Laryngeal mask airway for general anesthesia in

interventional neuroradiology procedures

Mehmet Ö. Özhan, MD, Mehmet B. Eşkin, MD, Bülent Atik, MD, Mehmet A. Süzer, MD, Ceyda Ö. Çaparlar, MD.

ABSTRACT Methods: The electronic medical records database,

patient files, and anesthesia charts were examined
‫ تقييم ما إذا كان استخدام مجرى الهواء للقناع احلنجري‬:‫األهداف‬ between May 2008 and September 2016 to
،‫) قد أحدث فرقًا من حيث سالمة مجرى الهواء التنفسي‬LMA( identify patients with the following inclusion
‫ وأوقات الشفاء مقارن ًة‬،‫ واملضاعفات‬،‫والتغيرات في الدورة الدموية‬ criteria: 1) aged 18-70 years; 2) American Society
‫بالتنبيب الرغامي أثناء اإلجراء في املرضى الذين يخضعون للتخدير‬ of Anesthesiologists (ASA) classification I-III;
.‫العام للعالجات الوعائية لتمدد األوعية الدموية الدماغيه‬ 3) diagnosis of unruptured CVA; 4) Glasgow
coma scale of 15 without neurological deficit;
‫ مت فحص قاعدة بيانات السجالت الطبية اإللكترونية‬:‫الطريقة‬ and 5) underwent elective EVT under general
‫م‬2008 ‫وملفات املرضى ومخططات التخدير خالل الفترة من مايو‬ anesthesia.
‫م لتحديد املرضى الذين يعانون من معايير االشتمال‬2016 ‫وسبتمبر‬ Results: Tracheal tube (TT) was used in 46 patients
‫) اجلمعية األمريكية‬2 ‫ عا ًما؛‬70‫ و‬18 ‫) تتراوح أعمارهم بني‬1 :‫التالية‬ (group TT, n=46) and LMA in 42 patients (group
‫ غير‬CVA ‫) تشخيص‬3 ‫ ؛‬I-III ‫) تصنيف‬ASA( ‫ألطباء التخدير‬ LMA, n=42). Mean arterial pressure (MAP) levels
)5 ‫ دون عجز عصبي؛ و‬15 ‫) مقياس غيبوبة غالسكو‬4 ‫املنقطع ؛‬ were increased to >20% of baseline in 14 patients
.‫ اختياري حتت التخدير العام‬EVT ‫خضع‬ (30.4%) after intubation and in 6 (13%) after
extubation in group TT. All LMA patients remained
‫ مريضا‬46 ‫) في‬TT( ‫ مت استخدام أنبوب القصبة الهوائية‬:‫النتائج‬ within normal MAP limits (p<0.05). Six patients
‫ مريضا (مجموعة‬42 ‫ في‬LMA ‫) و‬46 =‫ العدد‬، TT ‫(مجموعة‬ (13%) displayed coughing or straining at extubation
‫ متت زيادة متوسط مستويات الضغط الشرياني‬.)42=‫ العدد‬،LMA in group TT whereas none in group LMA (p<0.05).
Recovery and discharge times were similar (p>0.05).
)30.4%( ‫ مريضا‬14 ‫ من خط األساس في‬20% ‫) إلى أكثر من‬MAP(
.TT ‫) بعد نزع األنبوب في املجموعة‬13%( 6 ‫بعد التنبيب وفي‬ Conclusion: Laryngeal mask airway and TT
.)p<0.05( ‫ العادية‬MAP ‫ ضمن حدود‬LMA ‫بقي جميع املرضى‬ provided comparable airway security during
‫) ظهر لديهم السعال أو الشد في نزع األنبوب في‬13%( ‫ستة مرضى‬ procedure. Laryngeal mask airway attenuated stress
‫ كانت‬.)p>0.05( LMA ‫ بينما ال شيء في املجموعة‬TT ‫املجموعة‬ response in hemodynamic parameters at intubation
.)p<0.05( ‫أوقات اإلفاقه واخلروج من املستشفى متشابهة‬ and extubation and smoother emergence compared
to TT without delay in recovery.
‫ال من مجرى الهواء التنفسي لقناع احلنجرة و‬ ً ‫ أعطى ك‬:‫اخلامتة‬
Saudi Med J 2019; Vol. 40 (5): 463-468
‫ قناع مجرى الهواء‬.‫ سالمة ملجرى الهواء باملقارنه أثناء اإلجراء‬TT doi: 10.15537/smj.2019.5.24131
‫احلنجري يخفف من اإلجهاد في معلمات الدورة الدموية في التنبيب‬
‫ دون تأخير في‬TT ‫ونزع األنبوب وظهور أكثر سالسة باملقارنة مع‬ From the Department of Anesthesiology and Reanimation (Özhan,
Süzer), Çankaya Hospital, Department of Anesthesiology and
.‫االفاقة‬ Reanimation (Eşkin), University of Medical Sciences, Gülhane
Training and Research Hospital, Department of Anesthesiology and
Reanimation (Atik), Balikesir Ataturk City Hospital, Balikesir, and
Objectives: To evaluate whether using laryngeal mask From the Department of Anesthesiology and Reanimation (Çaparlar),
airway (LMA) made a difference in terms of airway Ankara, Turkey.
security, hemodynamic changes, complications, Received 13th January 2019. Accepted 19th March 2019.
and recovery times compared to tracheal intubation
during the procedure in patients undergoing general Address correspondence and reprint request to: Dr. Bülent Atik,
anesthesia for endovascular treatments of unruptured Department of Anesthesiology and Reanimation, Balikesir Universty,
Çağış Yerleşkesi, Balikesir, Turkey. E-mail: [email protected]
cerebrovascular aneurysms. ORCID ID: orcid.org./0000-0002-6876-2963

