Three Interesting Case Reports of Intracranial Aneurysm Managed with Triple H Therapy

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1 472 Case Report Three Interesting Case Reports of Intracranial Aneurysm Managed with Triple H Therapy L. F. Vali, Associate Professor, Dept. of Cardiac and Neuro Anaesthesiology, Sonali Khobragade, Assistant Professor, Dept. of Cardiac and Neuro Anaesthesiology, Pramod Giri, Assistant Professor, Dept. of Neurosurgery Superspeciality Hospital & Government Medical College, Nagpur. Abstract Anaesthesia for aneurysm surgeries is highly specialized and unique. Vasospasm is the most important determinant for morbidity and mortality in intracranial aneurysms. For prevention and management of vasospasm Triple-H therapy (Hypertension, Hypervolemia and Haemodilution) is recommended. Triple-H therapy is gold standard in neuroanaesthesia in intracranial aneurysm surgeries in order to increase cerebral blood flow in areas affected by vasospasm and avoid damage caused by ischemia. First patient was 52 years old female with Right vertebral artery posterior inferior cerebellar artery aneurysm of size 1cm, operated successfully who became unconscious 22 hours after surgery and treated with Triple-H therapy for vasospasm. Second case was 48 years old male patient of right anterior cerebral artery aneurysm of 9mm size operated successfully after intraoperative rupture of aneurysm and subsequent vasospasm. Third case was 35 years pregnant female patient of anterior communicating artery aneurysm of 5mm size treated with triple H therapy for vasospasm. Keywords intracranial aneurysm, triple H therapy, vasospasm Introduction An aneurysm is the disease of the vessel caused by abnormal dialatation due to weakness in the elastic layer of the artery. Although etiology is originally congenital they can develop subsequently due to degenerative changes in the wall of vessels associated with hypertension. The rupture of aneurysm is the most common cause of Subarachnoid Hemorrhage (SAH), with an annual frequency of cases per 1,00,000 people. Vasospasm is most important cause of morbidity and mortality after subarachnoid hemorrhage. Thus prevention and treatment of vasospasm is one of the most important consideration in patients with subarachnoid hemorrhage. Vasospasm hampers blood supply to the vital cerebral tissue. Hence, Triple H therapy consisting of hypervolemia, hypertension and haemodilution is recommended. Triple H therapy increases cerebral blood flow in cerebral areas affected by vasospasm and avoid ischemic damage. Thus, anaesthesia for intracranial aneurysm surgeries along with management of vasospasm is a challenging job for an anaesthesiologist. Case 1 A 52 years old female patient presented with headache, vomiting, generalized tonic clonic convulsions and visual field defect. Computerized Axial Tomography( CAT-Scan) was suggestive of subarachnoid hemorrhage. MRI angiography was suggestive of right vertebral artery Address for correspondence: Dr. L. F. Vali, Villa Ruqaiyah, 272, Nelson Square, Near Marina Residency, Chaoni, Nagpur lulu_fatema@gmail.com

