Anesthesia Management in Aneurysm Clipping Surgery with Chilaiditi Sign : a Case Report

Abstract

Chilaiditi sign is the asymptomatic interposition of the colon between the liver and diaphragm; when accompanied by gastrointestinal symptoms, it is termed Chilaiditi syndrome. Its coexistence with aneurysmal subarachnoid haemorrhage creates competing anaesthetic priorities, including aspiration prevention, lung protection, and control of cerebral haemodynamics. We report a 79-year-old woman who presented with sudden severe headache and transient loss of consciousness. Imaging demonstrated subarachnoid haemorrhage from a ruptured left posterior communicating artery aneurysm, together with incidental colonic interposition beneath an elevated right hemidiaphragm, bilateral pleural effusions, and partial right-lower-lobe collapse. After 10 hours of fasting and pharmacological aspiration-risk mitigation, general anaesthesia was induced with thiopental, remifentanil, and rocuronium using a modified rapid-sequence approach that included preoxygenation, cricoid pressure, gentle mask ventilation, and video laryngoscopy. Pressure-controlled ventilation and close haemodynamic control were maintained throughout aneurysm clipping. No intraoperative rupture, aspiration, haemodynamic instability, or respiratory deterioration occurred. The patient was extubated 36 hours after surgery and discharged on postoperative day 8 with a modified Rankin Scale score of 1. This case highlights the need to individualise induction and ventilation when Chilaiditi sign coexists with urgent intracranial surgery. The uneventful outcome of a single case should not be interpreted as evidence that modified induction is generally safer than classical rapid-sequence induction.