title: Efficacy and outcomes of perioperative anesthetic management of extracranial to intracranial bypass for complex intracranial aneurysm in the absence of advanced neurological monitoring.
abstract: OBJECTIVE
  Anesthetic management of extracranial to intracranial (EC-IC) bypass for complex intracranial aneurysms is challenging as the goals involve balancing the cerebral perfusion during parent artery clamping and avoiding factors that predispose to rupture of the unsecured aneurysm. There is very sparse literature available on anesthetic management for this procedure.
  
  
  METHODS
  A retrospective review of the records of 20 patients undergoing EC-IC bypass was performed with an objective of assessing the efficacy and outcomes of anesthetic management in the absence of advanced neurological monitoring.
  
  
  RESULTS
  A total of 20 patients underwent EC-IC bypass as an adjunct cerebral revascularization in the management of complex intracranial aneurysms. Intraoperatively normotension and normocarbia were maintained. During the EC-IC bypass, when the temporary clamp was applied, mild hypertension (increase from baseline by 20%) and hypervolemia (central venous pressure increased to 12 mmHg) were maintained. Cerebral protection during temporary clipping of intracranial vessel was provided using moderate hypothermia to 34°C and intravenous thiopentone. Temporary clip time ranged from 15 min to 54 min (mean-25 min). All patients except one were extubated post-operatively (19/20 = 95%). None of the patients had rupture of aneurysm in the peri-operative period. Three patients developed neurologic events (3/20 = 15%). One patient had cerebral vasospasm and two patients developed cerebral infarction. Two patient subsequently improved and one succumbed to the neurological deterioration (mortality 1/20 = 5%).
  
  
  CONCLUSIONS
  Adherence to the principal goals for the procedure, avoidance of hemodynamic fluctuations such as hypotension and hypertension, maintenance of normocarbia, and cerebral protection, result in favorable neurological outcome even in the absence of advanced neuromonitoring.
authors.affiliation: Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
authors.forename: Padmaja
authors.initials: P
authors.lastname: Durga
authors.affiliation: Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
authors.forename: Sudhakar
authors.initials: S
authors.lastname: Kinthala
authors.affiliation: Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
authors.forename: Barada Prasad
authors.initials: BP
authors.lastname: Sahu
authors.affiliation: Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
authors.forename: Manas Kumar
authors.initials: MK
authors.lastname: Panigrahi
authors.affiliation: Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
authors.forename: Srinivas
authors.initials: S
authors.lastname: Mantha
authors.affiliation: Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
authors.forename: Gopinath
authors.initials: G
authors.lastname: Ramachandran
keywords: Anaesthesia; cerebral protection; complex; extracranial to intracranial bypass; goals; intracranial aneurysm; neuromonitoring; outcome; peri-operative; rupture