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Nager GB, Pontes JPM, Udoma-Udofa OC, Gomes FC, Larcipretti ALL, de Oliveira JS, Dagostin CS, Fernandes MNF, de Andrade Bannach M. Efficacy and safety of adenosine, rapid ventricular pacing and hypothermia in cerebral aneurysms clipping: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:215. [PMID: 38730072 DOI: 10.1007/s10143-024-02450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/03/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Cerebral aneurysms in complex anatomical locations and intraoperative rupture can be challenging. Many methods to reduce blood flow can facilitate its exclusion from the circulation. This study evaluated the safety and efficacy of using adenosine, rapid ventricular pacing, and hypothermia in cerebral aneurysm clipping. METHODS Databases (PubMed, Embase, and Web of Science) were systematically searched for studies documenting the use of adenosine, rapid ventricular pacing, and hypothermia in cerebral aneurysm clipping and were included in this single-arm meta-analysis. The primary outcome was 30-day mortality. Secondary outcomes included neurological outcomes by mRs and GOS, and cardiac outcomes. We evaluated the risk of bias using ROBIN-I, a tool developed by the Cochrane Collaboration. OpenMetaAnalyst version 2.0 was used for statistical analysis and I2 measured data heterogeneity. Heterogeneity was defined as an I2 > 50%. RESULTS Our systematic search yielded 10,100 results. After the removal of duplicates and exclusion by title and abstract, 64 studies were considered for full review, of which 29 were included. The overall risk of bias was moderate. The pooled proportions of the adenosine analysis for the different outcomes were: For the primary outcome: 11,9%; for perioperative arrhythmia: 0,19%; for postoperative arrhythmia: 0,56%; for myocardial infarction incidence: 0,01%; for follow-up good recovery (mRs 0-2): 88%; and for neurological deficit:14.1%. In the rapid ventricular pacing analysis, incidences were as follows: peri operative arrhythmia: 0,64%; postoperative arrhythmia: 0,3%; myocardial infarction: 0%. In the hypothermia analysis, the pooled proportion of 30-day mortality was 11,6%. The incidence of post-op neurological deficits was 35,4% and good recovery under neurological analysis by GOS was present in 69.2%. CONCLUSION The use of the three methods is safe and the related complications were very low. Further studies are necessary, especially with comparative analysis, for extended knowledge.
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Affiliation(s)
- Gabriela Borges Nager
- School of Surgery and Medicine, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Julia Pereira Muniz Pontes
- Department of Surgical Specialities, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Fernando Cotrim Gomes
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Caroline Serafim Dagostin
- School of Medicine, University of the Extreme South of Santa Catarina, Criciúma, Santa Catarina, Brazil
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2
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Teranishi A, Ooigawa H, Take Y, Shibata A, Suzuki K, Kurita H. Influence of Perioperative Three-Dimensional Computed Tomography (CT) Angiography and Surgical Clipping for Unruptured Cerebral Aneurysms on Renal Function in Patients with Chronic Kidney Disease. World Neurosurg 2024:S1878-8750(24)00670-3. [PMID: 38670454 DOI: 10.1016/j.wneu.2024.04.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
BACKROUND Surgical clipping is a valuable treatment option for unruptured intracranial aneurysms in patients with chronic kidney disease (CKD). However, the comprehensive impact of clipping and perioperative three-dimensional computed tomography angiography (3D-CTA) on renal function remains unclear. This study aimed to evaluate the effects of perioperative 3D-CTA and surgical clipping on renal function in patients with CKD. METHODS We retrospectively analyzed 529 patients who underwent surgical clipping and perioperative 3D-CTA. An estimated glomerular filtration rate (eGFR) < 60 was defined as CKD. Patients were stratified according to their renal function (group 1: eGFR ≥60, group 2: 45 ≤ eGFR <60, group 3: 30 ≤ eGFR <45, group 4: eGFR <30 ml/min/1.73 m2), and eGFR was assessed preoperatively and 1 week and several months postoperatively. RESULTS Of the 529 patients, 442 did not have CKD and 87 had CKD. Hypertension, hyperlipidemia, and hyperuricemia were significantly more common in those with CKD. After the surgery and perioperative series of 3D-CTA, renal function deterioration was not observed in any group, whether in the acute or chronic postoperative period. Notably, eGFR significantly increased in groups 2 (66.7 ± 10.1, P < 0.01) and 3 (48.9 ± 9.2, P = 0.02) 1 week postoperatively, despite the CKD. CONCLUSIONS Surgical clipping of unruptured intracranial aneurysms and perioperative 3D-CTA with normal-dose contrast media did not impair renal function in patients with CKD. These results could be valuable in determining treatment strategies for those with CKD and intracranial aneurysms.
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Affiliation(s)
- Akio Teranishi
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka City, Saitama, Japan
| | - Hidetoshi Ooigawa
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka City, Saitama, Japan.
| | - Yushiro Take
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka City, Saitama, Japan
| | - Aoto Shibata
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka City, Saitama, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka City, Saitama, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka City, Saitama, Japan
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3
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Budiansky AS, Hjartarson EP, Polis T, Krolczyk G, Sinclair J. Emerging anesthesia techniques for managing intraoperative rupture of cerebral aneurysms. Int Anesthesiol Clin 2023; 61:64-72. [PMID: 37218511 DOI: 10.1097/aia.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Adele S Budiansky
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Emma P Hjartarson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tomasz Polis
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gregory Krolczyk
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John Sinclair
- Division of Neurosurgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Dugani SM. Management of Intraoperative Rupture of Intracranial Aneurysms: Agony and Ecstasy. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:65-79. [PMID: 37548725 DOI: 10.1007/978-3-030-12887-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Intraoperative rupture (IOR) of an intracranial aneurysm is a serious complication, often with catastrophic consequences that are difficult to manage even by the best hands. Like most surgical complications, this one is better to avoid than to treat, but any vascular neurosurgeon should know how to deal with IOR of an aneurysm, because it is bound to occur. The aims of this study were to evaluate the incidence and factors associated with IOR during clipping of intracranial aneurysms, to analyze strategies for controlling hemorrhage in such cases, and to assess outcomes. Overall, 911 cases of intracranial aneurysms, which were treated surgically by the author during 26 years of his professional career, were reviewed. IOR was never noted during clipping of an unruptured intracranial aneurysm (65 cases) but was encountered in 49 of 846 cases (5.8%) presenting with subarachnoid hemorrhage. This complication occurred most often in cases of internal carotid artery aneurysms (22 cases; 45%), followed by anterior communicating artery aneurysms (12 cases; 24%), distal anterior cerebral artery aneurysms (6 cases; 12%), middle cerebral artery aneurysms (6 cases; 12%), and posterior circulation aneurysms (3 cases; 6%). IOR was mostly encountered during early surgery (within 3 days) after the ictus (26 cases; 53%) and most frequently occurred during dissection of the aneurysm (26 cases; 53%). Overall, 22 patients (45%) had good outcome, 18 (37%) had variable morbidity, and 9 (18%) died. Fatal consequences of IOR were noted only in cases of big or multilobulated internal carotid artery aneurysms. Detailed planning of the surgical procedure, application of meticulous microdissection techniques, and anticipation of possible intraoperative incidents during intervention aimed at clipping of an intracranial aneurysm can reduce the risk of IOR, as well as the associated morbidity and mortality.
