Introduction: Primary (IVH) is non traumatic intracerebral hemorrhage confined to the ventricular system which is relatively infrequent, but is more commonly caused by hypertensive (52%) hemorrhagic stroke, followed by trauma (15%), intraventricular arteriovenous malformation (7.5%), coagulopathy (7.5%), diabetic vasculopathy (7.5%), anterior communicating artery aneurysms (3%), and undetectable cause. Clipping of ruptured anterior communicating artery with hypertension possess anesthetic challenges in managing intra-operatively, and when it comes for an ideal neuroprotective agent, barbiturates induced anesthesia was planned.

Case Report: A 70 years old male came to our hospital with history of sudden loss of consciousness and a known case of systemic hypertension for 3 years and was on irregular medications, intubated in emergency medicine department in view of low GCS which was difficult intubation.

CT brain Angiogram was done and diagnosed as ruptured Anterior Communicating Artery Aneurysm and underwent Aneurysmal clipping of anterior communicating artery aneurysm under general anesthesia.

Emergency medications were kept ready. Intensive neuro monitoring, invasive blood pressure monitoring and to decrease the intraoperative intracranial pressure, to preserve autoregulation of cerebral blood flow, barbiturates induced anesthesia were planned (thiopentone as an induction agent and maintained with inhalational anesthetic agent). Patient was shifted to ICU for observation and extubated on next day uneventfully.

Conclusion: We present a successful anesthetic management of hypertensive patient with  ruptured anterior communicating artery who underwent clipping of aneurysm. A detailed pre-anesthetic evaluation and proper planning is utmost important to encounter the risk of ischemic injury to brain while clipping of ruptured aneurysmal vessel.