Adenosine-assisted clipping of intracranial aneurysms

  • Torstein R. Meling
  • Luis Romundstad
  • Geir Niemi
  • Jon Narum
  • Per Kristian Eide
  • Angelika G. Sorteberg
  • Wilhelm A. Sorteberg
Original Article

Abstract

Temporary parent vessel clip occlusion in aneurysm surgery is not always practical or feasible. Adenosine-induced transient cardiac arrest may serve as an alternative. We retrospectively reviewed our clinical database between September 2011 and July 2014. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole were included. A total of 18 craniotomies were performed, and 18 aneurysms were clipped under adenosine-induced asystole (7 basilar arteries, 8 internal carotid arteries, 1 middle cerebral artery, and 1 anterior communicating artery) in 16 patients (10 females, 6 males). Nine cases were elective and seven after subarachnoid hemorrhage. Mean age was 54 years (range 39–70). The indications for adenosine use were proximal control in narrow surgical corridors in 13 cases and “aneurysm softening” in 4 cases. A single dose was used in 14 patients; 3 patients had multiple boluses. The median (range) total dose was 30 (18–135) mg. Adenosine induced a bradycardia with concomitant arterial hypotension in all patients, and the majority also had asystole for 5–15 sec. Transient cardiac arrhythmias were noted in one patient (AFib in need of electroconversion after two boluses). Nine clinical scenarios where adenosine-induced temporary cardiac arrest and deep hypotension was an effective adjunct to temporary clipping during microsurgical clipping of intracranial aneurysms were identified.

