Anaesthetic management of a case of cavernous carotid aneurysm with thrombus

1. ANAESTHETIC MANAGEMENT OF A CASE OF
CAVERNOUS CAROTID ANEURYSM WITH THROMBUS
Presented by – Dr Neelima Nath 2nd yr PGT
Guided by Prof. Dr. Laxmidhar Dash
Dept. of Anaesthesiology & Critical care, SCB
MCH,Cuttack

2. NAME – Kusuma Rout
AGE – 45 yrs, female, 50 kgs
W/o – Manas Rout
AT/PO – Rajakanika,Kendrapara
Admitted to Dept. of Neurosurgery, SCBMCH
Regd.no – 325/19.04.23

3. C/C-
Right hemicranial headache - since 1 month
Drooping of eyelid-28 days

4. H/O PRESENT ILLNESS :
• Patient was apparently alright 1 yrs back .
• To start with he developed tingling and numbness of both foot since one
year
• Slipage of foot wear unknowningly -6 months
• Headache-1 month back which was hemicranial a/w vomiting relived on
medication and present throught out the day
• Drooping of right eyelid since 28 days
• Numbness of right side face-4days .
• Following this she presented to the PHC RAJAKANIKA,then refered
toSCBMCH ,CUTTACK
• There is no h/o LOC,double vision,diminution of vision,watering of
eye,frequency or urgency of micturition,dysphagia,dysarthria, a/w this
symptoms.

5. H/O PAST ILLNESS
• No h/o similar illness in past
• No h/o HTN,DM,TB,ASTHMA,EPILEPSY
• No past h/o any surgery

6. • PERSONAL HISTORY :
Low socioeconomic status
housewife
Married and blessed with one child
Not addicted to Bidi/Pan/Gutkha/Tobacco
• FAMILY HISTORY :
Nothing suggestive

7. GENERAL EXAMINATION
• Pt conscious oriented to time,place,person and
cooperative.
• Average body built
• PR – 87/min, regular with good volume without radio-
radial or radio-femoral delay.
• BP – 118/76 mm Hg, right arm supine position.
• RR – 15/min ,regular
• Temp – Afebrile.

8. SYSTEMIC EXAMINATION
CNS Examination
• Conscious, Co-operative, well oriented to time ,place & person
• GCS – 15/15
• B/L Pupil – Normal size & RTL
• Higher Mental Function (HMF) – INTACT
• CN 1 (olfactory)- Intact through b/l nostrils
• CN 2 (optic) – B/L eyes VA 6/6
• CN 3(oculomotor)-Rt-palsy
• CN 4(Trochlear)-Rt palsy
• CN 5(trigemina)l-V,V2,V3 Rt-palsy
CN 6(Abducens) – Rt palsy
• CN 7(facial) – All facial muscle & taste sensation of ant. 2/3rd of tongue INTACT
• CN 8(vestibulocochlear) –Normal hearing b/l
• CN 9(glossopharyngeal)- Post 1/3rd tongue (S+T) INTACT
• CN 10,11,12 - INTACT
• No skull or spine abnormality
• No cerebellar signs

9. All other systemic examination like
• CVS
• Respiratory System
• Gastro-intestinal system and
• Genitourinary system appears to be
normal.

10. AIRWAY EXAMINATION
• MPG – 1I
• MO – 3 finger
• Neck Movement – normal in all direction
• No loose dentition or protruding teeth

11. INVESTIGATIONS
HB- 12.5gm% , PCV- 43.5%
TLC- 9069/cu mm
DC- N-67%, E-3%, B-0% ,L-25%, M-3%
TPC- 3.95 lac/cu mm
PT =13.8sec, APTT = 30.2sec, INR = 1.10sec
HIV,HCV,HbsAg – NEGATIVE
RBS – 82 mg/dl , BL.urea – 17 mg/dl, Sr.creat – 0.5 mg/dl
Sr.K – 4.5 mEq/L, Sr.Na – 141 mEq/L
LFT. – S.BILL.(D)- 0.8mg/dl ,(T)-0.2mg/dl , AST- 34 IU/L, ALK.PHOS-
116 IU/L

12. CHEST X RAY PA VIEW –
APPEARS TO BE
NORMAL

13. ECG

14. MRI BRAIN AND MRA –
>SELLAR CIRCUMSCRIBED WALL ENHANCING SOL WITH MASS
EFFECT OVER PITUITARY CAUSING ITS DISPLACEMENT-CAVERNOUS
CAROTID ANEURYSM WITH THROMBOSIS.
MRA-ANEURYSMAL DILATATION OF BILATERALCAVERNOUS
CAROTID ANEURYSM WITH THROMBOSIS IN IT.

15. PROVISIONAL DIAGNOSIS
-B/L CAVERNOUS CAROTID ANEURYSM WITH
THROMBOS
-Rt 3rd,4th,5th,6th CRANIAL NERVE PALSY

16. DIFFERENTIAL DIAGNOSIS
Carotid tumor

17. PAC
• HISTORY
• GENERAL AND CLINICAL EXAMINATION OF CVS ,
RESPIRATORY & CENTRAL NERVOUS SYSTEM
• AIRWAY EXAMINATION
• VITALS
• INVESTIGATIONS
• PRE-OP ADVICE

18. PRE OPERATIVE PREPARATION,
INDUCTION AND MONITORING
• NPO for 8hrs
• 18G iv peripheral line
• Premedication(30mins prior to surgery) – inj ceftriaxone 1
gm iv
inj phenytoin 1amp
iv
inj pantop (40) iv
• 5 lead ECG
• Pulse oximeter
• NIBP
• Urinary catheterization

19. • Cont.
• INDUCTION
• Premedicated with inj glycopyrollate – 0.005 mg/kg iv
• inj midazolam – 0.02 mg/kg iv
• inj nalbufine – 0.2 mg/kg iv
• Induced with inj propofol – 2 mg/kg iv
• Intubated with inj succinylcholine - 2 mg/kg iv
• Relaxant inj vecuronium - 0.1 mg/kg iv ,loading dose
• EtCO2
• Temperature probe

20. POSITIONING – PARK BENCH POSITION
• Facilitate access to midline structures
• Care taken for pressure area protection
• After positioning pt covered with warmer.

21. INTRA OP MONITORING
• Maintain deep plane of anaesthesia
• Blood loss monitoring and transfusion to be done.
• Avoid dextrose containing solutions as it increases chances of
cerebral edema and hyperglycemia.
• Monitering of IBP ,HR closely to early diagnosis of rupture of
aneurysm

22. EMERGENCE & EXTUBATION
• Considerations
• Awake following
commands& return of
airway reflexes.
• pre op neurological status
• Extent, severity and
duration of surgery
• Hemodynamic stability &
blood loss
• Goals
• Prevent abrupt rises in BP.
• Minimize coughing and
straining on ETT.