2 473 Fig. 1 Right Vertebral Artery Posterior Inferior Cerebellar Artery Aneurysm (Unclipped) of size 1 cm. posterior inferior cerebellar artery aneurysm of size 1cm (Fig. 1 & Fig. 2). Patient was known hypertensive taking Tablet Atenolol 50mg once daily. Tablet Nimodipine was started on admission. On the day of surgery, patient received morning dose of anti- hypertensive with sips of water. After attaching electrocardiography (ECG) monitor, non invasive blood pressure (NIBP)cuff and SPO2 probe, a peripheral venous access was secured. Patient was pre-medicated with Fig. 2 Right Vertebral Artery Posterior Inferior Cerebellar Artery Aneurysm (Clipped) of size 1 cm. intravenous (IV) pantoprazole 40 mg, IV glycopyrrolate 0.2 mg, IV dexamethasone 8 mg, IV fentanyl 50 mcg and IV midazolam 1mg. Left radial artery cannulated for invasive blood pressure monitoring and right internal jugular vein cannulated for central venous pressure (CVP) monitoring under local anaesthesia. After adequate preoxygenation trachea was intubated with flexometallic cuffed tube No Intubation was facilitated with IV thiopentone 5 mg/kg, IV fentanyl 5mcg/kg and IV vecuronium 0.2mg/ kg. IV lignocaine 1.5mg/kg was given to attenuate the response to laryngoscopy and intubation. Anaesthesia was maintained with O 2, sevoflurane (1-2%), top ups of vecuronium for muscle relaxation and titrated doses of fentanyl for adequate analgesia during surgery. During positioning adequate depth of anesthesia was ensured avoiding hyperflexion or extreme rotation of neck and obstruction of neck veins with adequate padding of pressure points. Brain bulk reduction was done by administering IV mannitol 1 gm/kg, IV furosemide mg/kg, 50 mg bolus of thiopentone and maintaining PaCO 2 between 30 to 35 mmhg. Intraoperatively heart rate, systolic and diastolic blood pressure, central venous pressure, SPO2, endtidalcarbondioxide (ETCO 2 ), temperature, urine output, blood sugar, arterial blood gas (ABG) and electrolytes were monitored meticulously. Blood loss was replaced adequately with blood transfusion. After clipping of aneurysm IV papavarine 30 mg was given. After completion of surgery, patient was reversed with IV neostigmine and glycopyrrolate and extubated by giving IV lignocaine 1.5 mg/kg to blunt the hemodynamic response to tracheal extubation. Post operatively patient was shifted to high dependency unit. After 22 hours of surgery, patient became unconscious. Transcranial Doppler with blood flow velocities 10 and repeat angiography showed adequate clipping of posterior inferior cerebellar artery aneurysm with vasospasm. Triple H Therapy was instituted by maintaining systolic BP between mmhg, diastolic BP between 80 to 90 mmhg, CVP between mm Hg and haematocrit between 30-35%. Subsequently patient gained consciousness with smooth recovery and shifted to ward after 7 days. Case 2 A 48 years old male patient presented with headache, convulsions and altered level of consciousness. CT scan was suggestive of subarachnoid hemorrhage (Fig. 3).Magnetic Resonance Imaging(MRI) angiography was suggestive of right anterior cerebral artery aneurysm

3 474 Fig. 3 Subarachnoid Hemorrhage associated with Aneurysm rupture. of 9mm in size. Tab. Nimodipine was started on admission. Induction of Anaesthesia, monitoring and maintenance of anaesthesia was similar to the first case. During dissection of aneurysm, there was excessive bleeding due to rupture of aneurysm. Patient s peripheral pulses disappeared & blood pressure (B.P.) was 45/29 mm Hg. Patient was immediately resuscitated with IV mephentermine 6 mg and rapid injection of blood, colloid and crystalloids. Vasopressors IV epinephrine(0.1mcg/kg/min) and IV norepinephrine (0.05mcg/kg/min) were started in infusion. Neurosurgeon identified the site of aneurysm rupture and clipped it. ABG analysis revealed acidosis. Metabolic acidosis was corrected by giving IV sodium bicarbonate. Blood flow velocities was measured with Transcranial Doppler intraoperatively from the temporal region suggesting of vasospasm and Triple H therapy was instituted to maintain SBP and DBP 80-90mm Hg to treat and prevent vasospasm. Post operatively after achieving haemodynamic stability, patient was shifted to high dependency unit for continuous monitoring and mechanical ventilation. After adequate gain of consciousness and reversal from muscle relaxant, patient was extubated. Postoperative recovery was uneventful. Case 3 A 35 years old, 24 weeks pregnant female patient presented with severe headache, nuchal rigidity, vomiting, diplopia, generalized tonic clonic convulsions with cranial nerve palsy. CT scan revealed subarachnoid hemorrhage Fig. 4 Anterior Communicating Artery Aneurysm (Unclipped) of size 5 mm. with sign of rupture of aneurysm. MRI angiography was suggestive of anterior communicating artery aneurysm of 5 mm in size (Fig. 4 & Fig. 5).The decision of early intervention in this patient was to prevent rebleeding and evacuation of blood from intraventricular space. Induction of anaesthesia and intraoperative monitoring were similar to the first case. Intraoperative monitoring of foetal heart rate was also done. After clipping of aneurysm, IV papavarine 30mg was given. Surgeon suspected vasospasm in the affected vessel, hence Transcranial Doppler to record Fig. 5 Anterior Communicating Artery Aneurysm (Clipped) of size 5 mm.