OPEN ACCESS www.smj.org.sa Saudi Med J 2019; Vol. 40 (5) 463

 LMA in neuroradiology ... Özhan et al

E ndovascular treatment (EVT) for cerebrovascular

aneursyms (CVAs) became one of the primary
therapeutic options after the introduction of detachable
between May 2008 and September 2016 to identify
patients with the following inclusion criteria: 1) aged
18-70 years; 2) American Society of Anesthesiologists
coils, because this technique is reported to be minimal (ASA) classification I-III; 3) diagnosis of unruptured
invasive and similar efficient with lower complication CVA; 4) Glasgow coma scale of 15 without neurological
rates compared to open surgery with surgical clipping.1 deficit; and 5) underwent elective EVT under general
Anesthetic management for EVT shares many anesthesia.
principles with neurosurgical anesthesia including The patients with accompanying cerebrovascular
hemodynamic stability, immobilization of patient, disease including arteriovenous malformation, stenosis,
control of arterial blood pressure (ABP) and early and so forth, history of surgical treatment for
recovery to diagnose neurological deficits.2-4 General cerebrovascular disease, history of difficult ventilation
anesthesia (GA) is still the most preferred technique and intubation, and failed airway management after the
because it fulfills the requirements of the procedure induction of GA were excluded from the study.
with ensuring airway safety.5,6 It has been also proposed All pre-anesthesia documents and intraoperative
to use tracheal intubation for GA as in neurosurgery.4,6,7 anesthesia charts were reviewed by study members in
Supraglottic airway devices are recently introduced in detail to obtain: 1) demographic characteristics; 2) type
EVT settings, but the availability of their routine use is of anesthesia used for induction and maintenance;
currently not clear. Only 3 reports have addressed the use 3) choice of airway management technique (TT or
of supraglottic airway devices in an EVT setting in the LMA); 4) vital parameters - before induction (baseline),
past 10 years.8-10 In the interventional neuroradiology before (pre-intubation), after tracheal intubation or
unit of the hospital, we have been using both laryngeal LMA insertion (post-intubation), and after extubation
mask airway (LMA) and tracheal tube (TT) for airway or removal of the LMA (post-extubation); 5) recovery
management in EVTs under GA for nearly 8 years. In and discharge times (time to extubation or to removal
this retrospective study, we aimed to evaluate whether of the LMA, time to neurological assessment, and time
using LMA made a difference in terms of airway to discharge from the INR unit to the intensive care
security, hemodynamic changes, complications, and unit [ICU]); and 6) complications and adverse events
recovery times; compared to tracheal intubation during related to EVT and anesthesia. All data were collected
the procedure in patients undergoing GA for EVTs of and 2 groups were identified according to the type of
unruptured CVA. airway management for GA that was performed: group
Primary outcome was to compare the effect of airway LMA and group TT (Figure 1).
management using LMA or TT on hemodynamic The same anesthetic protocol is used for the
parameters. Secondary outcomes were to compare patients undergoing EVTs under GA. All patients were
adverse respiratory events related to the airway monitored according to standards for basic anesthetic
technique, recovery and discharge times, including monitoring of ASA in the interventional neuroradiology
time to extubation, time to neurological assessment, unit. In addition, an arterial catheter was inserted in
and time to discharge. the left radial artery after local anesthetic infiltration
to monitor intra-arterial bood pressure. Baseline vital
Methods. This retrospective study was approved by parameters were measured and recorded.
the hospital’s ethics committee (protocol 042010/1780) General anesthesia was induced with intravenous
and registered with the Australian New Zealand Clinical propofol and fentanyl. A cuffed TT (internal diameter
Trials Registry (ACTRN12618000509268). It was 7.0-8.5 mm) was placed using direct laryngoscopy
carried out at radiology units in 29 Mayıs and Çankaya and orotracheal intubation or a correctly sized
Hospitals, Turkey. LMA (no. 3-5) was inserted for airway securing. A
The electronic medical records database, neuromuscular blocking agent, rocuronium 0.6 mg kg-1
patient files, and anesthesia charts were examined was given to facilitate orotracheal intubation in patients
whose airway management was achieved with TT.
Maintenance of GA was achieved by using remifentanil
and propofol based total intravenous anesthesia.
Infusion doses were adjusted to keep the mean arterial
Disclosure. Authors have no conflict of interests, and the pressure (MAP) between 50 and 60 mmHg. All drugs
work was not supported or funded by any drug company. and interventions were used in the same manner for
all patients including ventilatory settings, activated

