Intraoperative jugular bulb desaturation during acute aneurysmal rupture

Abstract

Purpose:To describe an episode of acute jugular venous desaturation during intraoperative rupture of a cerebral aneurysm. Clinical features:A 57-yr-old patient was scheduled for clipping of a large unruptured basilar tip aneurysm. Abrupt bulging of the brain was observed after bone flap removal, but before dura was opened. This was associated with concurrent development of systemic hypertension to 200/120 mmHg and jugular venous bulb (S jv O 2 ) desaturation to 13%. Rupture of aneurysm was confirmed by frank blood in cerebrospinal fluid drainage from the lumbar subarachnoid catheter.Conclusions: Abrupt S jv O 2 desaturation prior to dural opening may suggest an acute increase in intracranial pressure, which in our case followed aneurysmal rupture; the systemic response to increased intracranial pressure (Cushing's response) may be ineffective in maintaining cerebral perfusion.

Perioperative Management of Aneurysmal Subarachnoid Hemorrhage

“…26 Simultaneously, the jugular venous oxygen saturation may acutely decrease. 27 Intraventricular bleeding can cause acute ventricular dilatation and hydrocephalus. 25 Timely restoration of cerebral perfusion by the placement of external ventricular drain often improves the patient's neurologic status almost immediately.…”

Controversies in the Anesthetic Management of Intraoperative Rupture of Intracranial Aneurysm

“…Other monitoring methods such as transcranial Doppler, ultrasound, and different devices to monitor cerebral oxygenation may be useful to detect intraoperative rupture, especially if rupture occurs before dural opening [33–35]. One report highlighted the significance of TCD for detection of IAR and the major finding was the loss of diastolic flow or even the reversal of diastolic flow [33].…”

“…This technique utilizes the special window (Paine's point) to provide axial images showing the anterior interhemispheric fissure, lentiform nucleus, insular cortex, Sylvian fissure, and ventricular system. On the other hand, other devices such as noninvasive and invasive cerebral oximetry have been employed mainly for detection of cerebral ischemia during clip placement; however, sudden reduction of values may be one of the earliest signs of IAR if other possibilities have been ruled out [35]. …”