BASILAR ARTERY ANEURYSM COILING UNDER

GENERAL ANESTHESIA
Dr P Deepak1, Dr Maya G2, Dr Ushakumari 3, Dr Chithra V3
1. Resident, 2. HOD, 3. Assosciate Prof
Department of Anesthesiology, Government Medical College, Thiruvananthapuram

INTRODUCTION: Case Profile ANESTHETIC MANAGEMENT DISCUSSION

• 67 yrs/Male k/c/o Hypertension, Diabetes,
Dyslipidemia, well controlled
• h/o acute onset altered sensorium, releived after 1
day  2 episodes 6 months ago
• Was evaluated and found to have a basilar artery
aneurysm
• Currently asymptomatic
• Ht: 160 cm, Wt: 95 kg BMI: 37.1 kg/m2
• o/e, E4V5M6,
BP: 140/90mm of Hg, HR: 65/min
systemic examination normal
• Airway: MO 3 fingers, MPC III, Limited neck
extension , TMJ, Spine: Normal
• CT Angiogram: inferior portion of the basilar artery
appears fenestrated for a length of 1.2 cm, wide neck
saccular aneurysm out-pouching is seen arising from
the inferior end projecting superomedial into the
region of fenestration with a size of 4.4x 4.1 mm with
dome neck ratio 0.82
• Pre op sugars, Renal Function and electrolytes within
normal limits
Fenestrated basilar artery aneurysm Post coiling check angio
• Procedure: Stent Assisted Aneurysm Coiling
Anesthetic Concerns
• Anesthetic Plan: General Anesthesia with Controlled • Remote location ( all concerns of NORA)
Ventilation with COETT ID- 8.0mm • Risk of Aneurysmal rupture secondary to
• O2 supply checked, Machine Checkout done, Difficult airway
hemodynamic changes
equipent and suction kept ready, drugs loaded and • Difficult Airway
labelled, • Stress response to Laryngoscopy, Intubation and
resuscitation equiment kept ready
Extubation
• Rotating C-Arm moved to the foot end of bed
• Managing Anticoagulation
• Patient brought to IR Suite and monitors attatched
• High chance of anaphylaxs and perioperative AKI
• Pre Induction Monitors: ECG, SpO2, NIBP
due to contrast administration
• 2 wide bore IV lines secured and venous extensions
• Risk of intraprocedural hemorrhage
connected
• Radiation risk to personnel
• Premedication: Inj Midazolam 1.2 mg + Inj Ondansetron 4
mg
Anesthetic Goals
+ Inj Fentanyl 150 mcg + Inj Glycopyrrolate 0.2 mg iv
• Continuous BP monitoring and Avoiding sudden
• Induction: Inj Thiopentone 300 mg iv+ Inj Succinyl Choline 100
changes in BP
mg iv •
Blunting stress response to airway manipulation
• Airway: VLS COETT ID 8.0mm , cuffed and fixed, Stress
• Securing airway
response of Laryngoscopy blunted with Inj Lignocaine 90 mg •
Facilitating absolute stillness to allow correct
given 90 sec before scopy, connected to ventilator with
guidance of sheath
tubings of adequate length •
Prophylactic steroids prior to dye injection
• Post Induction Monitors: IBP via Left Radial arterial
• Adequate hydration and urine output
Catheter,
monitoring
EtCO2,, urine output and pre induction monitors
• Fast reversal and return of Muscle power to
• Maintenance: O2+Air 1:1 with Sevoflurane titrated to BP, HR +
facilitate neurological evaluation
Inj Vecuronium 6mg followed by 1.2mg boluses every 20
minutes+ Inj Dexmedetomidine 30 mcg/hr , IVF RL
• Intra procedural events: Inj UFH 5000 IU iv given Arterial
access through Right Femoral artery apnea maintained
REFERENCES
during advancements of sheath through aorta Inj 1. Lee CZ, Gelb AW. Anesthesia management for endovascular
Hydrocortisone 120 mg iv given before first injection of dye treatment. Curr Opin Anaesthesiol. 2014 Oct;27(5):484-8. doi:
10.1097/ACO.0000000000000103. PMID: 25014255.
procedure completed in 2 hours  Inj Protamine 50 mg slow 2. De Sloovere VT. Anesthesia for embolization of cerebral
iv infusion aneurysms. Curr Opin Anaesthesiol. 2014 Aug;27(4):431-6. doi:
• Extubation: Once spontaneous breathing efforts appeared, 10.1097/ACO.0000000000000096. PMID: 24979068.
Reversed with Inj Neostigmine 3.5 mg + Inj Glycopyrrolate 0.6
mg iv, extubated with suction, BP maintained with Inj Esmolol