piperidines and Intracranial-Aneurysm

Evaluate the use of entropy monitoring on anaesthetic drugs consumption, haemodynamic stability, and recovery time in patients undergoing embolisation of cerebral artery aneurysm (asymptomatic or low Hunt and Hess grades).. Two groups, G1 without entropy monitoring (Datex-Ohmeda S/5), G2 with entropy monitoring (16 patients in each group). Each group had similar anaesthetic protocol (propofol target control infusion and continuous intravenous infusion remifentanil). For G2, the state entropy (SE) values were kept between 35 and 45. We studied anaesthetic drug consumption, arterial pressure parameters, extubation delay and feasibility. Statistical analysis used Mann and Whitney test, Fisher test. Significativity was p<0.05.. No intraoperative incident. Propofol consumption was lower in G2 (7.49+/-2.28 mg/kg per hour versus 9.46+/-2.50mg/kg per hour; p<0.05). A tendency to reduction was observed for remifentanil consumption (6.65+/-2.04 microg/kg per hour versus 7.94+/-2.92 microg/kg per hour; p=0.056), and extubation delay (14.1+/-8.6 min versus 26.5+/-22.0 min; p=0.056), in G2. The entropy monitoring had no repercussion on haemodynamic stability, but the arterial pressure values were significantly higher in G2 (73.60+/-8.49 mmHg versus 67.10+/-5.58 mmHg). Entropy captor does not disrupt embolisation procedure. Coils liberation alter temporarily RE and SE values.

Topics: Anesthesia Recovery Period; Anesthesia, Intravenous; Electroencephalography; Embolization, Therapeutic; Entropy; Feasibility Studies; Hemodynamics; Humans; Intracranial Aneurysm; Monitoring, Intraoperative; Piperidines; Propofol; Prospective Studies; Remifentanil

The aim of the current study was to examine the effects of 10 degrees reverse Trendelenburg position (rTp) on subdural intracranial pressure (ICP), cerebral perfusion pressure (CPP), and dural tension. Additionally, the relationship between preoperative Hunt and Hess (H and H) grade and the subdural ICP in patients scheduled for cerebral aneurysm surgery was investigated. Twenty-eight consecutive patients with a cerebral aneurysm were subjected to craniotomy in propofol/fentanyl or propofol/remifentanil anesthesia. Subdural ICP was measured after opening of the bone flap and exposure of dura. After reference measurements of subdural ICP and mean arterial blood pressure (MABP), the measurements were repeated during 10 degrees rTp. No significant differences between the anesthetic groups were disclosed. During 10 degrees rTp, a significant decrease in MABP, ICP, and jugular bulb pressure was observed whereas CPP remained unchanged. In H and H 0 patients (unruptured aneurysm), the ICP decreased from 2.9 +/- 2.6 mmHg to 0.4 +/- 2.2 mmHg at 10 degrees rTp. In H and H I to II patients, the ICP decreased from 9.3 +/- 3.8 mmHg to 4.6 +/- 3.3 mmHg at 10 degrees rTp. A significant difference in the mean baseline subdural ICP and DeltaICP (change in ICP) was found between patients with unruptured aneurysm and patients with subarachnoid hemorrhage (H&H I and II). Furthermore, the relationship between the subdural ICP at neutral position and DeltaICP was significant. In patients without intracranial hypertension, 10 degrees rTp decreases subdural ICP and dural tension in patients with ruptured as well as patients with unruptured cerebral aneurysm; CPP is unchanged.

Topics: Anesthesia, General; Anesthetics, Intravenous; Blood Pressure; Cerebrovascular Circulation; Craniotomy; Female; Fentanyl; Head-Down Tilt; Humans; Intracranial Aneurysm; Intracranial Pressure; Jugular Veins; Male; Neurosurgical Procedures; Piperidines; Propofol; Remifentanil

The efficacy and safety of a new platelet-activating factor receptor antagonist, E5880, were investigated for preventing cerebral vasospasm after subarachnoid hemorrhage (SAH) in 71 patients with SAH who underwent surgery for ruptured aneurysms within 3 days. Intravenous E5880 administration (300 micrograms or 1200 micrograms twice daily) was begun within 4 days and continued for 14 days. The incidence of symptomatic vasospasm, low-density area on computed tomography, and angiographic vasospasm was lower than in placebo groups in previous studies. Clinical outcome was favorable compared with previous studies. No clinically important adverse events were observed. These results suggest that E5880 is safe and effective in the treatment of patients with cerebral vasospasm due to SAH.

