studies

Operating room setup

Patient preparation and premedication

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

Induction and airway management

Positioning

Maintenance and surgical considerations

Emergence

Postoperative management

Disposition

Pain management

Potential complications

References

  1. 1.0 1.1 Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (6 ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404.CS1 maint: others (link)
  2. Ahmadian, A.; Mizzi, A.; Banasiak, M.; Downes, K.; Camporesi, E. M.; Thompson Sullebarger, J.; Vasan, R.; Mangar, D.; van Loveren, H. R.; Agazzi, S. (2013). "Cardiac manifestations of subarachnoid hemorrhage". Heart, Lung and Vessels. 5 (3): 168–178. ISSN 2282-8419. PMC 3848675. PMID 24364008.