BoardsBridgeAneurysm Coiling — Anesthesia for Endovascular Intracranial Aneurysm Treatment
Peri-procedural anesthetic management of elective and ruptured aneurysm coiling: BP targets, heparin/protamine, intraprocedural rupture, VAE, and post-coiling vasospasm care.
Endovascular coiling of intracranial aneurysms requires tight BP control at or below baseline until the aneurysm is secured, full heparinization with ACT monitoring, immediate bedside access to protamine, mannitol, and nicardipine for intraprocedural rupture, and post-procedural nimodipine plus modified Triple H ONLY after the aneurysm is secured and vasospasm is confirmed.
If you forget
Headline — keep BP AT BASELINE until the aneurysm is coiled; permissive HTN is for AFTER it's secured and vasospasm is confirmed
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Key numbers
- Protamine: 1 mg per 100 U heparin; less needed as time from heparin dose increases — titrate to ACT
- Mannitol: 0.25–1 g/kg IV infused over 15 min (caution in CHF, severe renal disease with anuria)
- Nicardipine infusion: 2.5–15 mg/h IV
- IV nicardipine alternative: 0.075–0.15 mg/kg/h (≈5–10 mg/h for 70 kg)
- Nimodipine: 60 mg PO q4h × 21 days
- Typical ACT target during coiling: ~2–3× baseline (~250–300 s) — confirm with interventionalist
Uri Rozen, MD — Licensed Physician, Israel
Source guidelines: SNACC Neuroanesthetic Emergencies 2020 · SNACC Neuroanesthetic Emergencies 2020 · AHA SAH 2023 · AHA SAH 2023
Re-review cadence: 12 months from reviewed date.
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Card ID: aneurysm-coiling · Path: aba.neuro.neurointerventional.aneurysm-coiling