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Affiliation(s)
- Suresh M Dugani
- Department of Neurosurgery, SDM College of Medical Sciences & Hospital, Dharwad-Hubballi, Karnataka, India.
- Regional Neuroscience Centre, Shivakrupa Hospital, Dharwad-Hubballi, Karnataka, India.
- Suchirayu Hospital, Dharwad-Hubballi, Karnataka, India.
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5
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Schwandt E, Kockro R, Kramer A, Glaser M, Ringel F. Presurgical selection of the ideal aneurysm clip by the use of a three-dimensional planning system. Neurosurg Rev 2022; 45:2887-2894. [PMID: 35546216 PMCID: PMC9349090 DOI: 10.1007/s10143-022-01794-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/19/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
Aneurysm occlusion rate after clipping is higher than after endovascular treatment. However, a certain percentage of incompletely clipped aneurysms remains. Presurgical selection of the proper aneurysm clips could potentially reduce the rate of incomplete clippings caused by inadequate clip geometry. The aim of the present study was to assess whether preoperative 3D image-based simulation allows for preoperative selection of a proper aneurysm clip for complete occlusion in individual cases. Patients harboring ruptured or unruptured cerebral aneurysms prior to surgical clipping were analyzed. CT angiography images were transferred to a 3D surgical-planning station (Dextroscope®) with imported models of 58 aneurysm clips. Intracranial vessels and aneurysms were segmented and the virtual aneurysm clips were placed at the aneurysm neck. Operating surgeons had information about the selected aneurysm clip, and patients underwent clipping. Intraoperative clip selection was documented and aneurysm occlusion rate was assessed by postoperative digital subtraction angiography. Nineteen patients were available for final analysis. In all patients, the most proximal clip at the aneurysm neck was the preselected clip. All aneurysms except one were fully occluded, as assessed by catheter angiography. One aneurysm had a small neck remnant that did not require secondary surgery and was occluded 15 months after surgery. 3D image-based preselection of a proper aneurysm clip can be translated to the operating room and avoids intraoperative clip selection. The associated occlusion rate of aneurysms is high.
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Affiliation(s)
- Eike Schwandt
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Ralf Kockro
- Department of Neurosurgery, Klinik Hirslanden, Zurich, Switzerland
| | - Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Martin Glaser
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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6
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Cezayirli PC, Türe H, Türe U. Microsurgical Treatment of Deep and Eloquent AVMs. Adv Tech Stand Neurosurg 2022; 44:17-53. [PMID: 35107672 DOI: 10.1007/978-3-030-87649-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Over the past 30 years, the treatment of deep and eloquent arteriovenous malformations (AVMs) has moved away from microneurosurgical resection and towards medical management and the so-called minimally invasive techniques, such as endovascular embolization and radiosurgery. The Spetzler-Martin grading system (and subsequent modifications) has done much to aid in risk stratification for surgical intervention; however, the system does not predict the risk of hemorrhage nor risk from other interventions. In more recent years, the ARUBA trial has suggested that unruptured AVMs should be medically managed. In our experience, although these eloquent regions of the brain should be discussed with patients in assessing the risks and benefits of intervention, we believe each AVM should be assessed based on the characteristics of the patient and the angio-architecture of the AVM, in particular venous hypertension, which may guide us to treat even high-grade AVMs when we believe we can (and need to) to benefit the patient. Advances in imaging and intraoperative adjuncts have helped us in decision making, preoperative planning, and ensuring good outcomes for our patients. Here, we present several cases to illustrate our primary points that treating low-grade AVMs can be more difficult than treating high-grade ones, mismanagement of deep and eloquent AVMs at the behest of dogma can harm patients, and the treatment of any AVM should be tailored to the individual patient and that patient's lesion.
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Affiliation(s)
- Phillip Cem Cezayirli
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Hatice Türe
- Department of Anesthesiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey.
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7
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Lee KS, Zhang JJY, Nguyen V, Han J, Johnson JN, Kirollos R, Teo M. The evolution of intracranial aneurysm treatment techniques and future directions. Neurosurg Rev 2021; 45:1-25. [PMID: 33891216 PMCID: PMC8827391 DOI: 10.1007/s10143-021-01543-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 01/06/2023]
Abstract
Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK. .,Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.
| | - John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vincent Nguyen
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.,Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Julian Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Ramez Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK
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8
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Radhakrishna N, Khandelwal A, Chouhan RS, Pandia MP, Burman S, Mahapatra RR. Complications and Neurological Outcome following Intraoperative Aneurysm Rupture in Adult Patients Undergoing Intracranial Aneurysmal Clipping: A Retrospective Study. J Neurosci Rural Pract 2021; 12:382-388. [PMID: 33927528 PMCID: PMC8064845 DOI: 10.1055/s-0041-1724228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background Intraoperative aneurysmal rupture (IAR) is a catastrophic complication; however, its impact on neurological outcome is debatable. We studied the effects of IAR on intraoperative and postoperative complications and neurological outcome. Methods In this retrospective study, adult patients who underwent aneurysmal clipping over a period of 2 years were divided as follows: group R (with IAR) and group N (without IAR). Various perioperative parameters, intraoperative and postoperative complications were noted. Glasgow outcome scale (GOS) was noted at discharge from hospital and categorized as favorable (GOS IV and V) and unfavorable (GOS I, II and III). Collected data was statistically analyzed. Univariate and multiple logistic regression analyses were performed to identify predictors of IAR. A p value < 0.05 was considered significant. Results Thirty-two out of 195 (16.41%) patients suffered IAR, with majority involving anterior communicating artery aneurysm (46.88%). Duration of temporary clipping ( p < 0.001), volume of blood loss, and fluid and blood transfusion were significantly more in group R. Postoperatively, significantly more patients in group R developed intracranial hematoma, cerebral infarct, and required prolonged ventilatory support (≥5 days). Unfavorable neurological outcome was observed more in group R ( p = 0.013). In univariate analysis, blood loss > 500 mL, use of colloids, and duration of surgery > 5 hours were found to be associated with IAR. After multiple logistic regression analysis, only use of colloids and duration of surgery > 5 hours were the most predictive variables for IAR. Conclusions IAR is associated with serious intraoperative and postoperative complications and unfavorable neurological outcome.
