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author:MF manufacturerstime:2022-03-18 03:31:28

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source:Department of Anesthesiology, Beijing Tiantan Hospital

cbv brass tubes(cbv brass tubes)Features of intracranial aneurysms1



Intracranial aneurysms are mostly cerebral hemangioma-like protrusions produced by abnormal changes in cerebral blood vessels,subarachnoid hemorrhage(SAH)primary cause of,in cerebrovascular accident,second only to cerebral thrombosis and hypertensive cerebral hemorrhage,third。Most occur in40to60middle-aged and elderly women。The cause of intracranial aneurysms is unknown,Most scholars believe that intracranial aneurysms are caused by local congenital defects in the intracranial artery wall and increased intraluminal pressure.,hypertension、cerebral arteriosclerosis、Vasculitis is related to the occurrence and development of aneurysms。Intracranial aneurysms usually occur at the bifurcation of the basilar artery and its main branches。about85%of aneurysms are located inWillisInternal carotid arterial system,intracranial segment of the internal carotid artery、anterior cerebral artery、anterior communicating artery、middle cerebral artery、posterior half of the posterior communicating artery。The vast majority of congenital aneurysms are sac-like or berry-like,can also be lobulated, etc.。Intracranial aneurysms are usually0.5~2cm。The rupture of an aneurysm is related to its size,The critical size of aneurysm rupture is a diameter of0.5~0.6cm。diameter over0.5cmincreased chance of aneurysm bleeding,its diameter exceeds3.0cmback,Symptoms of increased intracranial pressure replace bleeding symptoms。

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pathophysiological changes

(cbv brass tubes)1.2.1 intracranial pressure(ICP)rise

(cbv brass tubes)SAHbackICPsharp increase,systemic blood pressure levels,thought to limit blood seepage in ruptured aneurysms。After the aneurysm re-ruptures due to the action of a blood clot、Hydrocephalus due to cerebral edema or obstruction can causeICPfurther increase。HypovolemiaICPincrease,May increase the incidence of delayed cerebral ischemia and cerebral infarction。SAHpatient's cerebral blood flow(CBF)and brain metabolic rate is usually reduced。Vasospasm can also causeCBFreduce,while peripheral vasodilation leads to cerebral blood volume(CBV)Increase,followed byICPfurther increase。in addition,Intracerebral and intraventricular hematomas can also causeICPincrease。

1.2.2 Cerebral blood flow autoregulation and impairment of carbon dioxide responsiveness

SAHPatients with impaired cerebral blood flow autoregulation。Impairment of autoregulation during cerebral vasospasm can cause delayed ischemic neurological impairment。SAHPosterior cerebral vascular response to hyperventilation persists。Most perioperative patientsCBFandCBVwhen reduced,Hyperventilation can improveSAHAutomatic adjustment function for critically ill patients。

1.2.3 cerebral vasospasm

cerebral vasospasm(CVS)leading cause of disability and death,aneurysmalSAHand other intracranial hematomas、traumatic brain injury(TBI)、Appears after neurosurgery。SAHbackCVSThe mechanism is complex,is a multifactorial process。CVSThe risk and severity of occurrence are directly related to the size of the clot in the subarachnoid space。speculation may causeCVSThe complex consists of two parts:existSAHcomplexes or their metabolites found in the blood,such as hemoglobin(Hb)、Bilirubin oxidation product(BOXes);or complexes resulting from perivascular blood stimulation,e.g. endothelin-1(ET-1)、Nitric oxide(NO)。Clinical manifestations of early brain injury(EBI)and delayed cerebral ischemia(DCI)。EBIbehave asICPTemporarily elevated,CBFdecreased secretion,Nerve cell death and edema;DCIinclude:symptomatic vasospasm,delayed ischemic neurological impairment,asymptomatic delayed cerebral infarction。CVShappened atSAHback3sky,6~8Tianda peak,Average time3~14sky。CVSmore likely to occur inHunt-HessGraded high level andCTpatients with more blood。

1.2.4systemic effect

(cbv brass tubes)36%~100%SAHpatient with hypovolemia,and the level of hypovolemia is related to clinical grade。in addition,CTimage hasICPPatients with elevated signs are more prone to systemic hypovolemia,Causes include bed rest、supine position、urination、Negative nitrogen balance、RBCreduce etc.。Hypovolemia can exacerbate cerebral vasospasm。However, hypovolemia is often associated with central hyponatremia(hyponatremia encephalopathy)related。Hyponatremia may be abnormal secretion of antidiuretic hormone(syndrome of abnormal antidiuretic hormone secretion,SIADH)caused by,Treatment requires fluid restriction。May also be related to natriuretic peptide release,cerebral salt wasting syndrome(CSWS)。CSWSandSIADHsame as laboratory test,butCSWSLow extracellular fluid volume,andSIADHhigh or unchanged,Thus, inCSWSRestricting fluid infusions in patients can be detrimental。Other electrolyte abnormalities include hypokalemia and hypocalcemia。