Topics: Adult; Aged; Aneurysm, Ruptured; Brain; Clinical Protocols; Dose-Response Relationship, Drug; Female; Humans; Incidence; Injections, Intravenous; Intracranial Aneurysm; Male; Middle Aged; Piperidines; Platelet Activating Factor; Platelet Membrane Glycoproteins; Pyridinium Compounds; Radiography; Receptors, Cell Surface; Receptors, G-Protein-Coupled; Subarachnoid Hemorrhage; Treatment Outcome; Vasospasm, Intracranial

Although the elicited responses of motor evoked potential (MEP) monitoring are very sensitive to suppression by anesthetic agents and muscle relaxants, the use of neuromuscular blockade (NMB) during MEP monitoring is still controversial because of serious safety concerns and diagnostic accuracy. Here, we evaluated the incidence of unacceptable movement and compared false-negative MEP results between no and partial NMB during cerebral aneurysm clipping surgery. We reviewed patient medical records for demographic data, anesthesia regimen, neurophysiology event logs, MEP results, and clinical outcomes. Patients were divided into 2 groups according to the intraoperative use of NMB: no NMB group (n = 276) and partial NMB group (n = 409). We compared the diagnostic accuracy of MEP results to predict postoperative outcomes between both groups. Additionally, we evaluated unwanted patient movement during MEP monitoring in both groups. Of the 685 patients, 622 (90.8%) manifested no intraoperative changes in MEP and no postoperative motor deficits. Twenty patients showed postoperative neurologic deficits despite preserved intraoperative MEP. False-positive MEP results were 3.6% in the no NMB group and 3.9% in the partial NMB group (P = 1.00). False-negative MEP results were 1.1% in the no NMB group and 4.2% in the partial NMB group (P = 0.02). No spontaneous movement or spontaneous respiration was observed in either group. Propofol/remifentanil-based anesthesia without NMB decreases the stimulation intensity of MEPs, which may reduce the false-negative ratio of MEP monitoring during cerebral aneurysm surgery. Our anesthetic protocol enabled reliable intraoperative MEP recording and patient immobilization during cerebral aneurysm clipping surgery.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthesia, Intravenous; Data Interpretation, Statistical; Evoked Potentials, Motor; False Negative Reactions; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Monitoring, Intraoperative; Paresis; Piperidines; Propofol; Remifentanil; Retrospective Studies

Neurosurgery often requires skull immobilization with a Mayfield clamp, which often causes brief intense nociceptive stimulation, hypertension and tachycardia. Blunting this response may help prevent increased intracranial pressure, cerebral aneurysm or vascular malformation rupture, and/or myocardial stress. While various interventions have been described to blunt this response, no reports have compared administration of a propofol versus a remifentanil bolus.. We retrospectively analyzed the hemodynamic response to Mayfield placement in over 800 patients who received a prior propofol or remifentanil bolus from 2004 to 2010.. Patients who received remifentanil experienced a 55% smaller increase in heart rate (p < 0.0001) and a 40% smaller increase in systolic blood pressure (p < 0.0001) after Mayfield placement than patients who received propofol. These data were retrospectively obtained from patients who were not randomized to receive remifentanil versus propofol, and hence these data could be subject to possible confounding. Nonetheless, these differences remained significant after multivariate analysis for possible confounding variables.. Thus, a remifentanil bolus is more effective than a propofol bolus in blunting hemodynamic responses to Mayfield placement, and possibly for other short, intense nociceptive stimuli.

Topics: Anesthetics, Intravenous; Blood Pressure; Female; Heart Rate; Hemodynamics; Humans; Intracranial Aneurysm; Intracranial Pressure; Male; Middle Aged; Neurosurgical Procedures; Nociceptive Pain; Piperidines; Propofol; Remifentanil; Restraint, Physical; Retrospective Studies; Skull