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Affiliation(s)
- Nayani Radhakrishna
- Department of Anaesthesia and Critical Care, Army Hospital Research and Referral, Delhi Cantt, India
| | - Ankur Khandelwal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajendra Singh Chouhan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mihir Prakash Pandia
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sourav Burman
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rashmi Rani Mahapatra
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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9
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Rao GU. Intraoperative Rupture of Aneurysm: Does It Add Insult to the Injury? J Neurosci Rural Pract 2021; 12:224-225. [PMID: 33927513 PMCID: PMC8064839 DOI: 10.1055/s-0041-1726660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ganne Umamaheswara Rao
- Department of Neuroanaesthesia and Critical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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10
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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Intarakhao P, Thiarawat P, Tewaritrueangsri A, Pojanasupawun S. Low-dose adenosine-induced transient asystole during intracranial aneurysm surgery. Surg Neurol Int 2020; 11:235. [PMID: 32874738 PMCID: PMC7451161 DOI: 10.25259/sni_79_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022] Open
Abstract
Background Few studies have evaluated the adenosine dose that induces cardiac arrest during intracranial aneurysm surgery. We present our experiences with adenosine-induced transient asystole (AiTA) during intracranial aneurysm surgery and dosage recommendations. Methods We retrospectively reviewed the medical records of all patients who underwent intracranial aneurysm surgery between July 2016 and December 2018. Patients who experienced AiTA during intracranial aneurysm surgery were included in the study. Results Our study included nine intracranial aneurysm surgeries performed in eight patients. Thirteen episodes of AiTA were reported. Five of these were performed to facilitate bleeding control due to intraoperative aneurysm rupture (IAR), and adenosine doses were 9 mg (0.20 mg/kg), 12 mg (0.25 mg/kg), 12 mg (0.26 mg/kg), 18 mg (0.34 mg/kg), and 18 mg (0.39 mg/kg), resulted in transient asystole for 12, 14, 9, 44, and 18 s, respectively. For episodes without IAR, adenosine doses ranging from 6 to 18 mg (0.11-0.39 mg/kg) caused asystole for 8-33 s. In five episodes without IAR, low-dose adenosine (lower than 0.2 mg/kg) was used and caused asystole ranging from 8 to 12 s. Postoperatively, two patients had elevated cardiac troponin T levels but normal electrocardiograms. Conclusion AiTA can facilitate the clipping of intracranial aneurysms at low-risk of serious cardiac complications. An adenosine dose of 0.2-0.4 mg/kg is safe and effective in both IAR and non IAR situations. In non IAR cases, we propose that low-dose AiTA is an option to facilitate aneurysm clipping. A starting dose of 6 mg or 0.1-0.2 mg/kg can adequately induce brief asystole by softening the aneurysmal sac during clip application.
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Affiliation(s)
- Patcharin Intarakhao
- Departments of Anesthesiology, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| | - Peeraphong Thiarawat
- Departments of Surgery, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| | - Apirak Tewaritrueangsri
- Departments of Anesthesiology, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| | - Surachart Pojanasupawun
- Departments of Anesthesiology, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
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12
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Nussbaum ES, Burke E, Nussbaum LA. Adenosine-induced transient asystole to control intraoperative rupture of intracranial aneurysms: institutional experience and systematic review of the literature. Br J Neurosurg 2020; 35:98-102. [PMID: 32558601 DOI: 10.1080/02688697.2020.1781057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intraoperative rupture of an intracranial aneurysm is a life-threatening situation that carries a high risk of morbidity and mortality. Since 2000, adenosine has been used successfully to induce transient hypotension and/or asystole to control bleeding and facilitate surgical clipping of aneurysms that rupture intraoperatively. Given the paucity of reports describing this method in a limited number of patients, we performed a systematic review of the literature detailing the use and outcomes of this technique. METHODS The authors performed a systematic review and identified all studies in which adenosine was used in the setting of an intracranial aneurysm that ruptured intraoperatively. We then determined overall morbidity and mortality rates, adding an additional six of our own patients. RESULTS Data was analyzed for a total of 29 patients, including 23 previously reported patients from the literature and 6 additional cases from our own experience (mean age 54.8 years, 58.6% female). Most patients (82.8%, 24/29) presented with subarachnoid hemorrhage (SAH). Overall mean dose of adenosine was 51.8 mg. Successful clipping was achieved in 100% of patients. Transient or permanent morbidity was reported in 5/29 (17.2%) and the overall mortality rate was 31% (9/29), which occurred primarily due to an initial severe SAH and its resultant complications. CONCLUSIONS Adenosine-induced circulatory arrest appears to safely control intraoperative bleeding and facilitate the clipping of ruptured intracranial aneurysms based on the limited published literature available. Further studies comparing patient outcomes using this technique to traditional approaches are required to validate the safety and efficacy of adenosine in this high-risk setting.
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Affiliation(s)
- Eric S Nussbaum
- National Brain Aneurysm and Tumor Center, Department of Neurosurgery, United Hospital, Minneapolis, MN, USA
| | | | - Leslie A Nussbaum
- National Brain Aneurysm and Tumor Center, Department of Neurosurgery, United Hospital, Minneapolis, MN, USA
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13
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Lim J, Shallwani H, Vakharia K, Siddiqui AH. Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation. Oper Neurosurg (Hagerstown) 2020; 18:E184-E190. [PMID: 31748780 DOI: 10.1093/ons/opz330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/24/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Few studies describe the use of adenosine-induced cardiac systole for treatment of cerebrovascular pathologies. We describe a midbrain arteriovenous malformation (AVM) treated with transvenous embolization using adenosine-induced asystole to achieve transient systemic hypotension with the purpose of furthering discussion on the technique and operative considerations for adenosine use in endovascular AVM treatments. CLINICAL PRESENTATION A 29-yr-old man presented with sudden onset of severe bilateral headache, blurred vision, and numbness on the right side of his face and tongue. Noncontrast head computed tomography revealed fourth ventricle hemorrhage. Diagnostic cerebral angiography revealed a high-flow midbrain AVM with a posterior wall perforator from the basilar artery terminus and a draining vein into the straight sinus. Transarterial AVM embolization was successful. The patient was discharged with no residual neurological deficits but returned 1 wk later with slurred speech and left-sided dysmetria. Repeat angiography revealed partial AVM filling. Attempts at transarterial embolization were unsuccessful. Thus, transvenous AVM embolization with adenosine-induced cardiac asystole and systemic hypotension was performed. A total of 60 mg of adenosine was administered, followed by 2 additional doses of 60 and 40 mg; and complete cardiac asystole with a mean arterial pressure of 40 mmHg was maintained, resulting in successful embolization of the AVM. No residual filling was visualized on postembolization arterial angiography runs. The patient was neurologically stable and discharged on postoperative day 2. CONCLUSION With appropriate and safe dosing, adenosine-induced asystole and systemic hypotension may be a feasible, safe option to reduce flow and assist endovascular transvenous embolization of high-flow AVMs.
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Affiliation(s)
- Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Hussain Shallwani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Jacobs Institute, Buffalo, New York
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Sai Kiran NA, Mohan D, Sivaraju L, Raj V, Vidyasagar K, Hegde AS. Adenosine-Induced transient asystole during surgical treatment of basilar artery aneurysms. Neurol India 2020; 68:419-426. [PMID: 32415018 DOI: 10.4103/0028-3886.284353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms. Materials and Methods All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study. Results Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. Conclusion AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.
