What are the recommendations for postoperative management of berry aneurysm syndrome?

Postoperative Management of Berry Aneurysm Syndrome

The postoperative management of berry aneurysm syndrome should focus on neurointensive care monitoring for at least 24 hours, maintaining normotensive and euvolemic conditions, and controlling blood pressure with agents that do not affect the central nervous system. 1

Immediate Postoperative Care

• Patients should receive neurological intensive care monitoring for at least 24 hours after surgical intervention 1
• Blood pressure should be monitored continuously with an arterial catheter 1
• Urine output should be monitored with an indwelling catheter to ensure euvolemia 1
• Normotensive and euvolemic conditions should be maintained to prevent both hypoperfusion and hypertensive complications 1
• Tight blood pressure control with agents that do not act in the central nervous system may be appropriate for selected individuals 1

Management of Specific Complications

Postoperative Nausea and Vomiting

• A multimodal regimen of antiemetics targeting different chemoreceptors is recommended to prevent aspiration of gastric contents 1
• Serotonin 5-HT3 receptor antagonists (e.g., ondansetron) and steroids (e.g., dexamethasone) are preferred antiemetics 1
• Propofol, reduction of narcotics, and maintenance of euvolemia should be considered as part of the antiemetic strategy 1
• Medications that can impair neurological examination (anticholinergics like scopolamine and phenothiazines like promethazine) should be avoided or used at lower doses 1

Glycemic Control

• Poor perioperative glycemic control has been associated with increased risk of poor clinical outcomes 1
• Prevention of both hyperglycemia and hypoglycemia is indicated during the postoperative period 1
• Hyperglycemia has been associated with long-term changes in cognition and gross neurological function 1

Temperature Management

• Postoperative hyperthermia may be detrimental and should be avoided 1
• Careful attention should be paid to controlling patient temperature in the intensive care unit 1
• Mild intraoperative-induced hypothermia may exacerbate postoperative hyperthermia 1

Emergence Hypertension

• Emergence hypertension is frequently encountered after aneurysm resection 1
• Elevated plasma renin and norepinephrine levels are associated with this phenomenon 1
• Blood pressure should be carefully controlled to prevent both ischemic deficits and hemorrhagic complications 1

Imaging and Follow-up

• An angiogram should be performed during the immediate postoperative period to confirm complete resection of the aneurysm 1
• New neurological deficits after surgery should be investigated with CT scan to rule out hemorrhage or hydrocephalus 1
• MRI with diffusion-weighted imaging may be appropriate if infarction is suspected 1
• For patients who have undergone endovascular treatment, follow-up imaging is recommended at 1 and 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalities are documented 1

Management of Brain Edema/Hemorrhage

• Two hypotheses for postoperative brain edema and hemorrhage include normal perfusion pressure breakthrough (NPPB) and occlusive hyperemia 1
• α-Adrenergic blockade may be useful in preventing and treating NPPB syndrome based on anecdotal information 1
• Marginally perfused areas may be critically dependent on collateral perfusion pressure, so maintenance of adequate blood pressure is important to prevent infarction 1
• Verification of potential borderline perfusion states may require intraoperative or immediate postoperative angiography 1

Special Considerations for Associated Aneurysms

• Intracranial aneurysms are found in 7-17% of patients with arteriovenous malformations 1
• Associated aneurysms should be treated during the same surgery if the operative field is adequate, or separately with endovascular or open surgical obliteration 1
• Management of associated aneurysms should be determined on an individual basis 1

Medication Management

• Perioperative antibiotics, steroids, and seizure medications are used variably and should be considered based on individual risk factors 1
• After the intensive care period, the patient should be transferred to a standard surgical floor for mobilization 1

By following these guidelines for postoperative management, clinicians can optimize outcomes and minimize complications in patients with berry aneurysm syndrome.