4 475 blood flow velocities was done and Triple-H therapy was immediately instituted by maintaining CVP between mmhg, haematocrit 30-35%, systolic BP mmHg, diastolic BP mmhg which is continued in postoperative period. After completion of surgery, patient was reversed with IV neostigmine and IV glycopyrrolate and extubated. Post operatively patient was shifted to high dependency unit. Hemodynamics and foetal heart rate with foetal movements were normal. Subsequent recovery of patient was uneventful. Post operative MRI Angiography was suggestive of adequate clipping of anterior communicating artery aneurysm without vasospasm. Discussion Anaesthesia for intracranial aneurysm surgery is highly specialised 1. Patients with subarachnoid hemorrhage from ruptured cerebral aneurysms frequently have systemic manifestation including hypovolemia and fluid and electrolyte disturbances in addition to neurologic symptoms. Anaesthetic management therefore begins with proper preoperative evaluation and optimization. Majority of patients present with subarachnoid hemorrhage due to rupture of aneurysm and therefore clipping of aneurysm is mandatory 2. Vasospasm is the most important cause of mortality and morbidity after subarachnoid hemorrhage (SAH). The prevention and treatment of vasospasm is one of the most important endpoints in treating patients with SAH. Nimodipine is a powerful cerebral vasodilator and reduce incidence of ischemic complications of vasospasm 5,6. Vasospasm may cause decrease level of consciousness, neurologic focal deficits, headache, meningism, fever and tachycardia. Triple H therapy includes hypervolemia, hypertension and haemodilution 3,4. The concept is to increase the cardiac output and arterial pressure by increasing intravascular volume. The increase in intravascular volume produces hemodilution with a hematocrit between 30-35%. Control of volume can be done by measuring central venous pressure(cvp), but more accurate by measuring pulmonary artery pressures. Increased mean arterial pressures will increase the cerebral blood flow in the vessels affected by vasospasm and in the ischemic cerebral areas. The application of the 3H (hemodilution, hypervolemia and hypertension) is showing favourable outcome 9. Mannitol is used for hemodilution and expansion of plasma, thus improving the rheological conditions of the blood. Different levels of arterial pressures have been recommended to treat vasospasm. Levels of 20 % above normal systolic pressures have been suggested to maintain cerebral blood flow (CBF). Also early intervention to prevent rebleeding and timing of surgery is important in a successful outcome 7,8. Pressure changes during induction, laryngoscopy and intubation changes intracranial hemodynamics and can cause rupture of aneurysm. All three cases were induced with IV thiopentone(5mg/kg), IV fentanyl (3-5mcg/kg) and IV lignocaine (1.5 mg/kg) was given 90 seconds before laryngoscopy to attenuate stress response. In all three cases patients had stable hemodynamics during induction and intubation. In all patients anesthesia was maintained with O 2, Sevoflurane and intermittent doses of muscle relaxants with titrated doses of fentanyl. Reduction in intracranial volume to facilitate cerebral retraction was done with the use of IV mannitol (0.5-1gm/ kg), IV furosemide ( mg/kg), boluses of thiopentone and maintaining PaCO 2 between mm Hg. Peri-operative vasospasm was prevented by using Triple H therapy. Conclusion To conclude, just as general anaesthesiology is a field where every step matters, anaesthesia for intracranial aneurysm surgeries is a specialized technique where every step matters to achieve a fine balance between excellent or catastrophic outcome. The main anaesthetic goal during cerebral aneursysm surgery is to reduce the risk of aneurysm rupture during intubation and introperatively to maintain adequate cerebral perfusion and to obtain quick awakening in order to be able to make early neurological test. References 1. Bekker A.Y., Baker K.Z., Baker C.J., Young W.L. Anesthetic considerations for cerebral aneurysm surgery. Am J Anesthesiology. 22: , Brilstra E.H., Algra A., Rinkel G.J., Tullekan C.A. Effectiveness of neurosurgical clip application in

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