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 LMA in neuroradiology ... Özhan et al

clotting time (ACT) measurements, heparinization the patients were awakened without complication
to a target ACT levels, renal protection to prevent and referred to awake fiberoptic intubation. The
contrast- induced nephropathy, gastric protection, other 2 cases had insufficient anesthetic data in their
bladder catheterization for urine output measurement, medical records. Finally, the data obtained from 88
and warming of patients to prevent hypothermia. cases were used for the analysis. TT was used in 46
A single neuroradiologist performed all interventions. patients (Group TT, n=46) and LMA in 42 patients
Digital subtraction angiography was performed to (Group LMA, n=42). Patient characteristics and the
visualize the 3-dimensional structure of the aneurysm duration of the procedures did not differ between
after femoral artery catheterization. Multiple Guglielmi groups (Table 1). All neuroradiological treatments
detachable coils were deployed through a microcatheter were completed successfully without procedure-related
into the aneurysm until sufficient occlusion was complications.
achieved. After completion of the EVT, anesthesia was After the induction of anesthesia, MAP levels were
discontinued and airway instruments were removed within ± 20% of the baseline levels in 30 TT patients
after achieving extubation criteria. Neostigmine, an (65.2%) and 37 LMA patients (88.1%) (p<0.05). In
anticholinesterase agent, was given to patients who were the remaining patients in both groups, MAP levels were
intubated to reverse the effect of the neuromuscular reduced to >20% below baseline but did not reach >30%.
blocking agent (rocuronium) to facilitate orotracheal Therefore, vasopressor drugs were not used to increase
intubation. blood pressure after induction (Table 2). After securing
Clinical outcome was assessed with the Glasgow the airway with the TT or LMA, postintubation MAP
outcome scale (GOS). Criteria for transfer to the levels were >20% of the baseline level in 14 patients
intensive care unit were stable neurological and (30.4%) in the TT group and 0 patients in the LMA
cardiovascular status, a modified Aldrete recovery score group (p<0.05) (Table 2). Those 14 TT patients received
>9, and a dry femoral artery puncture site. metoprolol.
Anesthetic protocol, MAP levels, peripheral oxygen Peripheral oxygen saturation, end-tidal CO2 levels,
saturation (SpO2), end-tidal CO2 levels and heart rate and peak airway pressures were within normal limits
were monitored and recorded before and after induction in both groups during the procedure. Recovery times
of anesthesia, of airway management, of removal of
airway instruments and also with 5 min intervals
throughout the procedure. Bolus doses of metoprolol Table 1 - Adverse respiratory events, recovery and discharge times of 88
patients.
(40 µg kg-1), a selective ß1- blocking agent, were given
when the MAP increased >20% above baseline values to Group TT Group LMA
avoid further increase in blood pressure. Also, respiratory Parameters P-value
(n=46) (n=42)
adverse events including laryngospasm, coughing, and Age (years) (mean ± SD) 47.3 ± 14.3 45.30 ± 12.8 0.521
straining, time to extubation, time to neurological Gender (female/male) 25/21 24/18 0.651
assessment (with GOS) and time to discharge (using Weight (kg) (mean ± SD) 73.8 ± 11.3 76.5 ± 8,9 0.127
Body mass index
modified the Modified Aldrete Recovery Scoring (mean ± SD)
25 ± 3.4 27± 3.0 0.221
Sytem) were recorded in all patients. ASA status
Statistical analysis. Data were analyzed using the ASA I 20 (43.5) 18 (42.9)
Statistical Packages for Social Sciences for Windows ASA II 21 (45.6) 20 (47.6) 0.782
version 11.5 pocket program (IBM Corp., Chicago, ASA III 5 (10.9) 4 (9.5)
Comorbidity
IL, USA). For intergroup comparisons, the Chi-square
Hypertension 15 (32.6) 14 (33,3)
test and Fisher’s exact test were used to analyze nominal Coronary artery disease 5 (10.9) 4 (9.5) 0.535
data and the t-test for independent samples was used for Diabetes mellitus 6 (13.0) 6 (14.3)
quantitative data. Data were expressed as means ± SD Mallampati
for continuous variables and numbers, and percentages Class I 35 (76.1) 30 (71.4)
for categorical variables. The value of p<0.05 was Class II 9 (19.6) 9 (21.5) 0.759
Class III 2 ( 4.3) 3 (7.1)
considered significant.
Duration of the
procedure (min) 70.1 ± 18.1 75.4 ± 19.8 0.219
Results. A total of 93 anesthesia documents (mean ± SD)
were reviewed, and 5 cases were excluded. Of those, P-value were considered as statistically significant. Data were
presented as number and percentage (%).
unanticipated difficult ventilation and intubation ASA - American Society of Anesthesiologists, TT - tracheal tube,
occurred in 3 cases, in which EVT was cancelled and LMA - laryngeal mask airway