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Affiliation(s)
- Narayanam A Sai Kiran
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Dilip Mohan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Laxminadh Sivaraju
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Vivek Raj
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Kanneganti Vidyasagar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Alangar S Hegde
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
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Meling TR, Lavé A. What are the options for cardiac standstill during aneurysm surgery? A systematic review. Neurosurg Rev 2019; 42:843-852. [DOI: 10.1007/s10143-019-01183-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/14/2019] [Accepted: 09/22/2019] [Indexed: 12/21/2022]
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Fastenberg JH, Garzon‐Muvdi T, Hsue V, Reilly EK, Jabbour P, Rabinowitz MR, Rosen MR, Evans JJ, Nyquist GN, Farrell CJ. Adenosine‐induced transient hypotension for carotid artery injury during endoscopic skull‐base surgery: case report and review of the literature. Int Forum Allergy Rhinol 2019; 9:1023-1029. [DOI: 10.1002/alr.22381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Judd H. Fastenberg
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Tomas Garzon‐Muvdi
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | | | - Erin K. Reilly
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Pascal Jabbour
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | - Mindy R. Rabinowitz
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Marc R. Rosen
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - James J. Evans
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | - Gurston N. Nyquist
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Christopher J. Farrell
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
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A literature review concerning contralateral approaches to paraclinoid internal carotid artery aneurysms. Neurosurg Rev 2018; 42:877-884. [PMID: 30519771 DOI: 10.1007/s10143-018-01063-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/12/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022]
Abstract
Ipsilateral approaches remain the standard technique for clipping paraclinoid aneurysms. Surgeons must however be prepared to deal with bony and neural structures restricting accessibility. The application of a contralateral approach has been proposed claiming that some structures in the region can be better exposed from this side. Yet, only few case series have been published evaluating this approach, and there is a lack of systematic reviews assessing its specific advantages and disadvantages. We performed a structured literature search and identified 19 relevant publications summarizing 138 paraclinoid aneurysms operated via a contralateral approach. Patient's age ranged from 19 to 79 years. Aneurysm size mainly varied between 2 and 10 mm and only three articles reported larger aneurysms. Most aneurysms were located at the origin of the ophthalmic artery, followed by the superior hypophyseal artery and carotid cave. All aneurysm protruded from the medial aspect of the carotid artery. Interestingly, minimal or even no optic nerve mobilization was required during exposure from the contralateral side. Strategies to achieve proximal control of the carotid artery were balloon occlusion and clinoid segment or cervical carotid exposure. Successful aneurysm occlusion was achieved in 135 cases, while 3 ophthalmic aneurysms had to be wrapped only. Complications including visual deterioration, CSF fistula, wound infection, vasospasm, artery dissection, infarction, and anosmia occurred in a low percentage of cases. We conclude that a contralateral approach can be effective and should be considered for clipping carefully selected cases of unruptured aneurysms arising from medial aspects of the above listed vessels.
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Wang X, Feletti A, Tanaka R, Yamada Y, Suyama D, Kawase T, Kato Y. Adenosine-induced Flow Arrest to Facilitate Intracranial Complex Aneurysm Clip Ligation: Review of the Literature. Asian J Neurosurg 2018; 13:539-545. [PMID: 30283502 PMCID: PMC6159025 DOI: 10.4103/ajns.ajns_207_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Complex intracranial aneurysms (CIAs) rank high among the most technically demanding neurosurgical pathologies. Microsurgery and clip ligation can be challenging in CIAs as circumferential visualization of the aneurysm, parent vessels, branches, perforators, and other neurovascular structures is important to prevent residual aneurysms or strokes from vessel or perforator occlusion. Decompression of the aneurysm sac is often required for CIAs. We reviewed the literature and PubMed advanced search showed 13 results of adenosine-induced flow arrest to facilitate intracranial complex aneurysm clip ligation which included three independent case reports and ten cases in a case series from 1999 to May 2016. Few case series have described the use of adenosine in intracranial aneurysm surgery. Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. We recommend that adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.
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Affiliation(s)
- XiangDong Wang
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan.,Department of Neurosurgery, Heji Hospital, Changzhi Medical College, ChangZhi City, Shan Xi Province, China
| | - Alberto Feletti
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Daisuke Suyama
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
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Intarakhao P, Thiarawat P, Rezai Jahromi B, Kozyrev DA, Teo MK, Choque-Velasquez J, Luostarinen T, Hernesniemi J. Adenosine-induced cardiac arrest as an alternative to temporary clipping during intracranial aneurysm surgery. J Neurosurg 2018; 129:684-690. [DOI: 10.3171/2017.5.jns162469] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVEThe purpose of this study was to analyze the impact of adenosine-induced cardiac arrest (AiCA) on temporary clipping (TC) and the postoperative cerebral infarction rate among patients undergoing intracranial aneurysm surgery.METHODSIn this retrospective matched-cohort study, 65 patients who received adenosine for decompression of aneurysms during microsurgical clipping were identified (Group A) and randomly matched with 65 selected patients who underwent clipping but did not receive adenosine during surgery (Group B). The matching criteria included age, Fisher grade, aneurysm size, rupture status, and location of aneurysms. The primary outcomes were TC time and the postoperative infarction rate. The secondary outcome was the incidence of intraoperative aneurysm rupture (IAR).RESULTSIn Group A, 40 patients underwent clipping with AiCA alone and 25 patients (38%) received AiCA combined with TC, and in Group B, 60 patients (92%) underwent aneurysm clipping under the protection of TC (OR 0.052; 95% CI 0.018–0.147; p < 0.001). Group A required less TC time (2.04 minutes vs 4.46 minutes; p < 0.001). The incidence of postoperative lacunar infarction was equal in both groups (6.2%). There was an insignificant between-group difference in the incidence of IAR (1.5% in Group A vs 6.1% in Group B; OR 0.238; 95% CI 0.026–2.192; p = 0.171).CONCLUSIONSAiCA is a useful technique for microneurosurgical treatment of cerebral aneurysms. AiCA can minimize the use of TC and does not increase the risk of IAR and postoperative infarction.
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Affiliation(s)
- Patcharin Intarakhao
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
- Departments of 2Anesthesiology and
| | - Peeraphong Thiarawat
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
- 3Surgery, Naresuan University, Phitsanulok, Thailand
| | | | - Danil A. Kozyrev
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Mario K. Teo
- 4Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, United Kingdom; and
| | | | - Teemu Luostarinen
- 5Department of Anesthesiology, Intensive Care, Emergency Care and Pain Clinic, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Konczalla J, Platz J, Fichtlscherer S, Mutlak H, Strouhal U, Seifert V. Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial. J Neurosurg 2018; 128:1741-1752. [DOI: 10.3171/2016.11.jns161420] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVETo date, treatment of complex unruptured intracranial aneurysms (UIAs) remains challenging. Therefore, advanced techniques are required to achieve an optimal result in treating these patients safely. In this study, the safety and efficacy of rapid ventricular pacing (RVP) to facilitate microsurgical clip reconstruction was investigated prospectively in a joined neurosurgery, anesthesiology, and cardiology study.METHODSPatients with complex UIAs were prospectively enrolled. Both the safety and efficacy of RVP were evaluated by recording cardiovascular events and outcomes of patients as well as the amount of aneurysm occlusion after the surgical clip reconstruction procedure. A questionnaire was used to evaluate aneurysm preparation and clip application under RVP.RESULTSTwenty patients (mean age 51.6 years, range 28–66 years) were included in this study. Electrode positioning was easy in 19 (95%) of 20 patients, and removal of electrodes was easily accomplished in all patients (100%). No complications associated with the placement of the pacing electrodes occurred, such as cardiac perforation or cardiac tamponade. RVP was applied in 16 patients. The mean aneurysm size was 11.1 ± 5.5 mm (range 6–30 mm). RVP proved to be a very helpful tool in aneurysm preparation and clip application in 15 (94%) of 16 patients. RVP was used for a mean duration of 60 ± 25 seconds, a mean heart rate of 173 ± 23 bpm (range 150–210 bpm), and a reduction of mean arterial pressure to 35–55 mm Hg. RVP leads to softening of the aneurysm sac facilitating its mobilization, clip application, and closure of the clip blades. In 2 patients, cardiac events were documented that resolved without permanent sequelae in both. In every patient with successful RVP (n = 14) a total or near-total aneurysm occlusion was documented. In the 1 patient in whom the second RVP failed due to pacemaker electrode dislocation, additional temporary clipping was required to secure the aneurysm, but was not as sufficient as RVP. This led to an incomplete clipping of the aneurysm and finally a remnant on postoperative digital subtraction angiography. A pacemaker lead dislocation occurred in 3 (19%) of 16 patients, but intraoperative repositioning requires less than 20 seconds. Outcome was favorable in all patients according to the modified Rankin Scale.CONCLUSIONSTo the best of the authors’ knowledge this is the first prospective interdisciplinary study of RVP use in patients with UIAs. RVP is an elegant technique that facilitates clip reconstruction in complex UIAs. The safety of the procedure is good. However, because this procedure requires extensive preoperative cardiological workup of the patient and an experienced neurosurgery and neuroanesthesiology team with much cerebrovascular expertise, actually it remains reserved for selected elective cases and highly specialized centers.Clinical trial registration no.: NCT02766972 (clinicaltrials.gov)
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Affiliation(s)
| | | | | | - Haitham Mutlak
- 3Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Ulrich Strouhal
- 3Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Abstract
BACKGROUND Temporary parent vessel clip occlusion in aneurysm surgery is not always practical or feasible. Adenosine-induced transient cardiac arrest may serve as an alternative. METHODS All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole performed by the author between September 2011 and July 2014 were retrospectively reviewed. RESULTS A total of 16 craniotomies were performed and 16 aneurysms were clipped under adenosine-induced asystole (in 8 basilar arteries, 7 internal carotid arteries, and 1 middle cerebral artery) in 14 patients (8 females, 6 males). Seven cases were elective and 7 were performed after subarachnoid hemorrhage. The patients' mean age was 54 years (range, 39-70 years). The indications for adenosine use were proximal control in narrow surgical corridors in 11 cases, aneurysm softening in 4 cases, and aneurysm rupture in 1 case. A single dose was used in 12 patients; 2 patients had multiple boluses. The median (range) total dose was 30 (18-60) mg. Adenosine induced bradycardia with concomitant arterial hypotension in all patients and the majority also had asystole for 5-15 s. Transient cardiac arrhythmias were noted in 1 patient (atrial fibrillation in need of electroconversion after two boluses). CONCLUSION Nine clinical scenarios were identified in which adenosine-induced temporary cardiac arrest and deep hypotension was an effective adjunct to temporary clipping during the microsurgical clipping of intracranial aneurysms.
