Myocardial Infarction and Subdural Hematoma Presenting a Neurosurgical Anesthetic Challenge: Successful Management With Scalp Block and Dexmedetomidine Infusion

This case report describes the anesthetic management of a 63-year-old patient with acute coronary syndrome (ACS) presenting as non-ST elevation myocardial infarction (NSTEMI) and a concomitant subdural hematoma requiring urgent neurosurgical intervention via burr hole trepanation. Given the high cardiovascular risk associated with general anesthesia in this scenario, the anesthetic team opted for an alternative approach using a scalp block combined with a dexmedetomidine infusion. The patient was monitored using standard ASA protocols with invasive blood pressure monitoring. Sedation was achieved with dexmedetomidine at 0.7 mcg/kg/hour, and the scalp block was performed using 15 mL of ropivacaine 0.75% and 5 mL of lidocaine 2%. The surgical procedure proceeded uneventfully, with the patient maintaining spontaneous ventilation, hemodynamic stability, and moderate sedation throughout. Postoperatively, the patient was transferred to the coronary care unit for further management, where subsequent coronary angiography revealed three-vessel ischemic heart disease. Scalp block combined with dexmedetomidine proved to be a safe and effective alternative to general anesthesia, minimizing hemodynamic instability, ensuring adequate analgesia, and avoiding factors that exacerbate myocardial oxygen demand. This approach underscores the importance of multidisciplinary collaboration in complex clinical scenarios and suggests a promising role for regional anesthesia techniques in high-risk neurosurgical patients.