---

{}

---

Anaesthesia for Interventional Radiology

See Intracranial bleeds for full details, this notes serves as a practical case

Case Scenario

A 52-year-old woman presents to the emergency department with sudden onset of a “thunderclap” headache while at work. She describes it as the “worst headache of her life.” She also had a brief loss of consciousness and now reports neck stiffness and photophobia. Her blood pressure is 180/95 mmHg and GCS is 13. CT brain confirms a diffuse subarachnoid haemorrhage, and CTA shows a 7 mm aneurysm at the anterior communicating artery. She is scheduled for emergency surgical coiling.

Topic Overview: Subarachnoid Hemorrhage and Aneurysm Clipping

Subarachnoid hemorrhage (SAH) involves bleeding into the subarachnoid space, commonly due to rupture of a cerebral aneurysm. SAH is a neurosurgical emergency with high morbidity and mortality. The early period carries a high risk of rebleeding, and delayed complications like vasospasm, hydrocephalus, and delayed ischemic neurological deficits (DIND) are significant contributors to poor outcomes.

Management goals include:

• Stabilizing the patient and preventing rebleeding.
• Prompt securing of the aneurysm by surgical clipping or endovascular coiling.
• Minimizing secondary brain injury via neuroprotection and hemodynamic control.
• Grading systems such as WFNS, Hunt and Hess, and Fisher Grade help stratify risk and predict outcomes.

Buzz Words

1. Unsecured aneurism: Minimize rise in transmural pressure. SBP<160mmhg
2. Associated conditions: Pregnancy, Marfan, Alcohol, Smoking, PCKD, ACS
3. Complications
   • Neurological: DCI, Vasospasm, rebleed, seizures, hydrocephalus
   • Cardiorespiratory: Edema, neurogenic shock, ECG abnormalities
   • Other: SAIDH, High ANP (Low sodium), DVT, renal failure, GIT bleed
4. Unfamiliar environment
5. Neuroprotection

Structured Framework

A. Preoperative Management (CARPPH)

• C–Consent

  • Risks: Stroke, death, seizures, vasospasm, infection, bleeding, need for ICU care.
  • Anaesthetic risks: awareness, difficult airway, hemodynamic instability, ventilation support.
  • Discuss surgical alternatives (clipping vs coiling).

• A–Assessment

  • AMPLE:

    • Allergies: Contrast agents, anaesthetic drugs.
    • Medications: Nimodipine, antiepileptics, antihypertensives.
    • PMH: HTN, smoking, PKD, connective tissue disorders.
    • Last Meal: Emergency → full stomach precautions.
    • Events: Sudden headache, LOC, seizures.

  • Neurological: GCS, cranial nerve deficits.

  • Cardiopulmonary: TTE for LV function (neurogenic cardiomyopathy).

  • Labs: U&E, LFTs, coagulation, ABG, ECG.

• R–Risk Stratification

  • WFNS Grade, Fisher Grade, Hunt and Hess
  • Neurogenic pulmonary edema, ECG changes = ↑ periop cardiac risk.

• P–Pre-medication

  • Avoid sedation

• P–Post-op Planning

  • ICU admission mandatory.
  • Post-op CT brain if neurological deterioration.
  • Pain: Paracetamol ± opioids (avoid NSAIDs).
  • Monitor for vasospasm (TCDs), seizure prophylaxis (phenytoin).

• H–Help

  • Early involvement of neurosurgery, neurology, ICU, cardiology (if LV dysfunction), and radiology.

B. Intraoperative Management (PIER-FB)

• P–Positioning & Padding

  • Supine or lateral with head elevation.
  • Protect pressure points during prolonged surgery.

• I–IV Access & Monitoring

  • 2 large-bore IVs.
  • Arterial line for beat-to-beat BP control.
  • Central line (femoral preferred) for CVP/vasopressors.
  • BIS/NIRS/Neuromuscular monitor.

• E–Environment

  • OR ready for neuro-emergency.
  • Warm environment (avoid hypothermia unless neuroprotective).

• R–Readiness

  • Difficult airway cart, emergency drugs (labetalol, GTN, vasopressors).
  • Blood products available (risk of massive hemorrhage).

• F–Fluids & Electrolytes

  • 0.9% NaCl; avoid glucose-containing fluids.
  • Maintain normovolemia (CVP 8–10 mmHg). Normoglycemia

• B–Blood Management

  • Crossmatch.
  • ACT monitoring if heparin used.
  • Keep Hct ~30–35%.

C. Airway Management (CAPAV)

• C–C-Spine Stability: Not typically a concern unless trauma is involved.
• A–Aspiration Risk: Full stomach → RSI or modified RSI.
• P–Plan
  • Propofol for ICP control.
  • Rocuronium preferred over suxamethonium.
  • Remifentanil/fentanyl to blunt response.
• A–Apnoea Risk
  • High ICP risk → preoxygenate, minimize apnoea.
• V–Ventilation
  • Aim for normocapnia (PaCO₂ 35–40 mmHg)
  • Avoid hypercarbia or hypoxia.

