Conscious sedation potential for intracranial aneurysm intervention

By Eleanor McDermid, Senior medwireNews Reporter

Coil embolization of ruptured intracranial aneurysms can be performed using conscious sedation and local anesthesia, report clinicians.

The approach has a number of potential advantages, say study author Elad Levy (University at Buffalo, New York, USA) and colleagues. These include avoidance of the risks associated with general anesthesia, simpler and cheaper operations, and reduced turnover time.

However, the anesthesia team must be immediately available, in case a patient does not tolerate conscious sedation or complications arise. Conversion to general anesthesia was required in seven of 78 procedures that Levy et al performed using conscious sedation. In this scenario, general anesthesia is given emergently; the team says conversion is possible in less than 10 minutes if an anesthesiologist is on standby.

"Conscious sedation also allows direct and frequent neurological examination of the patient without relying on the interpretation of electrophysiological monitoring," write Levy et al in Neurosurgery.

This potentially allows faster detection of and response to intraprocedural complications, they say.

The researchers performed frequent motor, sensory, and speech assessment during the conscious sedation operations. They were selective about which patients received conscious sedation, however, with 80.8% of these patients having a Hunt and Hess grade of I and II. And none had a poor grade (IV or V), compared with 54.5% of the 112 patients who received general anesthesia.

The overall rate of adverse events - perforations and embolic complications - was 10.2%, or 2.5%, counting only symptomatic events. There were six embolic complications in patients given conscious sedation and two in those given general anesthesia, all of which resolved spontaneously. The corresponding numbers of perforations were three and 11.

There was no significant difference between the adverse event rates during procedures using conscious sedation and those using general anesthesia, at 9.4% and 11.6%, respectively. The overall mortality rate was 15.5%; it was just 2.5% in the conscious sedation group, but the team puts this down to the low clinical grades in these patients.

Another potential problem is that patient movement could lead to poor-quality imaging, note the researchers. They say: "In our experience, this perceived disadvantage can be overcome by gentle stabilization of the patient's head in a headholder attached to the angiographic table." However, three of the conversions to general anesthesia were required because of excessive patient movement.

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