The detection of cerebral hypoperfusion with bispectral index monitoring during general anesthesia

We describe a patient in whom the bispectral index (BIS) decreased to 0 during surgery. A 42-yr-old man with chronic renal failure was scheduled to undergo construction of an arteriovenous shunt. He had a history of acute cerebral hemorrhage. An intracranial hematoma had been removed a month earlier with almost complete neurological recovery. He had uncontrolled hypertension. His systolic blood pressure was 180 mm Hg before anesthesia induction. Anesthesia was induced with 100 mg of propofol and 3% sevoflurane. After laryngeal mask insertion, anesthesia was maintained with nitrous oxide 60% in oxygen and sevoflurane. BIS decreased to near 0 on 2 occasions: after anesthesia induction and shortly after the start of the surgery. His systolic blood pressure decreased to 110 mm Hg and BIS increased when his blood pressure was increased to 130-140 mm Hg. The decrease in BIS was suspected to be the result of decreased cerebral blood flow. The systolic blood pressure of 110 mm Hg (mean blood pressure, 80 mm Hg) was probably less than the lower limit of autoregulation. Although BIS has some limitations as a cerebral monitor, it was useful for detecting possible cerebral hypoperfusion in this case.