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 LMA in neuroradiology ... Özhan et al

Table 2 - Mean arterial pressure and heart rate at 3 periods of the procedure. (N=88)

Parameters ± 20% of baseline <20% of baseline >20% of baseline

Group TT Group LMA Group TT Group LMA Group TT Group LMA
P-value
(n=46) (n=42) (n=46) (n=42) (n=46) (n=42)
Mean arterial pressure
Pre-intubation 30 (65.2) 37 (88.1) 16 (34.8) 5 (11.9) 0 0) 0.034*
Postintubation 32 (69.5) 42 (100) 0 0 14 (30.4) 0 0.003*
Postextubation 40 (87.0) 42 (100) 0 0 6 (13) 0 0.017*
Heart rate
Pre-intubation 24 (52.2) 23 (54.8) 22 (47.8) 19 (45.2) 0 0 0.485
Postintubation 38 (82.6) 39 (92.9) 0 0 8 (17.4) 3 (7.1) 0.043*
Postextubation 40 (87.0) 35 (83.3) 0 0 6 (13) 7 (16.7) 0.660
*p<0.05 considered as statistically significant. Values are presented as number and percentage (%) of patients’ vital parameters.
TT - Tracheal tube, LMA - Laryngeal mask airway

Figure 1 - Study flow diagram of 88 patients.

were longer in the TT group than in the LMA group Discussion. The results of this retrospective
after completion of the procedure and anesthesia, but study demonstrated that the use of LMA decreased
the difference was not statistically significant (p>0.05) the incidence of hemodynamic changes during
(Table 3). No extubation event was observed in the LMA airway management and extubation, providing a
group, whereas coughing was observed in 3 patients smoother emergence from anesthesia without airway
and straining in another 3 in the TT group (p<0.05) complications compared to TT. However, the recovery
(Table 3). Postextubation MAP levels were >20% of times for neurological evaluation were similar between
the baseline levels in 6 patients in the TT group (13%) LMA and TT.
and no patients in the LMA group (p<0.05) (Table 2). In one of only 3 reports in the literature address this
Further increases in the MAP levels were prevented by issue, Golshevsky and Cormack8 reported on the use
administering metoprolol. The postoperative GCS score of LMA during GA in 3 patients undergoing EVT for
was 15 in all patients, with no neurological impairment. ICAs and concluded that LMA may be a safe alternative
Discharge times were similar in both groups (p>0.05) by avoiding the hemodynamic effects of tracheal
(Table 3). intubation. In a non-randomized study, Karwacki et al9
evaluated the usefulness of GA with propofol and LMA