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Affiliation(s)
- Torstein R Meling
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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23
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Meling TR, Romundstad L, Niemi G, Narum J, Eide PK, Sorteberg AG, Sorteberg WA. Adenosine-assisted clipping of intracranial aneurysms. Neurosurg Rev 2017; 41:585-592. [DOI: 10.1007/s10143-017-0896-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/24/2017] [Accepted: 08/10/2017] [Indexed: 11/25/2022]
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Adenosine-assisted neurovascular surgery: initial case series and review of literature. Neurosurg Rev 2017; 42:15-22. [DOI: 10.1007/s10143-017-0883-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/10/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
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25
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Desai VR, Rosas AL, Britz GW. Adenosine to facilitate the clipping of cerebral aneurysms: literature review. Stroke Vasc Neurol 2017; 2:204-209. [PMID: 29507781 PMCID: PMC5829927 DOI: 10.1136/svn-2017-000082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 12/16/2022] Open
Abstract
Cerebral aneurysms have a high mortality rate when ruptured. Endovascular techniques have improved substantially in treating this pathology. However, surgical clip ligation remains the preferred option for some aneurysms. Various techniques are used intraoperatively to assist the surgeon in dissecting the aneurysmal dome free of surrounding tissue and placing a clip around the neck safely and effectively so that no nearby perforating vessels are affected and no residual remains. These techniques include temporary clip ligation, endovascular balloon occlusion and cardiac standstill. Adenosine use is one viable option for induced cardiac arrest leading to a short period of controlled hypotension. Its predictable course of action, rapid onset and offset and rare incidence of adverse side effects make it an attractive agent in this regard. Below, we provide an introduction to adenosine use, describing its pharmacokinetic properties, indications, contraindications, complications and future directions.
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Affiliation(s)
- Virendra R Desai
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Alejandro L Rosas
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
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Multidose Adenosine Used to Facilitate Microsurgical Clipping of a Cerebral Aneurysm Complicated by Intraoperative Rupture. ACTA ACUST UNITED AC 2017; 8:109-112. [DOI: 10.1213/xaa.0000000000000438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Thiarawat P, Jahromi BR, Kozyrev DA, Intarakhao P, Teo MK, Choque-Velasquez J, Hernesniemi J. Microneurosurgical Management of Posterior Communicating Artery Aneurysm: A Contemporary Series from Helsinki. World Neurosurg 2017; 101:379-388. [PMID: 28213191 DOI: 10.1016/j.wneu.2017.02.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objectives of this study were to analyze microsurgical techniques and to determine correlations between microsurgical techniques and the radiographic findings in the microneurosurgical treatment of posterior communicating artery aneurysms (PCoAAs). METHODS We retrospectively analyzed radiographic findings and videos of surgeries in 64 patients with PCoAAs who underwent microsurgical clipping by the senior author from August 2010 to 2014. RESULTS From 64 aneurysms, 30 (47%) had acute subarachnoid hemorrhage (SAH) that necessitated lamina terminalis fenestration (odds ratio [OR], 67.67; P < 0.001) and Liliequist membrane fenestration (OR, 19.62; P < 0.001). The low-lying aneurysms significantly necessitated the coagulation of the dura covering the anterior clinoid process (ACP) (OR, 7.43; P = 0.003) or anterior clinoidectomy (OR, 91.0; P < 0.001). We preferred straight clips in 45 (83%) of 54 posterolateral projecting aneurysms (OR, 45.0; P < 0.001), but preferred curved clips for posteromedial projecting aneurysms (OR, 6.39; P = 0.008). The mean operative time from the brain retraction to the final clipping was 17 minutes and 43 seconds. Postoperative computed tomography angiography revealed complete occlusion of 60 (94%) aneurysms. Three (4.6%) patients with acute SAH suffered postoperative lacunar infarction. CONCLUSIONS For ruptured aneurysms, lamina terminalis and Liliequist membrane fenestration are useful for additional cerebrospinal fluid drainage. For low-lying aneurysms, coagulation of the dura covering the ACP or tailored anterior clinoidectomy might be necessary for exposing the proximal aneurysm neck. Type of clips depends on the direction of projection. The microsurgical clipping of the PCoAAs can achieve good immediate complete occlusion rate with low postoperative stroke rate.
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Affiliation(s)
- Peeraphong Thiarawat
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Surgery, Naresuan University, Phitsanulok, Thailand.
| | | | - Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, North-Western State Medical University, Saint Petersburg, Russia
| | - Patcharin Intarakhao
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Anesthesiology, Naresuan University, Phitsanulok, Thailand
| | - Mario K Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, United Kingdom
| | | | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Nimjee SM, McDonagh DL, Agrawal A, Britz GW. A Case of High-dose Adenosine Usage for Anterior Communicating Artery Aneurysm Clip Ligation: What is the Dose Limit for a Resistant Response? Asian J Neurosurg 2017; 12:783-786. [PMID: 29114312 PMCID: PMC5652124 DOI: 10.4103/1793-5482.181145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Intraoperative adenosine is used to induce asystole to facilitate clip ligation of intracranial aneurysms. Typically, 5–10 mg doses are used per administration and approximately 30 mg is used for a given case. An obvious concern with using adenosine is that the patient can remain in asystole or that prolonged hypotension can result in cerebral or cardiovascular ischemia. The upper limit of adenosine administration remains unclear. We present a case of a patient with a large anterior communicating artery aneurysm requiring large doses of adenosine, far exceeding previously reported cases. The patient received a 90 mg dose of adenosine to achieve 5 s of asystole as well as 30 s of hypotension that facilitated vessel dissection and clip application. Moreover, in order to successfully clip his aneurysm, he received a total of 744 mg of adenosine. After each administration of adenosine, his heart rate and blood pressure returned to baseline without the need for chest compressions or other interventions. He tolerated the procedure and had a good neurological outcome. This case is the first report of using such a high dose of adenosine in intracranial aneurysm surgery and suggests that more aggressive administration of adenosine during aneurysm clipping is feasible. Transient hypotension, as seen in this report, can provide surgeons the crucial moments they need to safely secure an aneurysm from circulation.
