Anaesthetic management of neurogenic atrial fibrillation with rapid ventricular response in a patient undergoing decompressive hemicraniectomy

Acute ischaemic stroke is a leading cause of morbidity and mortality in the Philippines. Autonomic dysregulation via the brain–heart axis may trigger arrhythmias such as atrial fibrillation with rapid ventricular response (AF with RVR), complicating anaesthetic care. We report a male in his 60s with left middle cerebral artery infarct and haemorrhagic transformation, who developed new-onset AF with RVR and heart failure (ejection fraction 25%). He underwent emergency decompressive hemicraniectomy under general anaesthesia with remifentanil, dexmedetomidine, midazolam, etomidate, esmolol and low-dose sevoflurane plus transtracheal and topical airway blocks. Spontaneous cardioversion followed the neurosurgical, anaesthetic and medical intervention. He was extubated awake, recovered well and was discharged neurologically stable without arrhythmia recurrence. This case emphasises the importance of the application of neuroprotective and cardioprotective strategies, including sympatholysis and vigilant monitoring. The neurogenic-cardiac dysfunction may be reversible with timely neurosurgical cranial decompression and medical management.