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Update on transient cardiac standstill in cerebrovascular surgery

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Abstract

Transient cardiac standstill is a complementary procedure used with microsurgery to treat patients with particularly complex aneurysms, such as large or giant cerebral aneurysms. These procedures allow the aneurysms to be decompressed while maintaining a bloodless field and increased surgical exposure. Deep hypothermia combined with circulatory arrest provides cerebroprotection with optimal surgical conditions. However, its disadvantage is the relatively high risk of the procedure, which requires extensive expertise and infrastructure. Thus, its use is typically limited to patients with complex posterior circulation aneurysms. Adenosine-induced transient asystole is an easily applied technique in a variety of clinical situations. Its use requires minimal advanced preparation and no complex logistical coordination with other subspecialties. However, patient-specific dose-response relationships must be determined by exposure, so the relationship may not be known in an emergent situation. Persistent hypotension is a potentially major complication. Rapid ventricular pacing (RVP) has recently been reintroduced into cerebrovascular surgery. It is more predictable than adenosine in response time and, thus, can be used during unanticipated complications, such as aneurysmal rupture. It also induces a shorter period of hypotension compared with adenosine. However, RVP is more invasive and more complex from an anesthesia standpoint. Vascular neurosurgeons should be familiar with these techniques and know their applications and limitations.

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Conflict of interest

The authors have no conflicts of interest to disclose.

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Authors and Affiliations

  1. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

    Leonardo Rangel-Castilla, Jonathan J. Russin, Gavin W. Britz & Robert F. Spetzler

  2. Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA

    Gavin W. Britz

  3. c/o Neuroscience Publications; Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA

    Robert F. Spetzler

Authors
  1. Leonardo Rangel-Castilla
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  2. Jonathan J. Russin
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  3. Gavin W. Britz
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  4. Robert F. Spetzler
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Corresponding author

Correspondence to Robert F. Spetzler.

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Comments

Ernst J. Delwel, Rotterdam, The Netherlands

This is an interesting and instructive article on three techniques available for temporary standstill in cerebrovascular surgery. The advantages and drawbacks are well described.

RVP has recently been reintroduced after being abandoned in 1971 and seems to be the most predictable and probably the safest of the three described techniques. However, experience with RVP is limited and requires preoperative preparation and increases the anesthetic complexity.

The described techniques are particularly useful in cases of complex or giant aneurysms in which proximal control of the aneurysm by temporary clipping of the parent vessel is not feasible.

The authors claim that temporal clipping of the parent vessel can potentially injure the vessel, resulting in dissection, stroke, or even vessel rupture. Recommendations for estimating the risk of occurrence of such a complication are not provided in the article.

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Rangel-Castilla, L., Russin, J.J., Britz, G.W. et al. Update on transient cardiac standstill in cerebrovascular surgery. Neurosurg Rev 38, 595–602 (2015). https://doi.org/10.1007/s10143-015-0637-z

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  • DOI: https://doi.org/10.1007/s10143-015-0637-z

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