In the Name of Allah

Most Merciful Most

Compassionate
 Anaesthesia for Interventional
Neuroradiology

Sherif M El Hadi MD
Anaesthesia Department
Faculty of Medicine
Alexandria
Development of Interventional
Neuroradiology (INR)
n New imaging
technology
n Catheter systems
n Detachable balloons,
coils
n Vascular embolic
agents
 Method
n Digital road map is created
n Vascular system is imaged by
angiographic dye
n Projected onto a live fluoroscopy image
n Bone and soft tissue has been
subtracted (DSA)
n Accessed typically through the femoral
system
 Method
n Systemic heparinization
n Catheter system is advanced under
direct visualization into the
cerebrovascular system
n Superselective catheter advanced into
the vessels to be treated
 Indications of INR

n Selective occlusion
n Aneurysm ablation-GDC coiling
n Endovascular embolization of AVM
n Sclerotherapy of venous angiomas
 Indications of INR

n Selective increase in blood flow

n Balloon angioplasty
n Thrombolysis of acute stroke
n Carotid angioplasty with stent

n Arterial delivery:
n Chemotherapy or embolic in tumor
 Preoperative Assessment
n Allergies
n Contrast media reaction
5%-8% incidence of untoward
systemic reactions
n Allergies to Iodine and shellfish

n Protamine
 Preoperative Assessment
n Medications
n Anticoagulation
n Antihypertensive
n Anticonvulsants

n Blood sugar control

 Preoperative Assessment

n Cardiovascular and pulmonary

history
n Neurological history
n Physical exam
Impaired consciousness
favors General Anaesthesia
 Transportation
Guiding the medical management
of critical patients during transport
to and from the radiology suites
 Transport of Patient
Emergency Room

Radiology Suite Intensive Care Unit

Operating Theatre
 Anesthetic Objectives (1)
n Maintenance of patient immobility
and physiologic stability

n Manipulating systemic or regional

blood flow ..
 Anesthetic Objectives (2)
n Managing anticoagulation
n Treating and managing sudden
unexpected complications during the
procedure
n Rapid recovery from anesthesia to
facilitate neurological evaluation..
 Radiation exposure
n Exposure decreases proportionally to
the square of the distance from the
source of the radiation
n Digital subtraction angiography
(DSA) delivers more radiation than
fluoroscopy
n Optimal protection-apron, thyroid
shield, communication ..
 Anaesthetic Technique
Intravenous Sedation
n Goals are to alleviate
n Pain (introduction of contrast/prolonged
immobilization, distention or traction on
cerebral arteries)
n Anxiety (if high risk of bad outcome)
n Discomfort (prolonged immobility)
 Anaesthetic Technique
Intravenous Sedation (continued)
n Patient immobilty

n Rapid recovery to allow neurologic

examination
n Be prepared to secure the airway

n Various techniques, propofol infusion

..
Mild Sedation Moderate Deep Sedation

DANGER

Increasing sedative dose

 Dangers of IV sedation
n Poor control of the airway, potential:
•Hypoxia
•Hypercapnia
•Stertorous breathing and aspiration
n Side effects of IV sedatives
•Dysphoria
•Prolonged somnolence
•Extrapyramidal symptoms
 Benefits of IV sedation
n Techniques needing cooperation of
patient
n The Wada test before occlusion of a
vessel
General Anaesthesia
 Rationale for general
anesthesia
n Improved images
n Airway control in the supine position
n Induced hypotension facilitated
n Improved control of elevated ICP
n Augmentation of blood pressure with
occlusive disease
n Facilitating rescue operations
 Propofol
n No accumulation with prolonged use
TIVA – rapid BP control
n Antiemetic (short-lived)
n Inhibition of airway reflexes
n Permits SSEP and MEP monitoring.
CBF
Propofol