Remifentanil is an ultrashort-acting µ-opioid receptor agonist and is especially suitable for neuroanesthesia. We previously reported that general anesthesia with remifentanil for brain tumor resection was associated with lower postoperative mortality and shorter postoperative length of stay (LOS) when compared with surgeries without remifentanil. This phenomenon may also exist during clipping of intracranial aneurysms (ICAs), where brain tissue frequently suffers ischemia and reperfusion injury. We performed a propensity score-matching study to compare in-hospital mortality and postoperative LOS with and without remifentanil in such patients.. We used the Diagnosis Procedure Combination inpatient database in Japan that includes 926 acute care hospitals to identify patients who underwent clipping of ICAs under general anesthesia between July and December 2007.. Of the 4502 patients who underwent ICA clipping, 1380 propensity-matched pairs (n=2760) were included for outcome comparison. The remifentanil group had significantly lower in-hospital mortality than the nonremifentanil group (4.2% vs. 7.7%; P<0.001). Use of remifentanil was an independent factor for lower in-hospital mortality (odds ratio=0.52; 95% confidence interval, 0.37-0.74; P<0.001). By contrast, postoperative LOS did not differ significantly between the 2 groups. There was no difference in the occurrence of postoperative complications except for hydrocephalus, which was more common with remifentanil.. This retrospective observational study demonstrated a possible relationship between the use of remifentanil for neuroanesthesia and reduced mortality of patients undergoing clipping of ICAs with open craniotomy. Prospective interventional studies are necessary to confirm this relationship.

Topics: Female; Hospital Mortality; Humans; Hypnotics and Sedatives; Intracranial Aneurysm; Length of Stay; Male; Middle Aged; Odds Ratio; Piperidines; Propensity Score; Remifentanil

A 70-year-old woman underwent emergent clipping surgery for subarachnoid hemorrhage under general anesthesia. Her laboratory data showed thrombocytopenia (4.0 x 10(4) microl(-1)). She had taken prednisolone (3 mg x day(-1)) and methotrexate (MTX) (10 mg x week(-1)) for rheumatoid arthritis for the last 10 years. Anesthesia was induced with remifentanil as well as propofol, maintained with remifentanil and sevoflurane in oxygen. The operation was performed uneventfully without platelet transfusion. Since the cause of thrombocytopenia was suspected to be MTX, we started rescue therapy by calcium folinate postoperatively. Platelet count was normalized two days later (11.6 x 10(4) microl(-1)). One month after the operation, she was discharged uneventfully.

Topics: Aged; Anesthesia, General; Arthritis, Rheumatoid; Emergencies; Female; Humans; Immunosuppressive Agents; Intracranial Aneurysm; Leucovorin; Methotrexate; Piperidines; Platelet Transfusion; Postoperative Care; Propofol; Remifentanil; Subarachnoid Hemorrhage; Thrombocytopenia; Treatment Outcome; Vascular Surgical Procedures

Adenosine-induced transient flow arrest has been used to facilitate clip ligation of intracranial aneurysms. However, the starting dose that is most likely to produce an adequate duration of profound hypotension remains unclear. We reviewed our experience to determine the dose-response relationship and apparent perioperative safety profile of adenosine in intracranial aneurysm patients.. This case series describes 24 aneurysm clip ligation procedures performed under an anesthetic consisting of remifentanil, low-dose volatile anesthetic, and propofol in which adenosine was used. The report focuses on the doses administered; duration of systolic blood pressure <60 mm Hg (SBP(<60 mm Hg)); and any cardiovascular, neurologic, or pulmonary complications observed in the perioperative period.. A median dose of 0.34 mg/kg ideal body weight (range: 0.29-0.44 mg/kg) resulted in a SBP(<60 mm Hg) for a median of 57 seconds (range: 26-105 seconds). There was a linear relationship between the log-transformed dose of adenosine and the duration of a SBP(<60 mm Hg) (R(2) = 0.38). Two patients developed transient, hemodynamically stable atrial fibrillation, 2 had postoperative troponin levels >0.03 ng/mL without any evidence of cardiac dysfunction, and 3 had postoperative neurologic changes.. For intracranial aneurysms in which temporary occlusion is impractical or difficult, adenosine is capable of providing brief periods of profound systemic hypotension with low perioperative morbidity. On the basis of these data, a dose of 0.3 to 0.4 mg/kg ideal body weight may be the recommended starting dose to achieve approximately 45 seconds of profound systemic hypotension during a remifentanil/low-dose volatile anesthetic with propofol induced burst suppression.

