Durga Padmaja, Kinthala Sudhakar, Sahu Barada Prasad, Panigrahi Manas Kumar, Mantha Srinivas, Ramachandran Gopinath
Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
J Anaesthesiol Clin Pharmacol. 2014 Jul;30(3):345-50. doi: 10.4103/0970-9185.137265.
Anesthetic management of extracranial to intracranial (EC-IC) bypass for complex intracranial aneurysms is challenging as the goals involve balancing the cerebral perfusion during parent artery clamping and avoiding factors that predispose to rupture of the unsecured aneurysm. There is very sparse literature available on anesthetic management for this procedure.
A retrospective review of the records of 20 patients undergoing EC-IC bypass was performed with an objective of assessing the efficacy and outcomes of anesthetic management in the absence of advanced neurological monitoring.
A total of 20 patients underwent EC-IC bypass as an adjunct cerebral revascularization in the management of complex intracranial aneurysms. Intraoperatively normotension and normocarbia were maintained. During the EC-IC bypass, when the temporary clamp was applied, mild hypertension (increase from baseline by 20%) and hypervolemia (central venous pressure increased to 12 mmHg) were maintained. Cerebral protection during temporary clipping of intracranial vessel was provided using moderate hypothermia to 34°C and intravenous thiopentone. Temporary clip time ranged from 15 min to 54 min (mean-25 min). All patients except one were extubated post-operatively (19/20 = 95%). None of the patients had rupture of aneurysm in the peri-operative period. Three patients developed neurologic events (3/20 = 15%). One patient had cerebral vasospasm and two patients developed cerebral infarction. Two patient subsequently improved and one succumbed to the neurological deterioration (mortality 1/20 = 5%).
Adherence to the principal goals for the procedure, avoidance of hemodynamic fluctuations such as hypotension and hypertension, maintenance of normocarbia, and cerebral protection, result in favorable neurological outcome even in the absence of advanced neuromonitoring.
对于复杂颅内动脉瘤的颅外 - 颅内（EC - IC）搭桥手术，麻醉管理具有挑战性，因为目标是在夹闭供血动脉期间平衡脑灌注，并避免导致未处理动脉瘤破裂的因素。关于该手术麻醉管理的文献非常稀少。
对20例行EC - IC搭桥手术患者的记录进行回顾性分析，目的是评估在缺乏先进神经监测情况下麻醉管理的效果和结果。
共有20例患者接受EC - IC搭桥手术，作为复杂颅内动脉瘤治疗中的辅助性脑血运重建术。术中维持正常血压和正常碳酸血症。在EC - IC搭桥手术中，应用临时夹时，维持轻度高血压（较基线升高20%）和血容量过多（中心静脉压升至12 mmHg）。在颅内血管临时夹闭期间，通过将体温适度降至34°C和静脉注射硫喷妥钠提供脑保护。临时夹闭时间为15分钟至54分钟（平均25分钟）。除1例患者外，所有患者术后均拔除气管插管（19/20 = 95%）。围手术期无患者发生动脉瘤破裂。3例患者出现神经事件（3/20 = 15%）。1例患者发生脑血管痉挛，2例患者发生脑梗死。2例患者随后病情改善，1例患者因神经功能恶化死亡（死亡率1/20 = 5%）。
即使在没有先进神经监测的情况下，坚持该手术的主要目标，避免低血压和高血压等血流动力学波动，维持正常碳酸血症以及脑保护，可带来良好的神经学结局。
