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Xiao L, Ou X, Liu W, Lin X, Peng L, Qiu S, Zhang Q. Combined modified Valsalva maneuver with adenosine supraventricular tachycardia: A comparative study. Am J Emerg Med 2024; 78:157-162. [PMID: 38281376 DOI: 10.1016/j.ajem.2024.01.035] [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: 11/11/2023] [Revised: 01/11/2024] [Accepted: 01/20/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Paroxysmal supraventricular tachycardia (PSVT) is an arrhythmia commonly seen in the emergency department. Both modified Valsalva maneuver (MVM) and intravenous adenosine are the first line treatment, of which the former has e lower success rate while the latter has a higher success rate but some risks and adverse effects. Given both of these reverse rhythms quickly, combining them may achieve a better effect. OBJECTIVE The objective of this study is to evaluate the success rate and potential risk of combining the use of intravenous adenosine while patients were doing MVM as a treatment for paroxysmal supraventricular tachycardia(pSVT). DESIGN, SETTINGS AND PARTICIPANTS We recruited patients with pSVT from 2017 to 2022, and randomly assigned them into 3 groups, MVM group, intravenous adenosine group, and combination therapy group, in which MVM was allowed to be performed twice, while intravenous adenosine was given in a titration manner to repeat three times, recorded the success rate and side effects in each group. MAIN RESULTS The success rate of the MVM group, adenosine group, and combination group are 42.11%, 75.00 and 86.11%, respectively. The success rate of the adenosine group and combination group is significantly higher than the n MVSM group (p < 0.01, p < 0.001), while the success rate of the combination group is higher than the adenosine group, it has no significant difference (p = 0.340). In terms of safety, the longest RR durations (asystole period) are 1.61 s, 1.60s, and 2.27 s, there is a statistical difference among the three groups (p < 0.01) and between the adenosine and combination group (0.018). CONCLUSION Therefore, we can conclude that combination therapy has a relatively high success rate and good safety profile, but the current study failed to show its superiority to adenosine.
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Affiliation(s)
- Lifeng Xiao
- Emergency Department, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaomin Ou
- Emergency Department, Shantou Central Hospital, Shantou, Guangdong, China
| | - Wanshang Liu
- Emergency Department, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaorong Lin
- Emergency Department, The Second Affiliated Hospital of Shantou University Medical College, Guangdong, China
| | - Lin Peng
- Central Laboratory, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Shuyi Qiu
- School of Public Health, Shantou University, Shantou, Guangdong, China
| | - Qishuo Zhang
- General Internal Medicine, Department of Medicine, Medical College of Wisconsin, USA.
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Shenoy VS, Sekhar LN. Orbitozygomatic Transsylvian and Subtemporal Transzygomatic Approaches for Clipping of Basilar Tip Aneurysms: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00699. [PMID: 37114911 DOI: 10.1227/ons.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/12/2022] [Indexed: 04/29/2023] Open
Abstract
INDICATIONS CORRIDOR AND EXPOSURE The orbitozygomatic transsylvian approach is ideal for basilar tip aneurysms (BTAs) ≤15 mm located at or above the level of posterior clinoid process (PCP), whereas for larger, low-lying BTA's with fetal posterior cerebral artery (PCA), the subtemporal transzygomatic approach is preferred. Both approaches expose the basilar tip area and structures in the interpeduncular fossa from an anterolateral angle and the lateral angle, respectively. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT Aneurysm size and level, brainstem perforators, and PCA size (fetal or not) should be noted preoperatively. ESSENTIAL STEPS OF THE PROCEDURE A Orbitozygomatic transsylvian approach. Frontotemporal craniotomy with posterolateral orbitotomy. Extradural optic nerve decompression and anterior clinoidectomy. Transsylvian dissection and carotid-optic cistern decompression. Distal dural ring opening. Aneurysm exposure and clipping.Or. B Subtemporal transzygomatic approach1. Frontotemporal incision with zygomatic osteotomy. Temporal lobe retraction, subtemporal dissection, and tentorial division. Cavernous sinus opening and dorsum sellae drilling. Petrous apex resection. Aneurysm exposure and clipping. PITFALLS/AVOIDANCE OF COMPLICATIONS Complications such as cranial nerve injury, perforator stroke, aneurysm rupture, and hemorrhage can be prevented by neuromonitoring, avoiding temporary basilar occlusion for >10 minutes, use of transient adenosine arrest during clipping, and interposing rubber dam between perforators and aneurysm.1. VARIANTS AND INDICATIONS OF THEIR USE Cavernous sinus opening with posterior clinoidectomy and dorsum sellae drilling may be performed if aneurysm neck is at or below the level of PCP.1-7The patient consented to the procedure.