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Affiliation(s)
- Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David L McDonagh
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Abhishek Agrawal
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
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Lee SH, Kwun BD, Kim JU, Choi JH, Ahn JS, Park W, Yun JH. Adenosine-induced transient asystole during intracranial aneurysm surgery: indications, dosing, efficacy, and risks. Acta Neurochir (Wien) 2015; 157:1879-86; discussion 1886. [PMID: 26385113 DOI: 10.1007/s00701-015-2581-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/03/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Several flow-arrest techniques have been introduced for the treatment of complex aneurysms that cannot be treated with conventional clipping or endovascular coil embolization. Adenosine-induced transient asystole is an alternative method of flow arrest. However, given the limited number of studies that have reported on this topic, there is no consensus regarding the dose, regimen, efficacy, and potential risks of adenosine. METHOD A total of 22 aneurysms in 22 different patients that underwent adenosine-induced transient asystole during aneurismal neck clipping within the past 4 years were retrospectively reviewed. Adenosine was administrated intravenously in a test-incremental manner (starting with 6-12 mg and then giving additional doses as needed) in 11 patients and in an estimated manner (pre-calculated as 0.3-0.4 mg/kg) in 11 patients. RESULTS Overall, the study consisted of 18 unruptured saccular aneurysms, three ruptured saccular aneurysms, and a ruptured pseudoaneurysm. Adenosine-induced transient asystole was used in cases of temporary clipping inability, wide necked aneurysm, deep-seated aneurysm, or a thin aneurysm wall. The number of administrations, dose (mg/kg in ideal body weight) and duration of asystole were 1-4 (mean, 2.3) times, 0.08-1.27 (mean, 0.36) mg/kg and 0-30 (mean 13) seconds in the test-incremental manner and 1-2 (mean, 1.09) times, 0.24-0.42 (mean, 0.34) mg/kg and 13-41 (mean, 24) seconds in the estimated manner, respectively. There was a linear relationship between the dose and the duration of asystole. Twenty out of 22 aneurysms were clipped successfully with adenosine-induced transient asystole. However, in the other two cases, additional suction decompression was required for the final clipping. Adenosine-related cardiologic complications occurred in two cases of self-limited atrial fibrillation during restoration of the cardiac rhythm. CONCLUSIONS In our experience, adenosine-induced transient asystole was safe and helpful for satisfactory clipping of a complicated aneurysm. An estimated dose injection of adenosine was more convenient than the test-incremental method and did not result in serious cardiologic problems.
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Affiliation(s)
- Sung Ho Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea.
| | - Joung Uk Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, College of Medicine, Dankook University, Cheonan, Korea
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Abstract
Cerebral aneurysms are an important health issue in the United States, and the mortality rate following aneurysm rupture, or SAH, remains high. The treatment of these aneurysms uses endovascular options which include coil placement, stent assistant coiling and, recently, flow diversion. However, microsurgical clipping remains an option in those aneurysms not suited for endovascular therapy. These are often the more complicated aneurysms such as in large, giant aneurysms or deep-seated aneurysms. Circumferential visualization of the aneurysm, parent vessels, branches, perforators, and other neurovascular structures is important to prevent residual aneurysms or strokes from vessel or perforator occlusion. Decompression of the aneurysm sac is often required and we believe that adenosine-induced transient asystole should be an important option for clipping of complex cerebral aneurysms.
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Transient Cardiac Arrest Induced by Adenosine: A Tool for Contralateral Clipping of Internal Carotid Artery-Ophthalmic Segment Aneurysms. World Neurosurg 2015; 84:1933-40. [PMID: 26341426 DOI: 10.1016/j.wneu.2015.08.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND The disadvantages of a contralateral approach (CA) include deep and narrow surgical corridors and inconsistent ability to achieve proximal control of the supraclinoid internal carotid artery (ICA). However, a CA remains as a microsurgical option for selected ICA-ophthalmic (opht) segment aneurysms. OBJECTIVE To describe transient cardiac arrest induced by adenosine as an alternative tool to obtain proximal vascular control and soften the aneurysm sac in selected patients while performing a CA. METHODS From January 1998 to December 2013, we retrospectively identified 30 patients with ICA-opht segment aneurysms treated through a CA. Of those, 8 patients received an intravenous bolus of adenosine to induce transient cardiac arrest for softening of the aneurysm sac. We reviewed preoperative clinical status, characteristics of the contralateral aneurysm, adenosine doses, asystole time, recovery of normal circulation, outcome, and complications. RESULTS No preoperative cardiac or pulmonary pathologies were found in the study population. All contralateral ICA-opht segment aneurysms were unruptured, small, and saccular in shape. Transient cardiac arrest was induced because it was impossible to apply a temporary clip on the parent contralateral supraclinoid ICA. The median dose of adenosine was 22.5 mg (range, 5-50 mg) and the asystole time ranged from 20 to 40 seconds. All patients (n = 8) had good postoperative outcomes. No brain infarction or cardiac complications appeared postoperatively. CONCLUSIONS In selected patients, transient cardiac arrest induced by adenosine during a contralateral approach allows a brief flow arrest and softening of the aneurysm for safer exposure and clipping.