Keywords

Adenosine Aneurysm Cardiac arrest Carotid artery Basilar artery 

References

  1. 1.
    Batjer H, Samson DS (1990) Management of intraoperative aneurysm rupture. Clin Neurosurg 36:275–288PubMedGoogle Scholar
  2. 2.
    Batjer HH, Samson DS (1990) Retrograde suction decompression of giant paraclinoidal aneurysms. Technical note. J Neurosurg 73:305–306. doi:10.3171/jns.1990.73.2.0305 CrossRefPubMedGoogle Scholar
  3. 3.
    Bebawy JF, Gupta DK, Bendok BR, Hemmer LB, Zeeni C, Avram MJ, Batjer HH, Koht A (2010) Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile. Anesth Analg 110:1406–1411. doi:10.1213/ANE.0b013e3181d65bf5 CrossRefPubMedGoogle Scholar
  4. 4.
    Bebawy JF, Zeeni C, Sharma S, Kim ES, DeWood MS, Hemmer LB, Ramaiah VK, Bendok BR, Koht A, Gupta DK (2013) Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation does not worsen neurologic outcome. Anesth Analg 117:1205–1210. doi:10.1213/ANE.0b013e3182a6d31b CrossRefPubMedGoogle Scholar
  5. 5.
    Bendok BR, Gupta DK, Rahme RJ, Eddleman CS, Adel JG, Sherma AK, Surdell DL, Bebawy JF, Koht A, Batjer HH (2011) Adenosine for temporary flow arrest during intracranial aneurysm surgery: a single-center retrospective review. Neurosurgery 69:815–820; discussion 820-811. doi:10.1227/NEU.0b013e318226632c CrossRefPubMedGoogle Scholar
  6. 6.
    Benech CA, Perez R, Faccani G, Trompeo AC, Cavallo S, Beninati S, Berardino M (2014) Adenosine-induced cardiac arrest in complex cerebral aneurysms surgery: an Italian single-center experience. J Neurosurg Sci 58:87–94PubMedGoogle Scholar
  7. 7.
    Figueiredo EG, Zabramski JM, Deshmukh P, Crawford NR, Preul MC, Spetzler RF (2006) Anatomical and quantitative description of the transcavernous approach to interpeduncular and prepontine cisterns. Technical note. J Neurosurg 104:957–964. doi:10.3171/jns.2006.104.6.957 CrossRefPubMedGoogle Scholar
  8. 8.
    Golshani K, Ferrell A, Zomorodi A, Smith TP, Britz GW (2010) A review of the management of posterior communicating artery aneurysms in the modern era. Surg Neurol Int 1:88. doi:10.4103/2152-7806.74147 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Groff MW, Adams DC, Kahn RA, Kumbar UM, Yang BY, Bederson JB (1999) Adenosine-induced transient asystole for management of a basilar artery aneurysm. Case report. J Neurosurg 91:687–690. doi:10.3171/jns.1999.91.4.0687 CrossRefPubMedGoogle Scholar
  10. 10.
    Gruber A, Dorfer C, Standhardt H, Bavinzski G, Knosp E (2011) Prospective comparison of intraoperative vascular monitoring technologies during cerebral aneurysm surgery. Neurosurgery 68:657–673CrossRefPubMedGoogle Scholar
  11. 11.
    Guinn NR, McDonagh DL, Borel CO, Wright DR, Zomorodi AR, Powers CJ, Warner DS, Lam AM, Britz GW (2011) Adenosine-induced transient asystole for intracranial aneurysm surgery: a retrospective review. J Neurosurg Anesthesiol 23:35–40. doi:10.1097/ANA.0b013e3181ef2b11 CrossRefPubMedGoogle Scholar
  12. 12.
    Hernesniemi J, Ishii K, Niemela M, Kivipelto L, Fujiki M, Shen H (2005) Subtemporal approach to basilar bifurcation aneurysms: advanced technique and clinical experience. Acta Neurochir Suppl 94:31–38CrossRefPubMedGoogle Scholar
  13. 13.
    Hernesniemi J, Korja M (2013) At the apex of cerebrovascular surgery-basilar tip aneurysms. World Neurosurg. doi:10.1016/j.wneu.2013.07.112
  14. 14.
    Kahn RA, Moskowitz DM, Marin ML, Hollier LH, Parsons R, Teodorescu V, McLaughlin M (2000) Safety and efficacy of high-dose adenosine-induced asystole during endovascular AAA repair. J Endovasc Ther Off J Int Soc Endovasc Spec 7:292–296. doi:10.1583/1545-1550(2000)007<0292:SAEOHD>2.3.CO;2 Google Scholar
  15. 15.
    Khan SA, McDonagh DL, Adogwa O, Gokhale S, Toche UN, Verla T, Zomorodi AR, Britz GW (2014) Perioperative cardiac complications and 30-day mortality in patients undergoing intracranial aneurysmal surgery with adenosine-induced flow arrest: a retrospective comparative study. Neurosurgery 74:267–271; discussion 271-262. doi:10.1227/NEU.0000000000000258 CrossRefPubMedGoogle Scholar
  16. 16.
    Krisht AF, Krayenbuhl N, Sercl D, Bikmaz K, Kadri PA (2007) Results of microsurgical clipping of 50 high complexity basilar apex aneurysms. Neurosurgery 60:242–250; discussion 250-242. doi:10.1227/01.NEU.0000249265.88203.DF CrossRefPubMedGoogle Scholar
  17. 17.
    Lawton MT (2011) Seven aneurysms : tenets and techniques for clipping. Thieme, New YorkCrossRefGoogle Scholar
  18. 18.