1.2.5 impact on heart function

(cbv brass tubes)patients with normal coronary arteriesSAHCardiac dysfunction and neurogenic myocardial damage,with a history of coronary heart diseaseSAHpatients with myocardial ischemia。SAHThe effect on the myocardium is mainly manifested in the electrocardiogram(ECG)and echocardiography(UCG)The change。ECGAbnormalities include sinus bradycardia、sinus speed、Atrioventricular dissociation、ventricular tachycardia、ventricular fibrillation,also appearTwave inversion、S-Tsegment depression、UWave、Q-TInterval prolongation and abnormalitiesQWave。some patientsUCGManifested as left ventricular function depression and regional wall motion abnormalities。

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1.2.6 Effects on the respiratory system

neurogenic pulmonary edema(NPE),i.e. unintentional、lung、In the case of kidney and other diseases,Acute pulmonary edema due to acute increased intracranial pressure due to traumatic brain injury or other disorders of the central nervous system。aldultNPEThe incidence is5%~10%,The most common reason isSAH(42.9%),The second is epilepsy(33%)。It is generally believed thatNPEis the result of the combined effect of the two types of damage。Sudden increase in intracranial pressure following central nervous system injury,resulting in dysfunction of the hypothalamus and nucleus of the solitary tract of the medulla,The body's stress response leads to sympathetic excitation,Catecholamines in blood(epinephrine、norepinephrine, etc.)significantly increased content,In turn, systemic vasoconstriction and hemodynamic drastic changes。due to a sharp increase in arterial blood pressure,Therefore, a large amount of blood in the systemic circulation enters the pulmonary circulation。On the one hand, the effective filtration pressure of the pulmonary capillary bed increased sharply,Large amounts of fluid trapped in the spaces between the lung tissue,pulmonary edema;On the other hand, blood flow shock causes vascular endothelial cell damage,At the same time, vasoactive substances in the body(such as histamine and bradykinin)mass release,increase vascular permeability,Excessive extravasation of plasma proteins leads to further exacerbation of acute pulmonary edema。its onset is rapid,Conventional treatments for cardiogenic pulmonary edema are often ineffective,The result is often fatal。SAHPatients may also have aspiration pneumonia。

Clinical manifestation2


Cracked bleeding

(cbv brass tubes)Mainly manifested as a subarachnoid hemorrhage(SAH),Sudden illness,Headache is dramatic,Accompany vomiting,Syncope,Neck pain,Lash,Cranial symptoms(III),Disorder。Headache is also possible to expand or analyze the blood of the aneurysm,The symptoms of threatened headache are relatively light,Last few days,Mening film stimulus(+),hypertension,Crest neural dysfunction,Eye bleeding, etc.。As the aneurysm is broken around the blood clot,Aneurysm can break bleeding again。The second bleeding occurs in the first bleeding2Internal。SAHback,Red blood cell destruction5-Hydroxylamine、Pedicine, other vascular active substances, etc.,Vasospasm occurs。Partial vasospasm only occurs near the aneurysm,Patient symptoms are not obvious,Only displayed on cerebral angiography。Extensive cerebral vasospasm,It will cause cerebral infarction,Patient disorder、hemiplegia,even death。

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Several common methods for assessing the condition of subarachnoid hemorrhage:

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*Severe systemic system disease,High blood pressure、diabetes、Severe atherosclerosis、Chronic pulmonary diseases and severe cerebrovascular spasms found in angiography can lead to increased risk levels of patients。

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Focal symptom

Depending on the part of the aneurysm、Nearby anatomical structure and aneurysm。Headache、Cranial nerve paralysis、Crest motion dysfunction、Small infarction、Short-liver cerebral ischemic attack(TIA)、epilepsy(Tumor brain soft)Wait。Sometimes the stove symptoms appear before the bleeding of the subarachnoid,Temporary symptoms being treated as aneurysm,Slight migraine、Eyelid pain,Effective eye nerve paralysis,At this time, you should be alert to the subarammiral bleeding.。


Other combination

Patients with intracranial aneurysms also have systemic hypertension(21%)、heart disease(3%)、diabetes(2%)、Vein thrombosis and pulmonary embolism。

Diagnostic check

(cbv brass tubes)3


Determine the bleeding of the free space(SAH)

(cbv brass tubes)Bleeding,CTDiagnoseSAHHigh positive rate,Safe and reliable。Waist-wearing pressure rises with blood brain ridges often diagnose direct evidence of subarachnoid hemorrhage after cracking。But when the intracranial pressure is high,Waist is careful。