Topics: Adenosine; Adult; Aged; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Atrial Fibrillation; Cardiovascular Diseases; Cerebrovascular Circulation; Dose-Response Relationship, Drug; Female; Humans; Intracranial Aneurysm; Ligation; Male; Middle Aged; Nervous System Diseases; Neurosurgical Procedures; Piperidines; Postoperative Complications; Propofol; Remifentanil; Vasodilator Agents

The population of children undergoing successful surgery for congenital heart disease (CHD) continues to increase. Increasing number of patients with a Fontan circulation is reaching adulthood and requiring anesthesia for noncardiac surgeries. We anesthetized a patient with a Fontan circulation (9 years old) for giant internal carotid-ophthalmic artery aneurysm trapping. There was a difficulty in cannulating internal jugular vein for measuring central venous pressure because of abnormal collateral arteries around the internal jugular vein. Central venous pressure of around 15 mmHg seemed appropriate to keep good hemodynamic condition during this surgery. In this condition, cerebral cortex was not edematous. Careful management of circulatory volume stabilized hemodynamic state. However, when heart rate decreased below 75, ectopic atrial rhythm occured. Anesthetic time was 13 hr and 40 min. The patient was extubated in the operating room. We have to take into consideration that there are anatomical abnormalities and arrhythmia in the patients with a Fontan circulation.

Topics: Anesthesia, Intravenous; Carotid Artery, Internal; Child; Craniotomy; Fontan Procedure; Heart Defects, Congenital; Humans; Intracranial Aneurysm; Male; Ophthalmic Artery; Piperidines; Propofol; Remifentanil; Vascular Surgical Procedures

Topics: Adult; Anesthesia, General; Anesthetics; Cerebellum; Cesarean Section; Female; Humans; Infant, Newborn; Intracranial Aneurysm; Intracranial Embolism; Piperidines; Pregnancy; Pregnancy Complications, Cardiovascular; Radiography; Remifentanil; Treatment Outcome

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Local; Antiemetics; Carotid Artery, Internal; Dexamethasone; Granisetron; Humans; Intracranial Aneurysm; Intubation, Intratracheal; Lidocaine; Male; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Subarachnoid Hemorrhage; Surgical Mesh; Time Factors

The 53-year-old female patient had suffered massive subarachnoid bleeding due to rupture of left-localized aneurysm of the anterior communicant artery. Following the neurosurgical intervention, deterioration of consciousness related to strong vasospasm occurred. Cerebral CT examination was performed, showing a 0.5 cm ischaemic lesion of the left hippocampal fornix. Due to intensive therapy, the patient recovered gradually, however considerable short-time memory deficit and severe anterograde amnesia remained. Admission of the patient in psychiatric care 5 weeks after the operation was necessary since acute deterioration had been added to memory disturbance and anterograde amnesia. Clinical features included severe short-time memory deficit, continuous and severe anterograde amnesia, disorientation, alterations of verbal fluency and abstraction. The amnesic syndrome was probably related to the hippocampal damage, but considering the development of cognitive deficits, cerebral CT was performed again, which verified internal hydrocephalus. A ventriculo-peritoneal shunt has been implanted and the patient was re-admitted in psychiatry care because of her memory deficit, anterograde amnesia and disorientation. Thereafter, low doses of citalopram and donepezil therapy was started together with temporarily used antipsychotic medication (risperidone). Gradual, but continuous improvement of memory and cognitive function could be detected, with total recovery after one year. The deficits in long- and short-term memory, orientation and cognition were totally restored.

Topics: Amnesia, Anterograde; Citalopram; Donepezil; Female; Fornix, Brain; Humans; Indans; Intracranial Aneurysm; Korsakoff Syndrome; Middle Aged; Neurosurgical Procedures; Nootropic Agents; Piperidines; Risperidone; Rupture, Spontaneous; Subarachnoid Hemorrhage; Vasospasm, Intracranial

This prospective study was performed to compare the incidence of complications occurring after neurosurgical procedures in patients anesthetized with either sevoflurane-fentanyl or propofol-remifentanil anesthesia. We enrolled 162 American Society of Anesthesiologists (ASA) I to III patients (82 females and 80 males, Glasgow 15) undergoing elective neurosurgical procedures. Anesthesia was conducted using either propofol-remifentanil (T group; n=80 patients) or sevoflurane-fentanyl (S group; n=82 patients). All patients were monitored in the postanesthesia care unit for 6 hours after extubation. We analyzed and compared in both groups the incidence of high severity complications such as respiratory events (PaO2 <90 mm Hg; PaCO2 >45 mm Hg) and neurologic events (seizures, new motor or sensory deficit, unexpected delay of awakening) and the incidence of low severity complications such as hypertension (mean arterial pressure increase above 30% of baseline), hypotension (mean arterial pressure decrease below 30% of baseline), pain, shivering, nausea, and vomiting. A total of 162 complications occurred in 92 patients (57%) with 50 patients (31%) having had 1, 26 patients (16%) having had 2, and 16 patients (10%) having had 3 or more events. The most frequent complication was respiratory impairment (28%) which was frequently reported only in the first postoperative hour. Out of the total number of complicating events, 77 (48 %) were found in group S, and 85 (52%) in group T (P=ns). Severe complications were rarely reported and evenly distributed in the 2 anesthetic groups. Similarly, no difference could be demonstrated in the composite incidence of less serious complications between the 2 anesthetic regimens tested in this study. This study confirms that the recovery period after neurosurgical procedures remains a time of great potential danger to patients given the high incidence of postoperative complicating events independently from the anesthetic strategy.