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Rangel-Castilla L, Russin JJ, Britz GW, Spetzler RF. Update on transient cardiac standstill in cerebrovascular surgery. Neurosurg Rev 2015; 38:595-602. [DOI: 10.1007/s10143-015-0637-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 02/13/2015] [Accepted: 03/14/2015] [Indexed: 11/24/2022]
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Goehre F, Lehecka M, Jahromi BR, Lehto H, Kivisaari R, Hijazy F, Nayeb L, Sugimoto T, Morishige M, Elsharkawy A, von und zu Fraunberg M, Jääskeläinen JE, Hernesniemi JA. Subtemporal Approach to Posterior Cerebral Artery Aneurysms. World Neurosurg 2015; 83:842-51. [DOI: 10.1016/j.wneu.2015.01.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 12/10/2014] [Accepted: 01/19/2015] [Indexed: 10/24/2022]
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Luostarinen T, Lehto H, Skrifvars MB, Kivisaari R, Niemelä M, Hernesniemi J, Randell T, Niemi T. Transfusion Frequency of Red Blood Cells, Fresh Frozen Plasma, and Platelets During Ruptured Cerebral Aneurysm Surgery. World Neurosurg 2015; 84:446-50. [PMID: 25839398 DOI: 10.1016/j.wneu.2015.03.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of blood products after subarachnoid hemorrhage (SAH) is common, but not without controversy. The optimal hemoglobin level in patients with SAH is unknown, and data on perioperative need for red blood cell (RBC), fresh frozen plasma (FFP), or platelet transfusions are limited. We studied perioperative administration of RBCs, FFP, and platelets and the impact of red blood cell transfusions (RBCTs) on outcome in patients undergoing surgery for ruptured a cerebral arterial aneurysm. METHODS A retrospective analysis was performed of 488 patients with aneurysmal SAH during the years 2006-2009 at Helsinki University Central Hospital. Patients who received RBC, FFP, or platelet concentrates perioperatively were compared with a cohort of patients from the Helsinki database of aneurysmal SAH who did not receive transfusions. A multiple regression model was created to identify factors related to transfusion and outcome. RESULTS RBC, FFP, or platelet concentrates were given in 7.6% (37 of 488), 3.1% (15 of 488), and 1.2% (6 of 488) of patients intraoperatively and in 3.5% (17 of 486), 1.6% (8 of 488), and 0.9% (4 of 488) of patients postoperatively. Of 37 intraoperative RBCTs, 26 were related to intraoperative rupture of the aneurysm. Intraoperative RBCTs were associated with lower preoperative hemoglobin concentration, higher World Federation of Neurosurgical Societies classification, and intraoperative rupture of an aneurysm. In multivariate analysis, intraoperative RBCT (odds ratio = 5.13, 95% confidence interval = 1.53-17.15), worse World Federation of Neurosurgical Societies classification and Fisher grade (odds ratio = 1.97, confidence interval = 1.64-2.36 and odds ratio = 1.89, confidence interval = 1.23-2.92, respectively), and increasing age (odds ratio = 1.07, confidence interval = 1.04-1.10) independently increased the risk of poor neurologic outcome at 3 months. CONCLUSIONS Transfusion frequencies of RBCs, FFP, and platelets were relatively low. Intraoperative RBCT was strongly related to intraoperative rupture of the aneurysm in patients with poor-grade SAH. The observed association between poor outcome and RBCT in patients with SAH warrants further study.
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Affiliation(s)
- Teemu Luostarinen
- Division of Anaesthesiology, Department of Anaesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Hanna Lehto
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- Division of Intensive Care Medicine, Department of Anaesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tarja Randell
- Division of Anaesthesiology, Department of Anaesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tomi Niemi
- Division of Anaesthesiology, Department of Anaesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Andrade-Barazarte H, Kivelev J, Goehre F, Jahromi BR, Hijazy F, Moliz N, Gauthier A, Kivisaari R, Jääskeläinen JE, Lehto H, Hernesniemi JA. Contralateral Approach to Internal Carotid Artery Ophthalmic Segment Aneurysms: Angiographic Analysis and Surgical Results for 30 Patients. Neurosurgery 2015; 77:104-12; discussion 112. [PMID: 25812068 DOI: 10.1227/neu.0000000000000742] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Contralateral aneurysm clipping can be applied to bilateral intracranial aneurysms of the anterior circulation and to selected aneurysms on the medial wall of the internal carotid artery (ICA). OBJECTIVE To identify anatomic and radiological parameters that would favor a contralateral microsurgical approach to ICA-ophthalmic segment (ICA-opht) aneurysms. METHODS For the period January 1957 to December 2012, we retrospectively analyzed 268 patients with ICA-opht aneurysms treated in our institution. Of these patients, 30 underwent a contralateral approach; 15 patients (50%) had multiple intracranial aneurysms, and 15 patients had a single aneurysm on the contralateral side of the craniotomy. RESULTS Thirty saccular aneurysms located on the contralateral ICA were treated. Six aneurysms (20%) were present in patients with a subarachnoid hemorrhage due to associated aneurysms, whereas 24 aneurysms (80%) had no history of bleeding. Contralateral aneurysms were smaller than 14 mm and showed no wall irregularities, calcifications, or secondary pouches. Projections of the aneurysms were superomedial (n = 23, 77%), medial (n = 4, 13%), and superior (n = 3, 10%). The median prechiasmatic distance was 5.7 mm (range, 3.4-8.7 mm), the median interoptic distance was 10.5 mm (range, 7.6-15.9 mm), and the median distance between both ICAs was 14.7 mm (range, 10.4-21.4 mm). CONCLUSION The contralateral approach for ICA-opht aneurysms remains a treatment option for intracranial aneurysms. Its feasibility depends on specific anatomic parameters related to the aneurysm itself and to the prechiasmatic distance, interoptic distance, and relationship of the ICA with the anterior clinoid process.
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Affiliation(s)
- Hugo Andrade-Barazarte
- *Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland; ‡Department of Biosciences, University of Helsinki, Helsinki, Finland; §Department of Neurosurgery, NeuroCenter, Kuopio University Central Hospital, Kuopio Finland
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36
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Anesthesia for the surgical treatment of cerebral aneurysms☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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37
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Anestesia para el tratamiento quirúrgico de aneurismas cerebrales. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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38
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Lecours M, Gelb AW. Anesthesia for the surgical treatment of cerebral aneurysms. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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39
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Hernesniemi J, Goehre F. Approaches to upper basilar artery aneurysms. World Neurosurg 2014; 82:1001-2. [PMID: 24947119 DOI: 10.1016/j.wneu.2014.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
| | - Felix Goehre
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
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40
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Wright JM, Huang CL, Sharma R, Manjila S, Xu F, Dabb B, Bambakidis NC. Cardiac standstill and circulatory flow arrest in surgical treatment of intracranial aneurysms: a historical review. Neurosurg Focus 2014; 36:E10. [DOI: 10.3171/2014.2.focus13554] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since the first surgery for an intracranial aneurysm in 1931, neurological surgeons have long strived to determine the optimal methods of surgical correction. Significant challenges of aneurysm clipping include intraoperative rupture and complex dome morphology. Hypothermia, cardiopulmonary bypass, pharmacologically induced hypotension, and cardiac standstill are a few of the methodologies historically and currently employed in the management of these issues. In the 1980s, significant advances in pharmacology and anesthesiology led to the use of agents such as adenosine for chemically induced hypotension and eventually complete circulatory arrest. Since the institution of the use of these agents, the traditional methods of circulatory arrest under conditions of hypothermia and cardiopulmonary bypass have fallen out of favor. However, there still exists a subset of technically difficult aneurysms for which cardiac standstill, both chemical and hypothermic, remains a viable therapeutic option. In this paper, the authors describe the history of cardiac standstill by both hypothermic and chemically induced means as well as provide examples in which these techniques are still necessary.
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Affiliation(s)
- James M. Wright
- 1Department of Neurological Surgery, The Neurological Institute,
| | | | - Rahul Sharma
- 3The Commonwealth Medical College, Scranton, Pennsylvania; and
| | - Sunil Manjila
- 1Department of Neurological Surgery, The Neurological Institute,
| | - Feng Xu
- 1Department of Neurological Surgery, The Neurological Institute,
- 5Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Barbara Dabb
- 4Department of Anesthesiology, University Hospitals Case Medical Center, Cleveland, Ohio
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Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract 2014; 2014:595837. [PMID: 24723946 PMCID: PMC3958760 DOI: 10.1155/2014/595837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/26/2014] [Indexed: 01/08/2023] Open
Abstract
Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.
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42
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Elsharkawy A, Niemelä M, Lehečka M, Lehto H, Jahromi BR, Goehre F, Kivisaari R, Hernesniemi J. Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms. Acta Neurochir (Wien) 2014; 156:17-25. [PMID: 24101289 DOI: 10.1007/s00701-013-1894-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 09/17/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique. METHOD A 3D image-based anatomic orientation, clipping field-focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10-15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field. RESULTS The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches. CONCLUSION The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.
