Samad K, Hoda S F, Hoda M Q.
Anesthetic management of combined Cesarean Section and clipping of ruptured Cerebral Aneurysm.
J Pak Med Assoc Jan ;54(6):330-2.

A 27 year old, gravida 6, Para 2+3, 34 weeks pregnant female presented with one day history of headache, neck stiffness, vertigo and vomiting. She had mild pregnancy induced hypertension and an episode of dyspnoea in 2nd trimester of her previous pregnancy. She was allergic to sulphur group of drugs. Her vitals at the time of admission were: blood pressure 125/70 mmHg, pulse 90/min, temp afebrile and respiratory rate 16/min. Neurological examination was normal except for neck stiffness. Computerized tomography (C.T.) of head showed minimal subarachnoid haemorrhage in fourth ventricle. M.R.I showed high suspicion of tiny aneurysms arising from the peripheral portion of right anterior inferior cerebellar artery. Angiography showed 6mm aneurysm in mid right anterior inferior cerebellar artery. In view of her pregnancy and a leaking cerebral aneurysm, Cesarean section immediately followed by clipping of the leaking aneurysm was planned under general anaesthesia. After preoxygenation, a rapid sequence induction technique was used with cricoid pressure using fentanyl 2 ug/kg, propofol 2 mg/kg and rocuronium 1 mg/kg. Anaesthesia was maintained with Isoflurane 0.6-1 in 50:50 mixture of 02 and N20. Ventilation was adjusted to maintain ETCO2 between 30-34 mmHg. The anaesthetic management for clipping of cereberal aneurysm included intraoperative management of blood pressure by combination technique in which Nitroglycerine infusion 1-2 ug/kg/min, sodium nitroprusside infusion 1-2 ug/kg/min, IV Metoprolol (incremental doses as per requirement) were given. Fentanyl 50 ug IV stat every half an hour was used for analgesia as well as for controlling hemodynamics. Single IV bolus dose of thiopentone sodium 125 mg at the time of clipping of aneurysm was also administered for cerebral protection.

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