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 LMA in neuroradiology ... Özhan et al

Table 3 - Adverse respiratory events, recovery and discharge times. stimulate pain and airway reflexes, resulting in ABP and
ICP elevations. This hemodynamic response is associated
Time Group TT Group LMA P-value with cerebral hemorrhage with an incidence of one
Time to extubation (min) 10.1 ± 2.3 9.3 ± 2.7 0.202
percent during surgical clipping.18 Studies comparing
Time to neurological
assessment (min)
13.4 ± 2.3 12.5 ± 3.3 0.129 LMA with TT during induction and extubation have
Time to discharge (min) 16.0 ± 2.4 15.2 ± 3.3 0.222 indicated that the cardiovascular responses induced by
Adverse respirator events
6 (13) 0 0.017*
laryngoscopy and intubation may be more than twice as
(n=%) great as those induced by the insertion of an LMA.19,20
Data were expressed as mean ± SD. *p<0.05 were considered as
statistically significant. TT - tracheal tube,
Rapid recovery is an important factor in assessing
LMA - laryngeal mask airway neurological status and the early diagnosis of
post-procedural complications. In the present study, a
total intravenous anesthesia technique with propofol
for EVT of unruptured ICAs in 26 ASA I patients. They and remifentanil was used to for the maintenance
concluded that the use of LMA is the optimal method because these drugs reduce cerebral blood flow and
for securing the patency of the upper airways during ICP. They also provide stable hemodynamics and rapid
anesthesia for endovascular ICA repair.9 The 3rd study, recovery from GA.6,7,9 Recovery and discharge times in
Tan et al10 reported no complications related to the use our study were similar between 2 groups.
of LMA for GA in endovascular coil embolization. One limitation of this study is that the anesthetic
In contrast to the surgical treatment of cerebral depth was not monitored during the procedure due
aneurysms, securing the airway with tracheal intubation to the unavailability of a bispectral index, which
may not be necessary for EVTs under GA in which is also useful for detecting cerebral ischemia and
the patient lies supine on the operating table and intraventricular hemorrhage.21,22
the positions of the head and body are not changed. Another limitation is the retrospective design of the
Moreover, the procedure is shorter and painless and has study. Retrospective studies may suffer from selection
minimal blood loss compared to intracranial surgery. and recall bias. Therefore, we used the same inclusion
In the present study, the mean duration of the EVT and exclusion criteria for both groups to minimize
procedures was approximately 75 ± 20 min (range, selection bias. Additionally, all patients received the
30-125 min). This result is consistent with previous same EVT and anesthetic regimens except for the
studies that have reported a typical time frame of airway management interventions. We also attempted
approximately 1.5 hours (range, 1-2 hours) for coiling to minimize recall bias by using multiple data sources
an intracranial aneurysm.11 including an electronic medical records database,
Studies have reported that LMA can be used safely patient files, and anesthesia charts.
without gastroesophageal insufflation when inserted In conclusion, LMA may be routinely used
properly and used with positive-pressure ventilation at in patients undergoing EVTs under GA due to
volumes of less 10 mL kg-1, with ventilation pressuråes airway securing without respiratory complications.
kept lower than 20 cm H2O during procedures that last Hemodynamic stress responses at insertion and removal
longer than 120 min.12,13 periods were attenuated and emergence was smoother
The integrity of a cerebral aneurysm depends on the compared to tracheal intubation. Further prospective
transmural pressure (TMP), which is determined by the and randomized studies are required to determine the
difference between the pressure within the aneurysm availability of the routine use of supraglottic airway
(equivalent to the MAP) and the pressure surrounding devices in interventional neuroradiology.
the aneurysm (equivalent to the ICP).14 A rise in MAP
increases the TMP and makes rupture of the aneurysm References
more likely, which is the most dangerous complication
of the procedure, with a mortality rate of up to 50%.14,15 1. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M,
Thus, the prevention of exacerbated hemodynamic Shrimpton J, et al. International Subarachnoid Aneursym Trial
responses related to anesthetic management is essential. (ISAT) of neurosurgical clipping versus endovascular coiling in
Generally, hemodynamic fluctuations occur 2143 patients with intracranial aneursyms: a randomised trial.
Lancet 2002; 360: 1267-1274.
during the induction and emergence stages of GA.16,17 2. Patel S, Reddy U. Anaesthesia for interventional neuroradiology.
Laryngoscopy, tracheal intubation, or insertion of BJA Education 2016: 147-152. doi: 10.1093/bjaed/mkv032
supraglottic airway devices, as well as laryngospasm, 3. Young WL. Anesthesia for endovascular neurosurgery and
coughing, and straining caused by extubation, may interventional neuroradiology. Anesthesiol Clin 2007; 25:
391-412.

