Management of Intraoperative Aneurysmal Rupture

Sudden rerupture of an aneurysm after aSAH occurs quite frequently (2-19%) (80-82) and presents a life-threatening emergency that requires immediate communication and very close cooperation between the surgeon and the anesthesiologist until the situation is resolved. The use of video monitors that transmit the surgical view to the anesthesiologist greatly facilitates management of this crisis. The time of rupture determines immediate treatment options, morbidity, mortality, and outcome prognosis, whether it happens during induction, prior to aneurysmal dissection, or during final clip application. The critical timepoint for rerupture is during induction of anesthesia, which accounts for only 7% of all perioperative aneurysmal ruptures (80,81). Clinical signs include abrupt and dramatic increase in blood pressure, sudden bradycardia, seizures, or signs of cerebral herniation. Surgery is frequently postponed to reestablish control over ICP and cerebral perfusion and to allow for a neurologic reevaluation. The prognosis is generally poor, although some institutions have reported more favorable outcomes with the so-called "rescue clipping" approach after aneurysmal rupture during induction of anesthesia (25).

Approximately half of all intraoperative ruptures (48%) occur during aneurysmal dissection, whereas 45% are associated with final clip placement when the aneurysm is fully exposed (80 ). As would be expected, bleeding does not influence outcome if it is controlled quickly. The surgeon may provide suction and apply a final clip to the neck of the aneurysm. Alternatively, the feeding arteries can be temporarily clipped to allow final aneurysmal clipping in a more controlled fashion. If an aneurysm reruptures before it is fully dissected, temporary clipping is not an option, and if the bleeding is massive, other means must be considered. The anesthetic goals are twofold: maintain adequate cerebral perfusion and facilitate fast surgical control. One option is to rapidly reduce MABP to 50 mmHg or lower, which might reduce bleeding, improve surgical orientation in the field, allow further dissection, and, ultimately, aneurysmal clipping. However, this maneuver poses the risk of cerebral ischemia and, therefore, could impair neurologic recovery more than would temporarily clipping the feeding arteries, which clearly is the preferred technique (59), because it allows prior administration of putative neuroprotective agents to limit neurologic damage, as explained above.

The situation is very different if blood loss is significant and hemodynamic stability is lost. Rapid fluid resuscitation and transfusion of blood products is indicated to restore adequate cerebral perfusion. Deliberate hypotension and administration of IV hypnotics for neuroprotection could further worsen cerebral perfusion and should be withheld until the intravascular volume is appropriately restored. If temporary clipping is applied to stop bleeding, vasoactive drugs should be used to attain normotension and allow for adequate collateral perfusion, especially in the presence of limited intravascular volume (80 ).

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