Determine the etiology and lesion

(cbv brass tubes)CTACan replace cerebrovascular angiography in a certain extent,Provide more information for the treatment decisions of aneurysms。Cerebral blood(DSA)Is a gold standard for determination of intracranial aneurysms,Accurate position to judge the aneurysm、form、the inside diameter of、number、Vascular spasm and determination of surgery is very important。

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Anesthesia management4


main problem

(cbv brass tubes)Intraoperative anesthesia management is not limited to the operation of the operation,More important is perioperative management。Anesthesia induction and intraoperative aneurysm have a rupture,Secondly, cerebrovascular spasm and intracranial pressure increase。Besides,Should focus on:Epilepsy and epilepsy、Neuronic heart disease、Neuronic pulmonary edema、Cerebral vasospasm and central hyposis。

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Preoperative assessment

  • (cbv brass tubes)Evaluate the status of the patient's nervous system andSAHClinical grading;

  • (cbv brass tubes)Analysis of patients' intracranial pathological state(CTandDSA),Understand the location of the disease and size,Communicate with neurosurgeons,Clear position and surgery and special monitoring, etc.;

  • Evaluate the function of patients before the disease and other organ systems,Focus is possibleSAHEffected organ function;

  • Correct disorders of patient biochemistry and physiological functions,Strive to achieve the best state;

  • If possibleICPTranscranial Doppler(TCD)an examination。

Pathophysiological status of all organ systems in patients before surgery、Surgical and monitoring needs,Preoperative assessment and formulate a reasonable anesthesia program。

(cbv brass tubes)4.3


  • For high tension patients, calm anxiety drugs can be applied properly,It can also reduce the possibility of aneurysm rupture,Note that it should be open intravenous、Monitor blood pressure、Blood oxygen saturation(SPO₂)Case;

  • The use of anti-chochomei can be selected according to the patient's heart rate, etc.,Reduce respiratory secretion。

(cbv brass tubes)4.4


Strive to keep blood flow smooth。Due to the placed laryngoscope、Intubation、Striped position and upper end frame are more stimulated,It is easy to cause risks of blood pressure to increase the risk of anti-aneurysm,So these operations should be guaranteed enough anesthesia depth、Good muscles;If the blood pressure is too high,It should be controlled to be induced after a reasonable level.。It can be used to use Imomimid ester to elderly or physique.,In order to prevent muscle oluus, it can be pre-quietly injected with small dose of microidazolam or Ruifen.;Propofol induces rapid、reduceCBV、ICPBrain oxygen metabolism、Do not interfere with cerebral blood vessel autonomous regulation andCO2Reactivity,Brain protection,Is currently preferred,But the injection speed should not be too fast,Otherwise cause blood pressure drop。


Anesthesia monitoring

(cbv brass tubes)Routine monitoring:ECG、SPO₂、ABP、BIS、EtCO₂、Urine volume、body temperature,rightASALevel,It is best to monitor before induction of anesthesiaABP,Obvious heart disease needs to monitor central venous pressure(CVP)。Bleeding,Monitor blood cell compatibility(Hct)、Electrolyte、Blood gas analysis,Guide blood transfusion、Infusion。



Anesthesia maintenance principle is to keep normal brain perfusion pressure;Prevention and treatment of brain hypoxia and edema;Reduce cross-wall pressure(TMP)。Guaranteed enough brain relaxation,Provide good surgical conditions for surgery,Also take care of electrophysiological monitoring requirements。

(cbv brass tubes)(1) Brain organization“relaxation”Easy to retreat。

  • (cbv brass tubes)20%Mannitol(0.5~2g/kg)Can reduce brain tissue volume,generally30After the weight is over,Production of permeability diuretic effect。Common dose1g/kg。High permeation pressure,Temporarily increaseCBF、CBVandICP,Peripheral vascular resistance is sharply lowered,Especially fast infusion(<10minute),Can cause short hypotension,thenCVP、Pulmonary wedge pressure(PAWP)And heart discharge is significantly increased。Poor patient,Mannitol delayed action can cause liquid retention and pulmonary edema;

  • Sneaper underwater piercing drainage or ventricular puncture release cerebrospinal fluid(CSF)Promote the exposure of the surgery。Care should be carefully operated when puncture,Try to minimize cerebrospinal fluid(CSF)Lose andICPA sharp decline,avoidTMPSudden increased and re-bleeding。Fast drainage may stimulate brain to cause sudden reflex high blood pressure。Intracranial hematoma patients taboo waist,Dangerous danger;

  • Reduce cerebral blood volume(CBV)。Excessive ventilation can be reducedCBV,PaCO2Change1mmHg,CBVVariety1%。Individualization should be adjusted according to the situationPaCO2,Excessive hypocarbonate is reducedCBVadvantage,But there is also a risk of cerebral ischemia,Weighted;

