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Aneurysm coiling

Aneurysm coiling

Learning objectives

  • Describe the mechanisms of aneurysms and hemorrhage
  • Describe the risk factors for aneurysms
  • Recognize and treat aneurysmal hemorrhage
  • Manage patients undergoing endovascular coiling

Definition & mechanisms

  • Stroke is the second leading cause of death and the third most common cause of disability worldwide
  • Hemorrhagic strokes account for about 32% of all strokes globally and can be caused by subarachnoid hemorrhage or intracerebral hemorrhage
  • Most spontaneous (nontraumatic) subarachnoid hemorrhages are caused by ruptured saccular aneurysms
  • Intracranial aneurysms are estimated to occur with a prevalence of 3.2% in the general population
  • Aneurysmal subarachnoid hemorrhage accounts for approximately 5% of strokes and is caused by the rupture of an intracranial aneurysm, an acquired focal abnormal dilation of an arterial wall

Aneurysm risk factors 

  • Smoking
  • Hypertension
  • Connective tissue disorders
  • Autosomal dominant polycystic kidney disease
  • Ehlers–Danlos syndrome type IV
  • Neurofibromatosis type 1
  • Marfan syndrome 
  • Coarctation of the aorta
  • Genetic predisposition

Hemorrhage: Signs & symptoms

  • Sudden onset of “worst headache of life”
  • Loss of consciousness
  • Nausea and/or vomiting
  • Nuchal rigidity
  • Photophobia
  • Seizure

Hemorrhage treatment

  • Immediate management: Directed at stabilizing life-threatening conditions, minimizing neurologic injury, optimizing physiology and planning definitive care
    • Ensure a patent airway and adequate oxygenation and ventilation
    • External ventricular drain 
    • Control acute hypertension 
    • Control of headache with analgesics, anxiolysis, and bed rest
    • Stop and reverse anticoagulant therapy
    • Administer nimodipine (60mg orally or by nasogastric tube every 4h, starting within 48h of hemorrhage and continued for 21 days)
  • Definitive care
    • Surgical clipping or endovascular coiling

Endovascular coiling: Anesthetic management

aneurysm coiling, endovascular, hemorrhage, ecg, hyperglycemia, insulin, hypovolemia, electrolyte, arterial line, pacing, defibrillator, rebleeding, cerebral perfusion, brain swelling, immobility, hypertension, hypotension, depth, intubation, laryngoscopy, hypocarbia, hypercarbia, external ventricular drain, ICP, CPP, jugular oximetry, EEg, propofol, remifentanil, sevoflurane, ketamine, dexmedetomidine,

ICP, intracranial pressure; CPP, cerebral perfusion pressure

Keep in mind

  • The optimal anesthetic technique depends on patient characteristics, severity of the aneurysm, and monitoring

Suggested reading

  • Deepak Sharma; Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology 2020; 133:1283–1305
  • Campos JK, Lien BV, Wang AS, Lin LM. Advances in endovascular aneurysm management: coiling and adjunctive devices. Stroke Vasc Neurol. 2020;5(1):14-21. Published 2020 Mar 15.
  • Abd-Elsayed AA, Wehby AS, Farag E. Anesthetic management of patients with intracranial aneurysms. Ochsner J. 2014;14(3):418-425.

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