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Affiliation(s)
- Varadaraya Satyanarayan Shenoy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Co-Motion, University of Washington, Seattle, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Radiology, University of Washington, Seattle, Washington, USA
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Chandra SP, Bajaj J, Ghonia R, Doddamani R. Video Section-Operative Nuances: Step by Step - Single Stage Clipping of Ruptured Middle Cerebral Artery and Unruptured Basilar Top Aneurysm. Neurol India 2020; 68:800-802. [PMID: 32859816 DOI: 10.4103/0028-3886.293443] [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: 11/04/2022]
Abstract
Background and Introduction Presence of multiple aneurysms, especially a combination of anterior and posterior circulation aneurysm in the same patient, is rare. Surgical clipping of both the aneurysms in the same sitting, although ideal, may be surgically challenging and requires a good preoperative planning. Objective In this video abstract, we present a case of a ruptured middle cerebral artery (MCA) aneurysm with a simultaneous occurrence of an unruptured basilar top aneurysm. Surgical Technique A 45-year-old female presented with modified Hunt and Hess grade II subarachnoid hemorrhage (SAH). CT scan showed diffuse SAH with a dense bleed in the left sylvian cistern and mild hydrocephalus. Angiography showed a left MCA aneurysm (34 mm size) with a bleb and also an un-ruptured basilar bifurcation/right posterior cerebral artery aneurysm (20 mm). The patient underwent a left frontotemporal craniotomy, zygomatic osteotomy, and clipping of both aneurysms. No temporary clips were applied. The extended craniotomy allowed the surgeon to reach to the base of the aneurysm. Results The patient had an uneventful recovery. Conclusions Simultaneous occurrence of both anterior and posterior circulation aneurysms are rare, but maybe tackled surgically with proper planning.
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Affiliation(s)
- Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, Super Speciality Hospital, New Delhi, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Raj Ghonia
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jabalpur, Madhya Pradesh, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jabalpur, Madhya Pradesh, India
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Goroshchenko SA, Petrov AE, Rozhchenko LV, Samochernykh KA. [Endovascular embolization of high-flow arteriovenous fistulae with non-adhesive agents in the structure of cerebral arteriovenous malformations on the background of adenosine-induced cardioplegia]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:21-27. [PMID: 32649810 DOI: 10.17116/neiro20208403121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the initial results of endovascular embolization of cerebral arteriovenous malformations involving high-flow arteriovenous fistulae with non-adhesive agents on the background of cardioplegia. MATERIAL AND METHODS There were 13 patients who underwent surgery in 2018. Embolization of AVM with non-adhesive agents (ONYX, SQUID) was performed on the background of temporary cardiac arrest achieved by bolus intravenous administration of adenosine triphosphate. CONCLUSION Adenosine administration in endovascular treatment of AVM with non-adhesive agents is able to improve the safety of surgical intervention and ensure more qualitative embolization.
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Affiliation(s)
- S A Goroshchenko
- Polenov Russian Research Institute of Neurosurgery - a branch of the Almazov National Medical Research Centre of the Ministry of Health of the Russian Federation, St. Petersburg, Russia
| | - A E Petrov
- Polenov Russian Research Institute of Neurosurgery - a branch of the Almazov National Medical Research Centre of the Ministry of Health of the Russian Federation, St. Petersburg, Russia
| | - L V Rozhchenko
- Polenov Russian Research Institute of Neurosurgery - a branch of the Almazov National Medical Research Centre of the Ministry of Health of the Russian Federation, St. Petersburg, Russia
| | - K A Samochernykh
- Polenov Russian Research Institute of Neurosurgery - a branch of the Almazov National Medical Research Centre of the Ministry of Health of the Russian Federation, St. Petersburg, Russia
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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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Gopal S, Sekar A, Rudrappa S, Sunil, Masapu D. Adenosine induced cardiac pause in neuroendovascular management of AVM with fistula. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2020. [DOI: 10.1016/j.inat.2019.100662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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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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Bansal KK, Singh PK. “Transient reactionary physiological asystole” – TRAP phenomenon? Cause of fall or loss of consciousness after Sub Arachnoid Hemorrhage (SAH). Br J Neurosurg 2018; 32:302. [DOI: 10.1080/02688697.2018.1472216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Althunayyan SM, Khan AA, Samarkandi OA. Emergency department visits for paroxysmal supraventricular tachycardia in Saudi Arabia. Saudi J Anaesth 2018; 12:521-528. [PMID: 30429731 PMCID: PMC6180673 DOI: 10.4103/sja.sja_35_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE The present study aimed to compare the demographic, medical history, clinical features, and treatment management of paroxysmal supraventricular tachycardia (PSVT) in the emergency department of a teaching hospital in Riyadh, Saudi Arabia. A secondary purpose was to evaluate Adenosine response among numerous variables that might be used as predictors of the conversion. METHODS All PSVT cases presented to the Department of Emergency Medicine at King Khalid University Hospital, during the period from January 1, 2016, until December 31, 2016, were included in the study. Patients were assigned into two groups: adenosine sensitive (AS-group) and adenosine resistant (AR-group) according to adenosine conversion response. RESULTS A total of 38 patients were admitted during the study period. Fisher's exact test results showed that there were no significant (P > 0.05) differences among the AS-group and AR-group in the demographics, past medical history and clinical features, and post-ablation condition, except for the previous usage of the other anti-arrhythmic drugs to convert the last PSVT in the AR-group. The first bolus of adenosine had higher sensitivity and specificity, compared to the second bolus. Further, the second bolus of adenosine was not specific for short-term treatment of PSVT. CONCLUSIONS Differences in adenosine sensitivity among PSVT patients were independent of demographic, past medical history, and clinical features of PSVT patients. Thus, the difference in adenosine response among groups may be attributed to the heterozygosity in conducting pathways. The first bolus of adenosine had high sensitivity and specificity, compared to the second bolus, and their optimal levels were predictable by HR deceleration.
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Affiliation(s)
- Saqer M. Althunayyan
- Department of Trauma and Accident, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Anas A. Khan
- Department of Emergency Medicine, College of Medicine and University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Osama A. Samarkandi
- Department Basic Science, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Osama A. Samarkandi, Department of Basic Science, Prince Sultan College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia. E-mail:
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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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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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