Anesthesia for the surgical treatment of cerebral aneurysms
Keywords:
Subarachnoid hemorrhage, Aneurysm, Intracranial aneurysm, Anesthesia, Hemorrhage
Abstract
Although most cerebral aneurysms are asymptomatic and discovered incidentally, their rupture often results in significant morbidity and mortality. The anesthesiologist may become involved in surgical clipping of aneurysms either before aneurysm rupture or after subarachnoid hemorrhage. After subarachnoid hemorrhage, a multisystemic preoperative evaluation is mandatory because both neurological complications (elevated intracranial pressure, rebleeding, hydrocephalus, vasospasm) and non-neurological complications (respiratory insufficiency, cardiac dysfunction, electrolyte abnormalities, endocrine disturbances) might influence anesthetic management. Besides being prepared for potential sudden profuse bleeding, the anesthesiologist caring for craniotomy for aneurysm clipping should follow four main principles. First, acute increase in the aneurysm transmural gradient (mean arterial pressure minus intracranial pressure) should be avoided to prevent rupture or rebleeding. Second, the cerebral perfusion pressure should be maintained with euvolemia and vasopressors to avoid brain ischemia caused either by brain retractors or temporary clipping of the feeding vessel. Third, surgical exposure should be optimized by providing brain relaxation with normal cerebral oxygenation, normal ventilation or transient hyperventilation, appropriate anesthetic choice, mannitol and perhaps lasix, and occasionally cerebrospinal fluid drainage. Fourth, early emergence is favored to allow recognition of potentially reversible complications. By being vigilant and achieving these goals, the anesthesiologist will contribute to optimal patient outcomes. The following article provides information to guide the anesthesiologist in optimal management of surgical clipping of aneurysms.
References
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2. Vlaq MHM, Algra A, Brandenburg R, Rinkel GJE. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country and time period: a systemic review and meta-analysis. Lancet Neurol. 2011;10:626-36.
3. Conolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711-37.
4. International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362:103-10.
5. Schievink W. Intracranial aneurysms. N Engl J Med. 1997;336:28-40.
6. Feigin VL, Lawes CMM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 2009;8:355-69.
7. Friedman JA, Piepgras DG, Pichelmann MA, Hansen KK, Brown RD, Wiebers DO. Small cerebral aneurysms presenting with symptoms other than rupture. Neurology. 2001;57:1212-6.
8. Raps EC, Rogers JD, Galetta SL, Solomon RA, Lennihan L, Klebanoff LM, et al. The clinical spectrum of unruptured intracranial aneurysm. Arch Neurol. 1993;50:265-8.
10. Güresir E, Vatter H, Schuss P, Platz J, Konczalla J, Du Mesnil de Rochement R, et al. Natural history of small unruptured anterior circulation aneurysms. A prospective cohort study. Stroke. 2013;44:3027-31.
11. The International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms. Risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339:1725-33.
12. Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med. 2006;355:928-39.
13. Komotar RJ, Mocco J, Solomon RA. Guidelines for the surgical treatment of unruptured intracranial aneurysms: the first annual J. Lawrence pool memorial research symposium-controversies in the management of cerebral aneurysms. Neurosurgery. 2008;62:183-93.
14. Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, Brott T, et al. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation. 2000;102:2300.
15. Hunt WW, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14-20.
16. Drake CG, Hunt WE, Sano K, Kassell N, Teasdale G, Pertuiset B. Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg. 1988;68:985-6.
17. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6:1-9.
18. Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales. A systematic review. Neurocrit Care. 2005;2:110-8.
19. Diringer MN, Bleck TP, Hemphill JC III, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15:211-40.
20. Schneider HJ, Kreitschmann-Andermahr I, Ghigo E, Stalla GK, Agha A. Hypothalamopituitary dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage. A systematic review. JAMA. 2007;298:1429-38.
21. Naidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsimmons BF, Parra A, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62:410-6.
22. Lord AS, Fernandez L, Schimdt JM, Mayer SA, Classen J, Lee K, et al. Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. Neurology. 2012;78:31-7.
23. Drummond JC, Patel PM. Neurosurgical anesthesia. In: Miller RD, editor. Anesthesia. 7th ed. Philadelphia: Churchill Livingstone Elsevier; 2010. p. 2045-87.
24. Barker FG, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a meta analysis. J Neurosurg. 1996;84:405-14.
25. Abruzzo T, Moran C, Blackham KA, Eskey CJ, Lev R, Meyers P, et al. Invasive interventional management of post-hemorrhagic cerebral vasopasm in patients with aneurysmal subarachnoid hemorrhage. J Neurointervent Surg. 2012;4:169-77.
