Episode 113: Anesthesia for Aneurysm Clipping With Dave Mintz

In this 113th episode I welcome Dr. David Mintz back to the show to discuss anesthesia for intracranial aneurysm clipping.

References:

Chapter 13 Anesthetic management of cerebral aneurysm surgery in Cottrell and Young, Neuroanesthesia

https://www.ncbi.nlm.nih.gov/pubmed/25014255

2 Replies to “Episode 113: Anesthesia for Aneurysm Clipping With Dave Mintz”

  1. Great episode. I’ve enjoyed all of the aneurysm clippings I’ve done as a resident. They’re great cases. I just have a couple questions and comments:

    1) Would it be safe to say that Dr. Mintz values the very practical predictability of a volatile+nitrous+opiate anesthetic wakeup over the theoretical CMRO2/CBF advantages of a TIVA?

    2) At our institution, it is common practice to perform a burst suppression prior to temporary or permanent clipping. At first I thought that this was done just to titrate propofol dosing necessary reach burst suppression. More importantly, burst suppression can cause very unpredictable effects on SSEP monitoring. The burst suppression test allows the neuromonitoring provider to see the effects on SSEP’s so that they have a kind of burst suppression baseline. If burst suppression subsequently becomes necessary during clipping, they can then compare signals and better identify pathology.

    3) What is the incidence of seizures after elective clipping for non-ruptured aneurysms. I did a quick lit search and saw anywhere from 10-60%. I did a clipping last week, and my patient seized shortly after arrival to the ICU, despite no seizure history and having received Keppa 2g and fosphenytoin 2.5g for prophylaxis during the case. In talking to some of my colleagues, anecdotally seizure seems quite common.

    Thanks

    1. Great questions. Dr. Mintz’s answers are below:

      1. Absolutely correct.

      2. I think I may have forgotten to cover burst suppression test, and yes, the goal of the test is to establish the minimum dose necessary for burst suppression, which is disruptive both from an anesthetic and neuromonitoring perspective.

      3. Vascular intracranial neurosurgery is one of the highest risk scenarios for emergence seizures. I don’t know if there’s a really careful large scale study that quantifies the incidence and puts it in context with the prophylaxis that is commonly given, but both anecdotally and in smaller scale studies as well as textbook sources there’s general agreement that you need to be very alert to the possibility of seizures during and after emergence.

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