Author(s): Srinivasaiah R.; Lemos C.; Vadivel D.
Source: Journal of Neurosurgical Anesthesiology; Oct 2019; vol. 31 (no. 4); p. 478-479
Publication Date: Oct 2019
Publication Type(s): Conference Abstract
Abstract:Background: Sneddon syndrome is a rare progressive disease affecting small and medium sized blood vessels of multiple organs including brain. We report a case of patient with Sneddon syndrome posted for clipping of basilar artery aneurysm. Managing this patient was challenging as she had an aneurysm in the artery which was providing major contribution to cerebral circulation, she had virtually no carotid circulation. Case Description: A 42-year-old woman who was newly diagnosed with Sneddon syndrome presented to our institute with a 9 mm Basilar artery aneurysm with a wide neck. Her presenting symptoms were headache associated with nausea, photophobia, and dizziness. CT angiogram showed significant narrowing of both internal carotid arteries (picture 1) and lack of flow across both frontal areas. She had a 60% lifetime risk of rupture (ISUIA) therefore she was considered for clipping of the aneurysm. Pre-operative assessment was performed 1 week before the surgery, routine blood investigations, and physical examinations were normal. She was taking Aspirin, Propranolol, and Citalopram. Aspirin was stopped 1 week before surgery. After performing WHO checklist we established invasive arterial blood pressure monitoring before induction in the Anesthetic room and commenced on prophylactic Metaraminol and Nimodipine infusion. The goal of the anaesthetic management was to ensure adequate cerebral perfusion and to preserve the collateral circulation. Anesthesia was induced with Remifentanil TCI, Propofil, and Vecuronium. After the insertion of endotracheal tube patient was positioned prone on blocks for the surgery. Anesthesia was maintained with Remifentanil TCI and Desflurane. Intraop period was uneventful. After the successful clipping of the Basilar artery patient was woken up with a GCS of 15. Nimodipine and Metaraminol infusions were stopped at the end of the surgery and transferred her to Neurocritical care. On third postop day patient developed third nerve palsy, dysphasia and cognitive changes. Apixaban was started to prevent further ischaemic complications. Later she was transferred to neuro rehab facility. Discussion(s): Sneddon syndrome is a rare progressive disease characterised by presence of Livedo reticularis and neurological abnormalities. They can present with CVA, TIA, headache, dizziness, memory loss, reduced intellectual ability, hypertension, heart disease, etc., symptoms and presentations can vary, the important ones for the anesthetists are cerebral ischemia, valvular heart disease, renal failure, and thrombosis of vital blood vessels. Majority of the patients will be on anticoagulants and cardiac medications. Most of the anesthetic drugs used in everyday practice can be safely used in these patients.1 Use of ihromboelastog-raphy perioperatively is useful for managing bleeding. These patients should be monitored in neurocritical care during postop period.
Database: EMBASE