Clipping the Aneurysm
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The middle cerebral artery is one of the main arteries that supplies blood flow to the brain. It can develop an aneurysm (bulging) which is prone to rupture and an intracerebral hemorrhage - can be fatal.
The treatment involves putting a "clip" at the base of the aneurysm, preventing it from growing/rupturing.
The procedure involves a dance between the neurosurgeon and the anesthesiologist. If the blood pressure is too high, the application of the clip can cause a rupture of the aneurysm. In fact, if the blood pressure is "normal," the tension on the wall of the aneurysm can cause the rupture as well.
So, back in the day, "controlled hypotension" became a technique whereby the gas passer would lower the BP so that the wall tension on the aneurysm was low and the clip could be safely applied. Think an under inflated balloon.
One Saturday morning, when I was a resident, I was waiting to start a case. I started talking to my attending and we talked about controlled hypotension.
Me: Larry, how low will you take the BP in an aneurysm clipping.
Larry: Zero.
Me: What????
Larry: Yup. I would have a syringe of nitrospusside (powerful BP lowering drug) ready to go. As soon as the surgeon said he was ready, I'd ask, "Now, Ed?" And he would say, "Yes, I have the clip around the base of the aneurysm. Go ahead." I'd push the nitroprusside. As soon as the BP hit 0/0 I would say, "Now, Ed." He would apply the clip and I'd let the BP climb up.
Larry had very big balls. I was amazed.
He was one of the best clinicians I ever knew. Great with a needle, great with a laryngoscope and a great teacher.