26. Douglas MR, Daniel M, Lagord C, Akinwunmi J, Jackowski A, Cooper C, et al. High CSF transforming growth factor ß levels after subarachnoid haemorrhage: association with chronic communicating hydrocephalus. J Neurol Neurosurg Psychiatry. 2009;80:545-50.
27. Hravnak M, Frangiskakis M, Crago EA, Chang Y, Tanabe M, Gorcsan J, et al. Elevated cardiac troponin I and relation to persistence of electrocardiographic and echocardiographic abnormalities after aneurysmal subarachnoid hemorrhage. Stroke. 2009;40:3478-84.
28. Tung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton M, et al. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004;35:548-53.
29. Zaroff JG, Rordorf GA, Newell JB, Ogilvy CS, Levinson JR. Cardiac outcome in patients with subarachnoid hemorrhage and electrocardiographic abnormalities. Neurosurgery. 1999;44:34-9.
30. Junttila E, Vaara M, Koskenkari J, Ohtonen P, Karttunen A, Raatikainen P, et al. Repolarization abnormalities in patients with subarachnoid and intracerebral hemorrhage: predisposing factors and association with outcome. Anesth Analg. 2013;116:190-7.
31. Van der Bilt IAC, Hasan D, Vandertop WP, Wilde AAM, Algra A, Visser FC, et al. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage. Neurology. 2009;72:635-42.
32. Coghlan LA, Hindman BJ, Bayman EO, Banki NM, Gelb AW, Todd MM, et al., IHAST Investigators. Independent associations between electrocardiographic abnormalities and outcomes in patients with aneurysmal subarachnoid hemorrhage: findings from the intraoperative hypothermia aneurysm surgery trial. Stroke. 2009;40:412-8.
33. Naidech A, Kreiter KT, Janjua N, Ostapkovich ND, Parra A, Commichau C, et al. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation. 2005;112:2851-6.
34. Tung PP, Olmsted E, Kopelnik A, Banki NM, Drew BJ, Ko N, et al. Plasma B-type natriuretic peptide levels are associated with early cardiac dysfunction after subarachnoid hemorrhage. Stroke. 2005;36:1567-71.
35. Frontera JA, Parras A, Shimbo D, Fernandez A, Schmidt JM, Peter P, et al. Cardiac arrhythmias after subarachnoid hemorrhage: risk factors and impact on outcome. Cerebrovasc Dis. 2008;26:71-8.
36. Rahman M, Friedman WA. Hyponatremia in neurosurgical patients: clinical guidelines development. Neurosurgery. 2009;65:925-35.
37. Absalom A, Poole T. Intravenous anesthetic agents. In: Gupta AK, Gelb AW, editors. Essentials of neuroanesthesia and neurointensive care. Philadelphia: Saunders Elsevier; 2008. p. 51-8.
38. Marsh ML, Marshall LF, Shapiro HM. Neurosurgical intensive care. Anesthesiology. 1977;47:149-63.
39. Stoelting RK, Hillier SC. Diuretics. In: Stoelting RK, Hillier SC, editors. Pharmacology and physiology in anesthesia practice. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2006. p. 490-2.
40. Samson D, Batjer HH, Bowman G, Mootz L, Krippner WJ Jr, Meyer YJ, et al. A clinical study of the parameters and effects of temporary arterial occlusion in the management of intracranial aneurysms. Neurosurgery. 1994;34:22-9.
41. Lavine AD, Masri LS, Levy ML, Giannotta SL. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection. J Neurosurg. 1997;87:817-24.
42. Ogilvy CS, Carter BS, Kaplan S, Rich C, Crowell R. Temporary vessel occlusion for aneurysm surgery: risk factors for stroke in patients protected by induced hypothermia and hypertension and intravenous mannitol administration. J Neurosurg. 1996;84:785-91.
43. Hindman BJ, Bayman EO, Pfisterer WK, Torner JC, Todd MM, IHAST Investigators. No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial. Anesthesiology. 2010;112:86-101.
44. Bilotta F, Gelb AW, Stazi E, Titi L, Paoloni FP, Rosa G. Pharmacological perioperative brain neuroprotection: a qualitative review of randomized clinical trials. Br J Anaesth. 2013;110 Suppl. 1:1113-20.
45. Todd MM, Hindman B, Clarke WR, Torner JC, for the IHAST Investigators. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med. 2005;352: 135-45.
46. Li LR, You C, Chaudhary B. Intraoperative mild hypothermia for postoperative neurological deficits in intracranial aneurysm patients. Cochrane Database Syst Rev. 2012. Feb 15;2:CD008445, http://dx.doi.org/10.1002/14651858.CD008445.pub2.
47. Giannotta SL, Oppenheimer JHM, Levy ML, Zelman V. Management of intraoperative rupture of aneurysm without hypotension. Neurosurgery. 1991;28:531-5.
