Emerging anesthesia techniques for managing intraoperative rupture of cerebral aneurysms.

Intraoperative aneurysm rupture (IAR) is one of the most feared complications associated with microsurgical clipping of cerebral aneurysms. To the surgeon, this situation is typi fi ed by an operative fi eld that is rapidly fi lling with blood, often with the ultimate source of hemorrhage not readily identi fi ed. Coupled with the sudden and unexpected nature of the event, an IAR can create great stress for the surgeon and the anesthesiologist. In a survey of neurovascular surgeons, IAR was identi fi ed as one of the major technical challenges to aneurysm clipping. 1 Despite the advancement of endovascular techniques, microsurgical clipping performed via a craniotomy remains indicated for a variety of reasons, such as for patients with subarachnoid hemorrhage (SAH) with mass effect, cranial nerve palsies due to compression by the aneurysm, wide-necked bifurcation or irre-gularly-shaped aneurysms, and ones that have failed endovascular treatment. 2 As microsurgical clipping becomes reserved for more complex indications, the risk of IAR is likely to remain signi fi cant. In the event of IAR, the anesthesiologist plays a critical role, not only in providing adequate resuscitation but also in facilitating the surgeon ’ s visualization and treatment of the bleeding aneurysm. This narrative review focuses on anesthesia techniques that can aid the surgeon in the management of ruptured aneurysms, namely induced hypotension with either adenosine or rapid ventricular pacing (RVP). In addition to the incidence and risk factors for IAR, this review speci fi cally aims to present the management of IAR from the surgeon ’ s