    Li J, Zeng Z, Viollet B, Ronnett GV, McCullough LD (2007) Neuroprotective effects of adenosine monophosphate-activated protein kinase inhibition and gene deletion in stroke. Stroke 38:2992–2999. doi:10.1161/STROKEAHA.107.490904 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Luostarinen T, Takala RS, Niemi TT, Katila AJ, Niemela M, Hernesniemi J, Randell T (2010) Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture. World Neurosurg 73:79–83; discussion e79. doi:10.1016/j.surneu.2009.06.018 CrossRefPubMedGoogle Scholar
  20. 20.
    Neuloh G, Schramm J (2004) Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurosurg 100:389–399CrossRefPubMedGoogle Scholar
  21. 21.
    Plaschke K, Grant M, Weigand MA, Zuchner J, Martin E, Bardenheuer HJ (2001) Neuromodulatory effect of propentofylline on rat brain under acute and long-term hypoperfusion. Br J Pharmacol 133:107–116. doi:10.1038/sj.bjp.0704061 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ponce FA, Spetzler RF, Han PP, Wait SD, Killory BD, Nakaji P, Zabramski JM (2011) Cardiac standstill for cerebral aneurysms in 103 patients: an update on the experience at the Barrow Neurological Institute. Clinical article. J Neurosurg 114:877–884. doi:10.3171/2010.9.JNS091178 CrossRefPubMedGoogle Scholar
  23. 23.
    Powers CJ, Wright DR, McDonagh DL, Borel CO, Zomorodi AR, Britz GW (2010) Transient adenosine-induced asystole during the surgical treatment of anterior circulation cerebral aneurysms: technical note. Neurosurgery 67:461–470. doi:10.1227/NEU.0b013e3181f7ef46 PubMedGoogle Scholar
  24. 24.
    Rodriguez-Hernandez A, Lawton MT (2012) Management of a recurrent coiled giant posterior cerebral artery aneurysm with trapping and thrombectomy: 3-dimensional operative video. Neurosurgery 71:ons191. doi:10.1227/NEU.0b013e3182732081 CrossRefPubMedGoogle Scholar
  25. 25.
    Saldien V, Menovsky T, Rommens M, Van der Steen G, Van Loock K, Vermeersch G, Mott C, Bosmans J, De Ridder D, Maas AI (2012) Rapid ventricular pacing for flow arrest during cerebrovascular surgery: revival of an old concept. Neurosurgery 70:270–275. doi:10.1227/NEU.0b013e318236d84a CrossRefPubMedGoogle Scholar
  26. 26.
    Sanai N, Caldwell N, Englot DJ, Lawton MT (2012) Advanced technical skills are required for microsurgical clipping of posterior communicating artery aneurysms in the endovascular era. Neurosurgery 71:285–294; discussion 294-285. doi:10.1227/NEU.0b013e318256c3eb CrossRefPubMedGoogle Scholar
  27. 27.
    Small JM, Stephenson SC, Campkin TV, Davison PH, McIlveen JS (1966) Elective circulatory arrest by artificial pacemaker. Lancet 1:570–572CrossRefPubMedGoogle Scholar
  28. 28.
    Sughrue ME, Saloner D, Rayz VL, Lawton MT (2011) Giant intracranial aneurysms: evolution of management in a contemporary surgical series. Neurosurgery 69:1261–1270; discussion 1270-1261. doi:10.1227/NEU.0b013e31822bb8a6 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Taki W, Sakai N, Nakahara I, Osaka N, Koshiji T, Matsuda K, Enoki Y, Kikuchi H (1998) Circulatory arrest with profound hypothermia during the surgical treatment of large internal carotid artery aneurysm--case report. Neurol Med Chir (Tokyo) 38:725–729CrossRefGoogle Scholar
  30. 30.
    Waldron JS, Halbach VV, Lawton MT (2009) Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 64:301–315; discussion 315-307. doi:10.1227/01.NEU.0000335178.15274.B4 PubMedGoogle Scholar
  31. 31.
    Whiteley JR, Payne R, Rodriguez-Diaz C, Ellegala DB, Reeves ST (2012) Rapid ventricular pacing: a novel technique to decrease cardiac output for giant basilar aneurysm surgery. J Clin Anesth 24:656–658. doi:10.1016/j.jclinane.2012.04.013 CrossRefPubMedGoogle Scholar
  32. 32.
    Young WL, Lawton MT, Gupta DK, Hashimoto T (2002) Anesthetic management of deep hypothermic circulatory arrest for cerebral aneurysm clipping. Anesthesiology 96:497–503CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Torstein R. Meling
    • 1
    • 2
  • Luis Romundstad
    • 3
  • Geir Niemi
    • 3
  • Jon Narum
    • 3
  • Per Kristian Eide
    • 1
    • 2
  • Angelika G. Sorteberg
    • 1
    • 2
  • Wilhelm A. Sorteberg
    • 1
  1. 1.Department of NeurosurgeryOslo University Hospital-RikshospitaletOsloNorway
  2. 2.Institute of Clinical Medicine, Faculty of MedicineUniversity of OsloOsloNorway
  3. 3.Department of AnesthesiologyOslo University Hospital-RikshospitaletOsloNorway

Personalised recommendations