Adenosine-Assisted Clipping of Intracranial Aneurysms
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.
KeywordsAdenosine Aneurysm Cardiac arrest Carotid artery Basilar artery
The authors do not have any personal or institutional financial interest in the drugs, materials, or devices described in the article.
Grant Information/Other Acknowledgments
No grants have been received by the authors.
- 3.Waldron JS, Halbach VV, Lawton MT. Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery. 2009;64:301–15; discussion 315–7. https://doi.org/10.1227/01.NEU.0000335178.15274.B4.CrossRefPubMedGoogle Scholar
- 8.Ponce FA, Spetzler RF, Han PP, Wait SD, Killory BD, Nakaji P, Zabramski JM. Cardiac standstill for cerebral aneurysms in 103 patients: an update on the experience at the Barrow Neurological Institute. Clinical article. J Neurosurg. 2011;114:877–84. https://doi.org/10.3171/2010.9.JNS091178.CrossRefPubMedGoogle Scholar
- 11.Saldien V, Menovsky T, Rommens M, Van der Steen G, Van Loock K, Vermeersch G, Mott C, Bosmans J, De Ridder D, Maas AI. Rapid ventricular pacing for flow arrest during cerebrovascular surgery: revival of an old concept. Neurosurgery. 2012;70:270–5. https://doi.org/10.1227/NEU.0b013e318236d84a.CrossRefPubMedGoogle Scholar
- 14.Bebawy JF, Gupta DK, Bendok BR, Hemmer LB, Zeeni C, Avram MJ, Batjer HH, Koht A. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile. Anesth Analg. 2010;110:1406–11. https://doi.org/10.1213/ANE.0b013e3181d65bf5.CrossRefPubMedGoogle Scholar
- 15.Guinn NR, McDonagh DL, Borel CO, Wright DR, Zomorodi AR, Powers CJ, Warner DS, Lam AM, Britz GW. Adenosine-induced transient asystole for intracranial aneurysm surgery: a retrospective review. J Neurosurg Anesthesiol. 2011;23:35–40. https://doi.org/10.1097/ANA.0b013e3181ef2b11.CrossRefPubMedGoogle Scholar
- 16.Bendok BR, Gupta DK, Rahme RJ, Eddleman CS, Adel JG, Sherma AK, Surdell DL, Bebawy JF, Koht A, Batjer HH. Adenosine for temporary flow arrest during intracranial aneurysm surgery: a single-center retrospective review. Neurosurgery. 2011;69:815–20; discussion 820–1. https://doi.org/10.1227/NEU.0b013e318226632c.CrossRefPubMedGoogle Scholar
- 23.Hernesniemi J, Korja M. At the apex of cerebrovascular surgery—basilar tip aneurysms. World Neurosurg. 2013. https://doi.org/10.1016/j.wneu.2013.07.112.
- 24.Figueiredo EG, Zabramski JM, Deshmukh P, Crawford NR, Preul MC, Spetzler RF. Anatomical and quantitative description of the transcavernous approach to interpeduncular and prepontine cisterns. Technical note. J Neurosurg. 2006;104:957–64. https://doi.org/10.3171/jns.2006.104.6.957.CrossRefPubMedGoogle Scholar
- 25.Krisht AF, Krayenbuhl N, Sercl D, Bikmaz K, Kadri PA. Results of microsurgical clipping of 50 high complexity basilar apex aneurysms. Neurosurgery. 2007;60:242–50; discussion 250–2. https://doi.org/10.1227/01.NEU.0000249265.88203.DF.CrossRefPubMedGoogle Scholar
- 28.Bebawy JF, Zeeni C, Sharma S, Kim ES, DeWood MS, Hemmer LB, Ramaiah VK, Bendok BR, Koht A, Gupta DK. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation does not worsen neurologic outcome. Anesth Analg. 2013;117:1205–10. https://doi.org/10.1213/ANE.0b013e3182a6d31b.CrossRefPubMedGoogle Scholar
- 29.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: a retrospective comparative study. Neurosurgery. 2014;74:267–71; discussion 271–2. https://doi.org/10.1227/NEU.0000000000000258.CrossRefPubMedGoogle Scholar
- 30.Kahn RA, Moskowitz DM, Marin ML, Hollier LH, Parsons R, Teodorescu V, McLaughlin M. Safety and efficacy of high-dose adenosine-induced asystole during endovascular AAA repair. J Endovasc Ther. 2000;7:292–6. https://doi.org/10.1583/1545-1550(2000)007<0292:SAEOHD>2.3.CO;2.CrossRefPubMedGoogle Scholar