How is aneurysm rupture during aneurysm clipping managed?
Intraoperative aneurysm rupture may be catastrophic if not properly managed by the surgeon and anesthesiologist in a coordinated effort. Unless bleeding is controlled, the outcome is inevitably fatal. Therefore, the first priority is to permit the surgeon to visualize the rupture site and clip it.
If the arteries feeding the aneurysm have been previously dissected and exposed, the surgeon may need only apply temporary clips to these vessels. Thereafter, he can place a permanent aneurysm clip and then remove the tempo-rary clips.
Under challenging circumstances, the anesthesiologist will be required to induce hypotension very rapidly and profoundly to permit surgical visualization of the ruptured aneurysm. Typically, a large bolus of intravenous thiopen-tal is administered. Usually mean arterial blood pressure will need to be lowered well below 50 mmHg before adequate reduction in hemorrhage is achieved. A bolus of propofol may also suffice. With aneurysms of the anterior circulation it may be helpful to manually occlude both carotid arteries by reaching under the drapes and applying direct pressure on the patient’s neck. At our institution we have also administered intravenous adenosine to induce reversible complete circulatory arrest following aneurysm rupture. As one would expect, this provides a completely bloodless field until cardiac activity resumes. In these situations one must balance the risks of cerebral ischemia against the surgical need to visualize the cerebrovascular anatomy.