Page 20 - CASA Bulletin of Anesthesiologisy 2022 9(6)-1 (3)

CASA Bulletin of Anesthesiology

Anesthesia for Interventional Neuro Radiology

David R Wright, Associate Professor of Anesthesia and Pain Medicine,
University of Washington, Seattle, WA

Summary

This article summarizes the proliferation in endovascular interventions for neuro vascular
procedures that the Anesthesiologist will commonly encounter in the neuro interventional
radiology (NIR) suite. General principles applicable to most procedures are outlined as well as
some special considerations for different conditions such as cerebral aneurysms, arteriovenous
malformations and stroke. It is also of paramount importance that those taking care of patients in
the NIR suite are aware of the two most devastating complications of cerebral ischemia due to
intra- arterial thrombus formation and cerebral hemorrhage with accompanying intracranial
hypertension that can happen, what can be done to minimize the risk of them occurring and how
they should be managed.

Introduction

NIR is a growing specialty with a number of newer innovations in both devices and the
number of conditions that can be treated. Since the introduction of coils to treat brain aneurysms
1990’ w w
necks, giant aneurysms and complex aneurysms at branching points in the intracerebral
circulation. This evolution has gone hand in hand with techniques such as balloon and stent
assisted coiling that allow coils to be compacted within the aneurysm. Balloon assisted coiling
(BAC) also has the ability to arrest flow while the coils are deployed which is particularly useful
for the treatment of ruptured aneurysms. More recently the focus has shifted from coils deployed
k w “ ” “ w ”
to treat the parent artery and divert blood flow away from the aneurysm and thrombosis occurs
over a period of weeks due to stasis of blood within the aneurysm. Stent therapies are
thrombogenic and have to be combined with dual antiplatelet therapy (DAPT) thereby relatively
contraindicating their use in patients presenting with ruptured aneurysms. The newest device is a
Woven Endo Bridge (WEB) , a construct that is deployed across the neck a wide aneurysm
TM
without the need for a supporting stent device and antiplatelet agents and is being used off label
to treat ruptured aneurysms. For the endovascular enthusiast there are becoming few aneurysms
that cannot be treated in the NIR suite. Other conditions that are commonly encountered in the
R (A ’ ) , vasospasm
following subarachnoid hemorrhage and perhaps most commonly for the generalist covering the
NIR suite on call, mechanical thrombectomy for treatment of acute ischemic stroke. With this
rapid growth of both conditions and treatment options over the past 30 years there is much for
the Anesthesiologist to consider in the care of the patient in the NIR suite.

General considerations

NIR procedures typically take place in locations remote from the OR or increasingly in
newly designed and constructed hybrid suites within the OR. The former requires anticipation of

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