• Annemarie Akkermans, Judith A van Waes, Linda M Peelen, Gabriel J Rinkel, and Wilton A van Klei.
• From the Department of Anesthesiology (A.A., J.A.v.W., L.M.P., W.A.v.K.) the Department of Epidemiology, Julius Center for Health Sciences and Primary Care (L.M.P.) the Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus (G.J.R.), University Medical Center Utrecht, Utrecht University, The Netherlands.
• Anesthesiology. 2019 Jan 1; 130 (1): 92-105.

BackgroundHypocapnia, hypotension, and hypertension during aneurysm occlusion in patients with an aneurysmal subarachnoid hemorrhage may lead to a poor prognosis, but evidence for end-tidal carbon dioxide (ETCO2) and mean arterial pressure (MAP) targets is lacking. Within the ranges of standardized treatment, the authors aimed to study the association between hypocapnia (PaCO2 < 35 mmHg), hypotension (MAP < 80 mmHg), and hypertension (MAP >100 mmHg) during general anesthesia for aneurysm occlusion and neurologic outcome.MethodsThis retrospective observational study included patients who underwent early aneurysm occlusion after an aneurysmal subarachnoid hemorrhage under general anesthesia. ETCO2 and MAP were summarized per patient as the mean and time-weighted average area under the curve for various absolute (ETCO2 < 30, < 35, < 40, < 45 mmHg; and MAP < 60, < 70, < 80, > 90, > 100 mmHg) and relative thresholds (MAP < 70%, < 60%, < 50%). Clinical outcome was assessed with the Glasgow Outcome Scale at discharge and at three months, as primary and secondary outcome measure, respectively.ResultsEndovascular coiling was performed in 578 patients, and 521 underwent neurosurgical clipping. Of these 1,099 patients, 447 (41%) had a poor neurologic outcome at discharge. None of the ETCO2 and MAP ranges found within the current clinical setting were associated with a poor neurologic outcome at discharge, with an adjusted risk ratio for any ETCO2 value less than 30 mmHg of 0.95 (95% CI, 0.81 to 1.10; P < 0.496) and an adjusted risk ratio for any MAP less than 60 mmHg of 0.94 (95% CI, 0.78 to 1.14; P < 0.530). These results were not influenced by preoperative neurologic condition, treatment modality and timing of the intervention. Comparable results were obtained for neurologic outcome at three months.ConclusionsWithin a standardized intraoperative treatment strategy in accordance with current clinical consensus, hypocapnia, hypotension, and hypertension during aneurysm occlusion were not found to be associated with a poor neurologic outcome at discharge in patients with an aneurysmal subarachnoid hemorrhage.

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