48. Bebawy JF, Zeeni C, Sharma S, Kim ED, DeWood MS, Hemmer LB, et al. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation does not worsen neurologic outcome. Anesth Analg. 2013;117:1205-10.
49. Luostarinen T, Takala RSK, Niemi TT, Katila AJ, Niemelä M, Hernesniemi J, et al. Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture. World Neurosurg. 2010;73:79-83.
50. Chowdhury T, Petropolis A, Wilkinson M, Schaller B, Sandu N, Cappellani RB. Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract. 2014:1-11.
2. Vlaq MHM, Algra A, Brandenburg R, Rinkel GJE. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country and time period: a systemic review and meta-analysis. Lancet Neurol. 2011;10:626-36.
3. Conolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711-37.
4. International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362:103-10.
5. Schievink W. Intracranial aneurysms. N Engl J Med. 1997;336:28-40.
6. Feigin VL, Lawes CMM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 2009;8:355-69.
7. Friedman JA, Piepgras DG, Pichelmann MA, Hansen KK, Brown RD, Wiebers DO. Small cerebral aneurysms presenting with symptoms other than rupture. Neurology. 2001;57:1212-6.
8. Raps EC, Rogers JD, Galetta SL, Solomon RA, Lennihan L, Klebanoff LM, et al. The clinical spectrum of unruptured intracranial aneurysm. Arch Neurol. 1993;50:265-8.
10. Güresir E, Vatter H, Schuss P, Platz J, Konczalla J, Du Mesnil de Rochement R, et al. Natural history of small unruptured anterior circulation aneurysms. A prospective cohort study. Stroke. 2013;44:3027-31.
11. The International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms. Risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339:1725-33.
12. Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med. 2006;355:928-39.
13. Komotar RJ, Mocco J, Solomon RA. Guidelines for the surgical treatment of unruptured intracranial aneurysms: the first annual J. Lawrence pool memorial research symposium-controversies in the management of cerebral aneurysms. Neurosurgery. 2008;62:183-93.
14. Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, Brott T, et al. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation. 2000;102:2300.
15. Hunt WW, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14-20.
16. Drake CG, Hunt WE, Sano K, Kassell N, Teasdale G, Pertuiset B. Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg. 1988;68:985-6.
17. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6:1-9.
18. Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales. A systematic review. Neurocrit Care. 2005;2:110-8.
19. Diringer MN, Bleck TP, Hemphill JC III, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15:211-40.
20. Schneider HJ, Kreitschmann-Andermahr I, Ghigo E, Stalla GK, Agha A. Hypothalamopituitary dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage. A systematic review. JAMA. 2007;298:1429-38.
21. Naidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsimmons BF, Parra A, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62:410-6.
22. Lord AS, Fernandez L, Schimdt JM, Mayer SA, Classen J, Lee K, et al. Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. Neurology. 2012;78:31-7.
23. Drummond JC, Patel PM. Neurosurgical anesthesia. In: Miller RD, editor. Anesthesia. 7th ed. Philadelphia: Churchill Livingstone Elsevier; 2010. p. 2045-87.
24. Barker FG, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a meta analysis. J Neurosurg. 1996;84:405-14.
25. Abruzzo T, Moran C, Blackham KA, Eskey CJ, Lev R, Meyers P, et al. Invasive interventional management of post-hemorrhagic cerebral vasopasm in patients with aneurysmal subarachnoid hemorrhage. J Neurointervent Surg. 2012;4:169-77.
26. Douglas MR, Daniel M, Lagord C, Akinwunmi J, Jackowski A, Cooper C, et al. High CSF transforming growth factor ß levels after subarachnoid haemorrhage: association with chronic communicating hydrocephalus. J Neurol Neurosurg Psychiatry. 2009;80:545-50.
27. Hravnak M, Frangiskakis M, Crago EA, Chang Y, Tanabe M, Gorcsan J, et al. Elevated cardiac troponin I and relation to persistence of electrocardiographic and echocardiographic abnormalities after aneurysmal subarachnoid hemorrhage. Stroke. 2009;40:3478-84.
28. Tung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton M, et al. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004;35:548-53.
29. Zaroff JG, Rordorf GA, Newell JB, Ogilvy CS, Levinson JR. Cardiac outcome in patients with subarachnoid hemorrhage and electrocardiographic abnormalities. Neurosurgery. 1999;44:34-9.
30. Junttila E, Vaara M, Koskenkari J, Ohtonen P, Karttunen A, Raatikainen P, et al. Repolarization abnormalities in patients with subarachnoid and intracerebral hemorrhage: predisposing factors and association with outcome. Anesth Analg. 2013;116:190-7.
