Alternate site anesthesia

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					Alternate-site anesthesia
A case of vertebral artery stent insertion

<Admission note>
Name : 呂博 Age : 59 y/o Gender : male Chart No : 1236059

<Chief complaint > intermittent right blindness for 2 months <Present illness>
This 59-year-old male patient was a case of 1.NPC s/p radiotherapy in 1975 with the sequelae of bilateral hearing impairment 2.hypertension with regular control for 4 years 3.hyperlipidemia with diet control 4.drinking and smoking for more than 20 years.Right ICA,ECA and CCA total occlusion were noted accidentally during healthy examination 4 years ago without any symptoms.He was admitted to our ward for further evaluation.

The angiography,MRA and MRI were performed to assess the carotid system and revealed prominent carotid atherosclerosis with pseudoaneurysm formation.After discussion with neurosurgeon,he received conservative treatment and discharged . Several episodes of mouth deviation with saliva drooling but totally recover within 24 hours were noted 5 years ago.Intermittently transient right monocular blindness were noted 2 months ago.Right supra-orbital painful sensation,right ear tinnitus and dizziness associated his transient vision loss.Mild weakness of left side and dysarthria were noted himself in recent 1 year.

*Total occlusion of right ICA,proximal ECA and CCA with reversed right ophthalmic artery flow *Total occlusion of left CCA *Bilateral vertebral artery stricture (R’t: 50% L’t: 90%)

Stent insertion in angio-room →ICU (3B2) →decreasing left side muscle power(2 hours later) →emergent brain CT →right hemisphere ICH & midline shift

• Neurologic examination in interventional radiology

Provocative Pharmacologic Testing @Neurologic evaluation and monitoring are limited during general anesthesia @Direct arterial injection of testing agent through microcatheter before injection of an embolic agent @Barbiturate ;Lidocaine @Transient neurologic deficit Neurophysiologic testing

*Adjunct to surgical excision or reduce the size of AVM nidus to allow curative stereotactic radiosurgery *Anesthetic consideration : restricting patient motion and controlling pain *Light conscious sedation using small IV dose of midazolam and fentanyl *Provocative test

Carotid-cavernous fistulae embolization *Most common types of arteriovenous fistula Direct type:single point of communication between cavernous ICA and surrounding cavernous sinus Indirect type:multiple communication betweendural branches of the ECA or ICA and cavernous sinus *Anesthetic consideration :the same as AVM ;lower risk than AVM

Specific request : transient BP elevation to aid passage to detachable ballon

Aneurysm embolization
*Direct intra-aneurysmal embolization with passage of the artery from which the aneurysm arises *Occlusion of the parent artery along with the aneurysm *1990 : a new type of embolization coil ---the Guglielmi Detachable Coil (GDC system) It can be withdrawn or repositioned at any time

Excellent quality roadmapping is necessary to safely place GDC coils *General anesthesia will be necessary

Discussion : *Closely BP control *Extubation ? *Change anesthetic practice in case of stent placement for neurologic evaluation *ICU prepare after procedure

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