Topics: Adult; Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Brain; Brain Neoplasms; Endpoint Determination; Female; Fentanyl; Humans; Intracranial Aneurysm; Intracranial Arteriovenous Malformations; Male; Methyl Ethers; Middle Aged; Neurosurgical Procedures; Piperidines; Postoperative Care; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Respiratory Mechanics; Sevoflurane

Diagnosis of an intracranial aneurysm during pregnancy is a rare event requiring multidisciplinary care for successful management. The knowledge base for the anesthesiologist involves principles of both obstetric and neuroanesthesia, as well as critical care. This article reports such a case and discusses the relevant pathophysiology, along with details of the perioperative management by the anesthesiology team.

Topics: Adult; Anesthesia; Anesthetics, Intravenous; Embolization, Therapeutic; Female; Humans; Intracranial Aneurysm; Piperidines; Pregnancy; Pregnancy Complications, Cardiovascular; Propofol; Remifentanil

Remifentanil is a synthetic opiate with evident advantages for various anesthetic techniques, enhancing quality of anesthesia. Indications are increasingly well-defined. Remifentanil may be used in obstetric analgesia-anesthesia thanks to advantages demonstrated in patients with heart disease (cardiac and non-cardiac anesthesia) and in those requiring neuroanesthesia. Remifentanil is known to cross the placenta rapidly and to be rapidly metabolized and redistributed to both mother and fetus. Based on this, and on pharmacokinetic and pharmacodynamic studies in children, we judged remifentanil to be indicated for use in two patients undergoing emergency cesarean section, for whom hemodynamic stability and immediate postoperative assessment were basic requirements. The first case involved a woman 40 weeks pregnant with a history of mitral valve prolapse and an episode of acute pulmonary edema in the 28th week, who presented with ruptured membrane and the fetus in sacroposterior breech presentation without subsequent progression of labor. The second involved a woman 40-weeks pregnant with a diagnosis of Hunt-Hess grade II subarachnoid hemorrhage who had gone into labor. Outcome was satisfactory in both cases, with no complications potentially affecting the status of either mother or child. No infant respiratory insufficiency occurred and Apgar scores were favorable. We consider remifentanil to be safe and effective for general anesthesia for emergency cesarean delivery in patients with cardiac and/or neurological risk factors.

Topics: Adult; Anesthesia, General; Anesthesia, Obstetrical; Anesthetics, General; Apgar Score; Cesarean Section; Emergencies; Female; Humans; Infant, Newborn; Intracranial Aneurysm; Maternal-Fetal Exchange; Mitral Valve Prolapse; Obstetric Labor Complications; Piperidines; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Complications, Hematologic; Pregnancy Outcome; Pulmonary Edema; Remifentanil; Subarachnoid Hemorrhage

Peri-aneurysmal CSF was obtained at operation from 13 patients with subarachnoid haemorrhage from ruptured intracranial aneurysms. The 5-hydroxytryptamine antagonist ketanserin inhibited contractions of isolated human intracranial arteries, elicited by this CSF. The presence of 5-HT in CSF was confirmed by high performance liquid chromatography. The use of ketanserin in the therapy of postoperative cerebral vasospasm is discussed.

Topics: Adult; Aged; Animals; Female; Humans; Hydroxyindoleacetic Acid; Intracranial Aneurysm; Intraoperative Complications; Ischemic Attack, Transient; Ketanserin; Male; Middle Aged; Piperidines; Postoperative Complications; Rats; Rupture, Spontaneous; Serotonin; Serotonin Antagonists; Subarachnoid Hemorrhage; Vasoconstriction