Anesthésie pour chirurgie vasculaire cérébrale anévrismale [Anesthesia in surgery for intracranial aneurysms]

Détails

ID Serval
serval:BIB_B27B7A23519D
Type
Article: article d'un périodique ou d'un magazine.
Sous-type
Synthèse (review): revue aussi complète que possible des connaissances sur un sujet, rédigée à partir de l'analyse exhaustive des travaux publiés.
Collection
Publications
Titre
Anesthésie pour chirurgie vasculaire cérébrale anévrismale [Anesthesia in surgery for intracranial aneurysms]
Périodique
Annales Françaises d'Anesthésie et de Réanimation
Auteur(s)
Bruder N., Ravussin P., Young W.L., François G.
ISSN
0750-7658
Statut éditorial
Publié
Date de publication
1994
Peer-reviewed
Oui
Volume
13
Numéro
2
Pages
209-220
Langue
français
Notes
Publication types: English Abstract ; Journal Article ; Review
Résumé
The two major neurological complications of subarachnoid haemorrhage (SAH) due to an intracranial aneurysm are rebleeding and delayed cerebral ischaemia related to cerebral vasospasm. The best way to prevent rebleeding is early surgery. Even when surgery is performed within the first 72 hours posthaemorrhage, the risk of cerebral ischaemia due to vasospasm is high. Conventional medical treatment of cerebral vasospasm includes haemodilution, hypervolaemia and increase of arterial blood pressure. Haemodilution is of limited value as the patients suffering from SAH have usually a low haematocrit. The effectiveness of hypervolaemia is controversial and it may worsen cerebral and pulmonary oedema. Systemic hypertension is an effective therapy of vasospasm, but which can only be used once the aneurysm is controlled. Nimodipine and nicardipine, two calcium antagonists, have a beneficial effect on neurologic outcome following SAH. Today, it is still debated whether the beneficial effect of nimodipine results from the vascular effect of the drug or from a direct cerebral cytoprotective mechanism. Early surgery implies that surgeons operate on brains in acute inflammatory state. Thus, it is mandatory to use peroperative techniques improving cerebral exposure. These techniques include infusion of mannitol, lumbar cerebrospinal fluid (CSF) drainage, administration of anaesthetic agents known to decrease cerebral blood flow (CBF) and hypocapnia. Usually, the effect of CSF drainage is very effective and sufficient by itself. The second objective in the peroperative period is to avoid ischaemia. In areas with decreased flow distal to vasospasm, autoregulation is impaired and CBF is directly dependent on cerebral perfusion pressure. Furthermore, the safe practice of transient clipping of vessels supplying the aneurysm has dramatically reduced the indications of controlled hypotension. During temporary clipping, some authors recommend a pharmacological brain protection using barbiturates, etomidate or propofol, but this practice has not been validated by randomized studies. However, it is generally agreed that the arterial pressure should be increased during temporary clipping to improve collateral blood flow and to maintain it after the aneurysm has been secured. To conclude, together with lumbar CSF drainage and transient clipping, the anaesthetic management of the patients should include: maintenance of the arterial blood pressure close to its preoperative level, maintenance of PaCO2 between 30 and 35 mmHg and of normovolaemia through replacement of fluid and blood losses. After completion of surgery, recovery from anaesthesia should be rapid to allow fast diagnosis of neurological complications. The monitoring of the status of consciousness is the key of the diagnosis of early postoperative complications.
Mots-clé
Anesthesia, General/methods, Anesthetics/pharmacology, Cerebrovascular Circulation/drug effects, Glasgow Coma Scale, Humans, Intracranial Aneurysm/complications, Intracranial Aneurysm/surgery, Monitoring, Intraoperative, Spasm/etiology, Spasm/physiopathology, Subarachnoid Hemorrhage/etiology, Subarachnoid Hemorrhage/physiopathology, Time Factors
Pubmed
Web of science
Création de la notice
17/01/2008 17:19
Dernière modification de la notice
03/03/2018 20:38
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