Abstract
Background
Controlled hypotension is an important tool in the open treatment of complex intracranial aneurysms. Of the available methodologies, rapid ventricular pacing (RVP) provides titratable, sustained hypotension with a relatively safe profile.
Method
We report the case of a 63-year-old woman who underwent a combined subfrontal and subtemporal approach for clipping of anterior communicating artery and basilar apex aneurysms. RVP was used during initial dissection of the basilar apex aneurysm and perforators but caused uncontrolled ventricular tachycardia requiring synchronized defibrillation. After restoration of hemodynamic stability, the aneurysm was uneventfully clipped.
Conclusion
Preparation for unstable cardiac arrhythmias is needed with RVP.
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Data availability
All of the data are presented in the submitted paper.
Code availability
Not applicable.
References
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Contributions
Henson: data curation, manuscript writing; Rennert: data curation, manuscript writing and editing; Budohoski: manuscript editing; Couldwell: conceptualization, manuscript writing and editing, project administration, and resources.
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This study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Ethics approval was waived by the Institutional Review Board of the University of Utah for reporting a single case.
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Key points
- Controlled hypotension can aid aneurysm dissection, assist with intraoperative rupture, and limit the need for temporary clips.
- Techniques for controlled hypotension include adenosine, RVP, and deep hypothermic circulatory arrest with cardiac bypass.
- Transvenous RVP can provide minutes of titratable hypotension.
- Previously reported rare cardiac complications with RVP for cerebral aneurysm surgery include transient troponin increases, supraventricular tachycardia requiring cardioversion, and self-resolving ventricular fibrillation.
- Other options for induced hypotension include adenosine (short window [< 1 min] and variable dose–response across patients), and deep hypothermic circulatory arrest with cardiac bypass (longest and most dramatic vascular collapse but significant morbidity).
- When using RVP, preoperative cardiac clearance and preparation for unstable rhythms with external defibrillator pads is important.
- Operative positioning should allow for chest compressions when RVP is planned.
- The use of RVP for longer than 100 s at a time should be avoided.
- In consultation with cardiology, use of alternative strategies to RVP may be considered in patients with conduction abnormalities.
- In addition to the known risks associated with aneurysm surgery, discussion of the small risk of cardiac arrest and ischemic brain injury with RVP should be held.
This article is part of the Topical Collection on Vascular Neurosurgery—Aneurysms
Supplementary Information
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Supplementary file1 0:09 – Patient history0:16 – Preoperative imaging0:43 – Surgical plan1:01 – Patient positioning1:09 – Surgical procedure1:55 – Clipping of Acomm aneurysm3:13 – Episode of uncontrolled ventricular tachycardia with RVP3:51 – Clipping of basilar apex aneurysm4:52 – Postoperative imaging(MP4 483543 KB)
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Henson, J.C., Rennert, R.C., Budohoski, K.P. et al. Unstable ventricular tachycardia requiring defibrillation from rapid ventricular pacing during basilar apex aneurysm clipping. Acta Neurochir 164, 537–541 (2022). https://doi.org/10.1007/s00701-022-05125-w
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DOI: https://doi.org/10.1007/s00701-022-05125-w