www.smj.org.sa Saudi Med J 2019; Vol. 40 (5) 467

 LMA in neuroradiology ... Özhan et al

4. Lakhani S, Guha A, Nahser HC. Anaesthesia for endovascular 15. Santillan A, Gobin YP, Greenberg ED, Leng LZ, Riina HA,
management of cerebral aneurysms. Eur J Anaesthesiol 2006; Stieg PE, et al. Intraprocedural aneurysmal rupture during coil
23: 902-913.
embolization of brain aneurysms: role of balloon-assisted coil.
5. Van de Velde M. Interventional neuroradiology. Curr Opin
Anaesthesiol 2003; 16: 417-420. AJNR Am J Neuroradiol 2012; 33: 2017-2021.
6. Dorairaj IL, Hancock SM. Anaesthesia for interventional 16. Wilson IG, Fell D, Robinson SL, Smith G. Cardiovascular
neuroradiology. Anaesth Crit Care Pain Med 2008; 8: 86-89. responses to insertion of the laryngeal mask. Anaesthesia 1992;
7. Schulenburg E, Matta B. Anaesthesia for interventional 47: 300-302.
neuroradiology. Curr Opin Anaesthesiol 2011; 24: 426-432.
8. Golshevsky J, Cormack J. Laryngeal mask airway device during 17. Wood ML, Forrest ET. The haemodynamic response to the
coiling of unruptured cerebral aneurysms. J Clin Neurosci insertion of the laryngeal mask airway: a comparison with
2009; 16: 104-105. laryngoscopy and tracheal intubation. Acta Anaesthesiol Scand
9. Karwacki Z, Witkowska M, Niewiadomski S, Wiatr A, 1994; 38: 510-513.
Bukowski P, Wierzchowska J et al. Anaesthetic management for
18. Hop JW, Rinkel GJ, Algra A, van Gijn J. Case-fatality rates
endovascular treatment of unruptured intracranial aneurysms.
Anaesthesiol Intensive Ther 2013; 45: 145-148. and functional outcome after subarachnoid hemorrhage: a
10. Wen-Fei Tan, Yan-Hua Jiang, Hong Ma, Jun-Ke Wang. systematic review. Stroke 1997; 28: 660-664.
Sevoflurane, laryngeal mask airway and single-dose 19. Yu SH, Beirne OR. Laryngeal mask airways have a lower risk of
dexmedetomidine: a better choice for patients undergoing airway complications compared with endotracheal intubation: a
endovascular coil embolization. J Anesth Perioper Med 2015;
2: 153-157. systematic review. J Oral Maxillofac Surg 2010; 68: 2359-2376.
11. de Gast AN, Soepboer A, Sluzewski M, van Rooij WJ, Beute 20. Kihara S, Brimacombe J, Yaguchi Y, Watanabe S, Taguchi N,
GN. How long does it take to coil an intracranial aneurysm. Komatsuzaki T. Hemodynamic responses among three tracheal
Neuroradiology 2008; 50: 53-256. intubation devices in normotensive and hypertensive patients.
12. Bernardini A, Natalini G. Risk of pulmonary aspiration with
laryngeal mask airway and tracheal tube: analysis on 65 712 Anesth Analg 2003; 96: 890-895.
procedures with positive pressure ventilation. Anaesthesia 2009; 21. Lien CA, Kopman AF. Current recommendations for
64: 1289-1294. monitoring depth of neuromuscular blockade. Curr Opin
13. Verghese C, Brimacombe JK. Survey of laryngeal mask airway Anaesthesiol 2014; 27: 616-622.
usage in 11,910 patients: safety and efficacy for conventional
22. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol
and nonconventional usage. Anesth Analg 1996; 82: 129-133.
14. Cloft HJ, Kallmes DF. Cerebral aneurysm perforations N. Bispectral index for improving anaesthetic delivery and
complicating therapy with Guglielmi detachable coils: a meta- postoperative recovery. Cochrane Database Syst Rev 2014; (6):
analysis. AJNR Am J Neuroradiol 2002; 23: 1706-1709. CD003843.

468 Saudi Med J 2019; Vol. 40 (5) www.smj.org.sa