D. Anaesthesia Strategy (HARPS)

• H–Hemodynamics
  • Avoid acute BP surges → risk of rupture.
  • Target: SBP <160 mmHg, MAP >85 mmHg.
  • Labetalol, GTN, esmolol for control; noradrenaline/dobutamine if needed.
• A–Anaesthesia & Analgesia
  • Goals: Smooth induction/extubation, brain relaxation, hemodynamic stability.
  • Volatile (MAC <1) or TIVA.
  • Fentanyl/Remifentanil for intraop analgesia.
  • Paracetamol post-op; avoid NSAIDs.
• R–Regional Anaesthesia
  • Not applicable.
• P–Pharmacokinetics
  • Adjust drugs if renal/hepatic impairment.

E. Critical Events

Complication	Timing	Prevention	Management
Rebleeding	Within 24h	Early aneurysm securing, BP control	Antihypertensives, surgical
Vasospasm	Day 4–14	Nimodipine, TCD monitoring	Triple-H, IA vasodilators
DIND	Day 3–14	Nimodipine	Same as vasospasm
Hydrocephalus	Early or late	Monitor GCS/CT	EVD, shunt
Seizures	Anytime	Levetiracetam/phenytoin	Benzodiazepines, AEDs
Cardiac stunning	Early	Supportive	Dobutamine, fluids
Pulmonary edema	Early	Manage ICP and sympathetic surge	Diuretics, O₂, ventilation
Hyponatremia (CSW)	Day 3–10	Monitor Na⁺	Na⁺ replacement, fludrocortisone
DVT	After 3–5 days	Mechanical prophylaxis	LMWH after 48–72h
Pneumonia	Post-intubation	VAP bundle	Empiric antibiotics
Contrast nephropathy	Post-angiogram	Hydration	Supportive, avoid nephrotoxins

Hyponatremia (Cerebral Salt Wasting)

• Mechanism: Excess ANP/BNP → natriuresis and hypovolemia.
• Differential: Differentiate from SIADH (CSW = hypovolemia; SIADH = euvolemia/hypervolemia).
• Management
  • Avoid fluid restriction.
  • Replace Na⁺ with 3% hypertonic saline if severe.
  • Consider fludrocortisone or salt tablets in refractory cases.

F. Vigilance & Prevention (CID)

• C–Complications
  • Vasospasm, seizures, rebleeding, hydrocephalus, infection.
• I–Infection Control
  • Cefazolin 2g IV 30–60 min pre-incision.
  • Aseptic technique, line care, ventilator bundles.
• D–DVT Prophylaxis
  • Mechanical: TEDs, pneumatic stockings.
  • LMWH >48h post-op if no bleeding.

G. Other Considerations (DSP)

• D–Devices
  • TCDs for vasospasm, NIRS for cerebral oximetry.
  • External ventricular drain if hydrocephalus.
• S–Self-Protection
  • Radiation shielding if fluoroscopy used (coiling).
  • Ergonomics for long surgeries.
• P–Post-op Follow-up
  • ICU monitoring for 24–72h.
  • Repeat CT if neurological deterioration.
  • Continue nimodipine for 21 days.
  • Daily electrolyte, fluid, and BP monitoring.

Topic Summary

Subarachnoid hemorrhage (SAH) due to aneurysmal rupture requires prompt multidisciplinary intervention. Early intubation is critical in poor GCS or raised ICP. Surgical clipping is preferred when coiling is contraindicated due to aneurysm anatomy. The anaesthetic strategy is aimed at preventing rebleed, optimizing cerebral perfusion, and avoiding secondary injury. Induction must be smooth and controlled, suxamethonium is avoided if ICP is a concern, and BP must be tightly regulated throughout. ICU care postoperatively is essential for neurological monitoring, vasospasm prevention, and managing systemic complications like pulmonary edema, seizures, and hyponatremia. Prevention of vasospasm with nimodipine and careful attention to cerebral protection principles are crucial to optimizing outcomes.

Links

• Remote anaesthesia
• Neuroprotection
• Neurosurgery and Anaesthesia
• Intracranial bleeds
• Stroke
• Spine surgery
• Cath lab anaesthesia
• Carotid Endarterectomy (CEA)
• Neurophysiology

---

---

References:

1. Part Anaesthesia Refresher Course2015 University of Cape Town Anaesthesia for interventional neuroradiology /neuroendovascular procedures Dr Anthony Reed
2. Moss, C. and Wilson, S. (2014). Subarachnoid haemorrhage and anaesthesia for neurovascular surgery. Anaesthesia &Amp; Intensive Care Medicine, 15(4), 181-184. https://doi.org/10.1016/j.mpaic.2014.01.022
3. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
4. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/

Summaries:
Interventional Neuro

---

---

Copyright
© 2025 Francois Uys. All Rights Reserved.

id: “53583489-5ecb-41c3-a1d2-d1ca498d87e2”