  • Not satisfied with the above measures,Anesthesiologist should:Determine no hypoxemia and high blood pressure;Check the patient's neck,Intravenous obstruction;Check the underlying chamber drainage,make sureCSFPass through;When using inhaled anesthetics,Nitrogen oxide has a diastolic blood vessel effect,Should not use;Communicate with neurosurgeists,Take the head high to facilitate intravenousCSFReflow。

(2) Maintain appropriate anesthesia depth(BISexist40~60),Excessive ventilation,Blood gas analysis monitoring oxygen partial pressure and carbon dioxide partial pressure(PaCO₂),MakePaCO₂Maintain at30~40mmHg。

(3) Treatment of huge or complex aneurysms,Temporary blocking artery technology,At this time, blood pressure can be improved to ensure the blood supply。

(4) Surgery, hydrolysis should be due to blood loss、Urine volume、CVPorPAWPAdjustment。If controlled antihypertensive,Do not stop infusion,Because low blood volume low blood pressure is not conducive to organizational organs。Normal blood volume should be maintained before the aneurysm clip,The blood capacity after clamping is slightly higher than normal.。Maintain electrolyte balance。Hyperglycemia may increase local or whole ceremony。

(5) Temporary blocking and controlled buck。At present, the controlled buck is currently applied.,Because controlled antihypertensive can reduce the risk of cracking,Reducing bleeding,Better observe the anatomical and angiogenesis of the aneurysm,But there is a risk of increasing cerebral ischemia。especiallySAHAfter the cerebrovascular automatic adjustment function is damaged,Control antihypertensive can cause calendar vascular responses that cannot be predicted,Cerebrovascular spasm increase,Prognosis。

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(6) Once aneurysm is broken,The key to the management of anesthesia is to communicate well with,Close monitoring of patient vital signs and surgical processes。If the artery acute bleeding and blood pressure fall,It should be quickly filled with liquid at this time.、Autologous blood transfer and/Aligothasis。Apply vascular active drug to maintain cycle stability if necessary。

(cbv brass tubes)(7) Neurophysiological monitoring。EEGAnd induced potential and other neuroelectrophysiological technologies can monitor medium cerebral ischemia,Guide surgery and improve perfusion。SSEPsHigh rate of false,CombineMEPsSensitivity and specificity of cerebral ischemic monitoring。But inhalation anesthetics and muscle pine can affectMEPsmonitor,So monitoringSSEPsandMEPsI usually need a full vein anesthesia,Do not use muscle pine。


Anesthesia, wake up and recovery

(cbv brass tubes)Anesthesiologists and surgery doctors have essentials in the management of patient anesthesia.。

  • Avoid cough,In particular, when the wound is brought into the head,Diseopharyngeal and airway full of phenomenon,Keep intimidumin when necessary1.5mg/kg。

  • Appropriate increase in blood pressure after surgery(Shrink pressure<180mmHg)May not be processed,If severe hypertension(Shrink pressure>200mmHg)Brain edema or cerebral hemorrhage,Should be symptomatic,Allowed、Nica、Ulirage。

  • For multi-driven aneurysm patients,The blood pressure must be strictly controlled during anesthesia and restoration.±20%Within,Preventing no clutch。

  • PreoperativeSAHGrade0~ⅡPatient,Optional room clear extubation。SAHGradeⅢLevel and above patients,Whether to extract whether or not to decide according to the preoperative ventilation state and the extent and time of surgery。For patients with vertebral substrate aneurysms,May be due to perforated vascular blocking or brain dry retreat cause short or permanent brain nerve damage,Need to wake up slowly。

(cbv brass tubes)Problems need to be considered after surgery5

  • Operation aimshages need to assess patient situation,Clearly anesthesia recovery is satisfactory。The wake time is related to the type and dosage of the anesthetic and the patient's sensitivity to anesthetics。

  • It is important to distinguish between anesthesia after the lactation of anesthesia, such as epidural or epidural hematoma.。Store neurological damage should first consider the cause of operation,However, calm treated pain can aggravate or mask the symptoms of focal nervous system。

  • The patient is normal after surgery.,Light reaction,Respiratory no inhibition,Generally there is an excessive abnormal anesthetic。If the front pupil is normal,After the postoperative pupil is not equal,May be caused by surgery。

  • (cbv brass tubes)In recovery room or intensive care room,Each15Minutes evaluated patient neural function system,Some patients need immediateCTAlmond angiography。

cbv brass tubes(cbv brass tubes)Cerebrovascular anatomy and imaging examination is the foundation of therapeutic treatment and operational management,Click on the literacy to learn the knowledge of cerebral vascular system:

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