31. Van der Bilt IAC, Hasan D, Vandertop WP, Wilde AAM, Algra A, Visser FC, et al. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage. Neurology. 2009;72:635-42.
32. Coghlan LA, Hindman BJ, Bayman EO, Banki NM, Gelb AW, Todd MM, et al., IHAST Investigators. Independent associations between electrocardiographic abnormalities and outcomes in patients with aneurysmal subarachnoid hemorrhage: findings from the intraoperative hypothermia aneurysm surgery trial. Stroke. 2009;40:412-8.
33. Naidech A, Kreiter KT, Janjua N, Ostapkovich ND, Parra A, Commichau C, et al. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation. 2005;112:2851-6.
34. Tung PP, Olmsted E, Kopelnik A, Banki NM, Drew BJ, Ko N, et al. Plasma B-type natriuretic peptide levels are associated with early cardiac dysfunction after subarachnoid hemorrhage. Stroke. 2005;36:1567-71.
35. Frontera JA, Parras A, Shimbo D, Fernandez A, Schmidt JM, Peter P, et al. Cardiac arrhythmias after subarachnoid hemorrhage: risk factors and impact on outcome. Cerebrovasc Dis. 2008;26:71-8.
36. Rahman M, Friedman WA. Hyponatremia in neurosurgical patients: clinical guidelines development. Neurosurgery. 2009;65:925-35.
37. Absalom A, Poole T. Intravenous anesthetic agents. In: Gupta AK, Gelb AW, editors. Essentials of neuroanesthesia and neurointensive care. Philadelphia: Saunders Elsevier; 2008. p. 51-8.
38. Marsh ML, Marshall LF, Shapiro HM. Neurosurgical intensive care. Anesthesiology. 1977;47:149-63.
39. Stoelting RK, Hillier SC. Diuretics. In: Stoelting RK, Hillier SC, editors. Pharmacology and physiology in anesthesia practice. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2006. p. 490-2.
40. Samson D, Batjer HH, Bowman G, Mootz L, Krippner WJ Jr, Meyer YJ, et al. A clinical study of the parameters and effects of temporary arterial occlusion in the management of intracranial aneurysms. Neurosurgery. 1994;34:22-9.
41. Lavine AD, Masri LS, Levy ML, Giannotta SL. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection. J Neurosurg. 1997;87:817-24.
42. Ogilvy CS, Carter BS, Kaplan S, Rich C, Crowell R. Temporary vessel occlusion for aneurysm surgery: risk factors for stroke in patients protected by induced hypothermia and hypertension and intravenous mannitol administration. J Neurosurg. 1996;84:785-91.
43. Hindman BJ, Bayman EO, Pfisterer WK, Torner JC, Todd MM, IHAST Investigators. No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial. Anesthesiology. 2010;112:86-101.
44. Bilotta F, Gelb AW, Stazi E, Titi L, Paoloni FP, Rosa G. Pharmacological perioperative brain neuroprotection: a qualitative review of randomized clinical trials. Br J Anaesth. 2013;110 Suppl. 1:1113-20.
45. Todd MM, Hindman B, Clarke WR, Torner JC, for the IHAST Investigators. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med. 2005;352: 135-45.
46. Li LR, You C, Chaudhary B. Intraoperative mild hypothermia for postoperative neurological deficits in intracranial aneurysm patients. Cochrane Database Syst Rev. 2012. Feb 15;2:CD008445, http://dx.doi.org/10.1002/14651858.CD008445.pub2.
47. Giannotta SL, Oppenheimer JHM, Levy ML, Zelman V. Management of intraoperative rupture of aneurysm without hypotension. Neurosurgery. 1991;28:531-5.
48. Bebawy JF, Zeeni C, Sharma S, Kim ED, DeWood MS, Hemmer LB, et al. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation does not worsen neurologic outcome. Anesth Analg. 2013;117:1205-10.
49. Luostarinen T, Takala RSK, Niemi TT, Katila AJ, Niemelä M, Hernesniemi J, et al. Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture. World Neurosurg. 2010;73:79-83.
50. Chowdhury T, Petropolis A, Wilkinson M, Schaller B, Sandu N, Cappellani RB. Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract. 2014:1-11.
How to Cite
1.
Lecours M, Gelb AW. Anesthesia for the surgical treatment of cerebral aneurysms. Colomb. J. Anesthesiol. [Internet]. 2015 Jul. 1 [cited 2024 Apr. 25];43(Supplement):45-51. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/731
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2015-07-01
How to Cite
1.
Lecours M, Gelb AW. Anesthesia for the surgical treatment of cerebral aneurysms. Colomb. J. Anesthesiol. [Internet]. 2015 Jul. 1 [cited 2024 Apr. 25];43(Supplement):45-51. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/731
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