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Affiliation(s)
- Ahmed Elsharkawy
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland,
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Khan SA, McDonagh DL, Adogwa O, Gokhale S, Toche UN, Verla T, Zomorodi AR, Britz GW. Perioperative Cardiac Complications and 30-Day Mortality in Patients Undergoing Intracranial Aneurysmal Surgery With Adenosine-Induced Flow Arrest. Neurosurgery 2013; 74:267-71; discussion 271-2. [DOI: 10.1227/neu.0000000000000258] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Adenosine-induced flow arrest is a technique used to assist in the surgical clipping of complex aneurysms.
OBJECTIVE:
To assess the safety associated with adenosine-assisted intracranial aneurysm surgery.
METHODS:
Medical records of all patients presenting between January 1, 2009, and December 31, 2012, for intracranial aneurysm surgery were analyzed. Patients were divided into 2 groups based on the intraoperative administration of adenosine: the nonadenosine group (n = 262) and the adenosine group (n = 64). The primary outcome compared between groups included a composite of 30-day mortality and incidences of perioperative cardiac complications (perioperative myocardial infarction or perioperative cardiac arrhythmias).
RESULTS:
The study groups were statistically similar except for a difference in the size and location of cerebral aneurysms and the incidence of coronary artery disease. The primary composite outcome occurred in 4.6% and 9.4% of patients in the nonadenosine and adenosine groups, respectively (P = .13). After adjustment for differences in the incidence of coronary artery disease between the 2 groups, the odds of the primary outcome were not significantly different between the groups (adjusted odds ratio = 2.12; 95% confidence interval, 0.76-5.93; P = .15). There were also no significant differences in the durations of hospital and intensive care unit stay between the study groups.
CONCLUSION:
Our results suggest that adenosine-assisted intracranial aneurysm surgery is not associated with an increase in perioperative cardiac complications or mortality in patients with low risk of coronary artery disease and may be considered a safe technique to assist clipping of complex aneurysms.
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Affiliation(s)
- Shariq A. Khan
- Department of Anesthesiology, Methodist Neurological Institute, Houston, Texas
- Department of Anesthesiology, Singapore General Hospital, Singapore
| | - David L. McDonagh
- Department of Anesthesiology, Methodist Neurological Institute, Houston, Texas
| | - Owoicho Adogwa
- Departments of Surgery (Neurosurgery) and Radiology, Methodist Neurological Institute, Houston, Texas
| | - Sankalp Gokhale
- Division of Neurocritical Care, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | | | - Terence Verla
- Duke University Medical School, Durham, North Carolina
| | - Ali R. Zomorodi
- Departments of Surgery (Neurosurgery) and Radiology, Methodist Neurological Institute, Houston, Texas
| | - Gavin W. Britz
- Department of Neurosurgery, Methodist Neurological Institute, Houston, Texas
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Elsharkawy A, Hernesniemi J. Not all roads lead to Rome…. World Neurosurg 2013; 80:806-7. [PMID: 23924965 DOI: 10.1016/j.wneu.2013.07.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Ahmed Elsharkawy
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland; Department of Neurosurgery, Tanta University, Tanta, Egypt
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46
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Yamakawa K, Kiyama S, Murayama Y, Uezono S. Incidence and neurological outcomes of aneurysm rupture during interventional neuroradiology procedures in a hybrid operating suite. J Anesth 2012; 26:592-4. [DOI: 10.1007/s00540-012-1357-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 02/07/2012] [Indexed: 11/24/2022]
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47
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Saldien V, Menovsky T, Rommens M, Van der Steen G, Van Loock K, Vermeersch G, Mott C, Bosmans J, De Ridder D, Maas AIR. Rapid Ventricular Pacing for Flow Arrest During Cerebrovascular Surgery: Revival of an Old Concept. Oper Neurosurg (Hagerstown) 2011; 70:270-5. [DOI: 10.1227/neu.0b013e318236d84a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Intraoperative rupture of a cerebral aneurysm can be a devastating event that increases operative morbidity and mortality. Rapid ventricular pacing (RVP) is a technique used in interventional cardiology to obtain flow arrest for short periods of time.
OBJECTIVE:
To present our experience using RVP for flow arrest during cerebrovascular surgery.
METHODS:
We used RVP to produce flow arrest for periods of 40 seconds in 12 patients who underwent craniotomy for a cerebrovascular disorder (11 aneurysms and 1 arteriovenous malformation).
RESULTS:
During RVP, there was an immediate and significant reduction of blood pressure in each patient. The maximum degree of hypotension was obtained 3.2 ± 0.7 seconds (mean ± SD) after the start of RVP. When RVP was terminated, normal sinus rhythm returned instantaneously, along with recovery of indexes of hemodynamic function. Subjectively, the decrease in blood pressures facilitated dissection, and during clipping, the aneurysm sac felt softer and was easier to manipulate. No complications related to RVP occurred.
CONCLUSION:
Rapid ventricular pacing during cerebrovascular surgery is an effective method for lowering the arterial blood pressure in a controlled and directly reversible manner. Advances in cardiology now make RVP a promising and safe technique that can facilitate complex cerebrovascular surgery.
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Affiliation(s)
- Vera Saldien
- Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
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Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, von und zu Fraunberg M, Niemelä M, Rinne J, Hernesniemi J. Microsurgery for Previously Coiled Aneurysms: Experience With 81 Patients. Neurosurgery 2011; 68:140-53; discussion 153-4. [DOI: 10.1227/neu.0b013e3181fd860e] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Abstract
BACKGROUND:
Residual and recurrent intracranial aneurysms after endovascular treatment with Guglielmi detachable coils may necessitate a microsurgical occlusion.
OBJECTIVE:
To analyze the microsurgical technique and describe how the location, morphology, and appearance of the coiled aneurysm affect the technique.
METHODS:
We retrospectively analyzed 81 patients with 82 previously coiled aneurysms treated microsurgically at 2 Finnish neurosurgical university hospitals in Helsinki and Kuopio between July 1995 and August 2009. Seven videos were selected to demonstrate the microsurgical strategy in various locations.
RESULTS:
Fifty-eight aneurysms (71%) were located at anterior circulation and 24 (29%) at posterior circulation. Fifteen patients were operated on within the first month (early surgery) after coiling, whereas 66 were treated later (late surgery). Complete or partial removal of coils during surgery may facilitate clipping, but is significantly (P < .001) more difficult to accomplish in late surgery. Removal of coils may also increase the chance of poor outcome. Chance of poor outcome also increased with intraoperative aneurysm rupture, size of the aneurysm, and posterior circulation location. Good clinical outcome (same or better clinical condition 3 months after surgery) was achieved in 71 patients (88%). After microsurgery, 4 patients were severely disabled and 6 patients died, 3 of them because of poor clinical condition.
CONCLUSION:
Complete microsurgical occlusion of the residual aneurysm is possible. However, in large or giant aneurysms direct microsurgery is a challenging high-risk procedure, and we recommend that these patients be referred to a dedicated neurovascular center to minimize surgical complications. Even in experienced hands, use of different bypass procedures may be the best option for demanding growing lesions, especially those in the posterior circulation.
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Affiliation(s)
- Rossana. Romani
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Hanna. Lehto
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Aki. Laakso
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Angel. Horcajadas
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Riku. Kivisaari
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Mika. Niemelä
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Jaakko. Rinne
- Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Juha. Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| |
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