Propofol + hypocapnia

Zone of ischaemia
 Opioids
n Decreased CMRO2 (Max. 35%)
n Decreased CBF with higher doses
(Max. 50%)
n Depressed airway reflexes
n Autonomic tolerance to noxious
stimuli.
 Problems
n Muscle Rigidity
n Hypotension

n Increased ICP???
 Nitrous oxide:
Vacuolation of mitochondria and
cytoplasmic reticulum of posterior
cingulated gyri of rats after nitrous
oxide.
Jetovic-Todorovic. Nature 1998.
 Nitrous oxide:
n Thiopentone, isoflurane increase
survival time in mice if given before
exposure to ischaemia
n Nitrous oxide eliminates this
protective effect
n N2O alone decreases survival time.
 Nitrous oxide:
Protein synthesis:
n Cytoskeletal proteins damage

n ↑ Pro-apoptotic proteins when used

with isoflurane, midazolam and
ketamine.
 Halothane

CMRO2

Min. metabolic rate to

maintain membrane integrity

1 MAC 2 MAC 3 MAC

Concentration
Sevoflurane and Desflurane
n Speedier recovery than isoflurane
n Low solubility in blood and tissues
rapid recovery
n Desflurane increases BP and HR on
induction
Sevoflurane and Desflurane
Effect on ICP
Desflurane > isoflurane >
sevoflurane
BUT
Differences disappear with hyperventilation

Holmstrom A. J Neurosurg Anesthesiol. 2004

Intracranial aneurysm
ablation
Intracranial aneurysm ablation
Intracranial aneurysm
ablation
Intracranial aneurysm ablation
n Complications
n Distal thromboembolism
n Rupture
n Recurrence and hemorrhage
(incomplete obliteration)
n No guarantee the aneurysm is
removed from the circulation.
BP control essential
Seven coils to obliterate aneurysm
 Vasospasm
n Larger arteries: balloon angioplasty,
n Small arteries:
Intraarterial vasodilators
n Papaverine: hypotension, ↑ ICP,
worsened vasospasm, seizures
n Nimodipine (Biondi 2004)

n Nicardipine (Badjatia, 2004)

Effect of angioplasty on
spastic segment
 AV malformation
n Before surgical resection or solely
treated by embolization
n Factors leading to rupture:
n High feeding artery pressure
n Draining stenosis

n Potential risk of cerebral edema after

embolization of AVM
n Steroid pretreatment and fluid
restriction
 Carotid artery stenting
n Bradycardia and hypotension: 7%
(Mlekusch, 2004)
n Anticholinergic agents
n Prophylactic transvenous pacemaker
inserted
n Thromboembolism, dissection, TIA,
stroke
 Interventions
Deliberate Hypotension
n Indications
n Test cerebrovascular reserve in patients
undergoing carotid occlusion
n To slow flow in a feeding artery of brain
AVMs before cyanoacrylate injection
n Choice of agent at discretion of
attending
Determined by experience, patients
medical condition
 Interventions
Deliberate Hypertension
n Indications
n Arterial occlusion
n Vasospasm

n Augmentation of the collateral

perfusion pressure by increasing the
systemic blood pressure
 Crisis
Management
 Crisis Management
n Potentially rapid and life threatening

n Require effective communication between

anesthesia and radiology teams required

n headache, nausea, vomiting, localized vascular

pain, sudden LOC, seizures in awake patients
n sudden bradycardia, extravasation of contrast
in GA
 Crisis Management
n ABC
n Secure the airway if required
n Determine if the problem is:
-Hemorrhagic (immediate cessation of
anticoagulation, reversal with protamine or
platelets)
-Occlusive (increase distal perfusion by
increasing blood pressure with or without
direct thrombolysis
Postoperative Management
n Immediate postoperative period in
PACU or ICU
n Watch for signs of neurologic or
hemodynamic instability
n Blood pressure control may require
continuation
n Occasional requirement for CT scan
n Rarely a need for emergency
craniotomy
Thank
You