1
|
Nager GB, Pontes JPM, Udoma-Udofa OC, Gomes FC, Larcipretti ALL, de Oliveira JS, Dagostin CS, Fernandes MNF, de Andrade Bannach M. Efficacy and safety of adenosine, rapid ventricular pacing and hypothermia in cerebral aneurysms clipping: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:215. [PMID: 38730072 DOI: 10.1007/s10143-024-02450-9] [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: 12/04/2023] [Revised: 04/03/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Cerebral aneurysms in complex anatomical locations and intraoperative rupture can be challenging. Many methods to reduce blood flow can facilitate its exclusion from the circulation. This study evaluated the safety and efficacy of using adenosine, rapid ventricular pacing, and hypothermia in cerebral aneurysm clipping. METHODS Databases (PubMed, Embase, and Web of Science) were systematically searched for studies documenting the use of adenosine, rapid ventricular pacing, and hypothermia in cerebral aneurysm clipping and were included in this single-arm meta-analysis. The primary outcome was 30-day mortality. Secondary outcomes included neurological outcomes by mRs and GOS, and cardiac outcomes. We evaluated the risk of bias using ROBIN-I, a tool developed by the Cochrane Collaboration. OpenMetaAnalyst version 2.0 was used for statistical analysis and I2 measured data heterogeneity. Heterogeneity was defined as an I2 > 50%. RESULTS Our systematic search yielded 10,100 results. After the removal of duplicates and exclusion by title and abstract, 64 studies were considered for full review, of which 29 were included. The overall risk of bias was moderate. The pooled proportions of the adenosine analysis for the different outcomes were: For the primary outcome: 11,9%; for perioperative arrhythmia: 0,19%; for postoperative arrhythmia: 0,56%; for myocardial infarction incidence: 0,01%; for follow-up good recovery (mRs 0-2): 88%; and for neurological deficit:14.1%. In the rapid ventricular pacing analysis, incidences were as follows: peri operative arrhythmia: 0,64%; postoperative arrhythmia: 0,3%; myocardial infarction: 0%. In the hypothermia analysis, the pooled proportion of 30-day mortality was 11,6%. The incidence of post-op neurological deficits was 35,4% and good recovery under neurological analysis by GOS was present in 69.2%. CONCLUSION The use of the three methods is safe and the related complications were very low. Further studies are necessary, especially with comparative analysis, for extended knowledge.
Collapse
Affiliation(s)
- Gabriela Borges Nager
- School of Surgery and Medicine, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Julia Pereira Muniz Pontes
- Department of Surgical Specialities, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Fernando Cotrim Gomes
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Caroline Serafim Dagostin
- School of Medicine, University of the Extreme South of Santa Catarina, Criciúma, Santa Catarina, Brazil
| | | | | |
Collapse
|
2
|
Raper DMS, Abla AA. Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2022; 90:e84-e85. [PMID: 35118997 DOI: 10.1227/neu.0000000000001870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Unstable ventricular tachycardia requiring defibrillation from rapid ventricular pacing during basilar apex aneurysm clipping. Acta Neurochir (Wien) 2022; 164:537-541. [PMID: 35064349 DOI: 10.1007/s00701-022-05125-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 11/01/2022]
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.
Collapse
|
4
|
Hishikawa T, Murai S, Hiramatsu M, Haruma J, Nishi K, Ebisudani Y, Sato Y, Yasuhara T, Sugiu K, Shimizu K, Kobayashi M, Nakagawa K, Kimura-Ono A, Hotta K, Morimatsu H, Date I. An Evaluation of the Safety and Feasibility of Adenosine-assisted Clipping Surgery for Unruptured Cerebral Aneurysms: Study Protocol. Neurol Med Chir (Tokyo) 2021; 61:393-396. [PMID: 34024879 PMCID: PMC8280325 DOI: 10.2176/nmc.st.2021-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The effectiveness of adenosine-induced flow arrest in surgical clipping for the cerebral aneurysms with difficulties in temporary clip placement to the proximal main trunk has been reported. This is the first clinical trial to evaluate the safety and feasibility of adenosine-assisted clipping surgery for unruptured cerebral aneurysms (UCAs) in Japan. The inclusion criteria are as follows: patients over 20 years old, patients who agree to be enrolled in this study after providing informed consent, patients who undergo clipping surgery for UCA in our institute, and patients in whom the surgeons (T.H. or I.D.) judge that decompression of the aneurysm is effective. The primary endpoint is a modified Rankin Scale (mRS) score 30 days after surgery. We plan to enroll 10 patients in this study. The original protocol of adenosine administration was established in this trial. Herein, we present the study protocol.
Collapse
Affiliation(s)
- Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Satoshi Murai
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Jun Haruma
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuhiko Nishi
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yuki Ebisudani
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yu Sato
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takao Yasuhara
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Motomu Kobayashi
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Aya Kimura-Ono
- Center for Innovative Clinical Medicine, Okayama University Hospital
| | - Katsuyuki Hotta
- Center for Innovative Clinical Medicine, Okayama University Hospital
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| |
Collapse
|
5
|
Lee KS, Zhang JJY, Nguyen V, Han J, Johnson JN, Kirollos R, Teo M. The evolution of intracranial aneurysm treatment techniques and future directions. Neurosurg Rev 2021; 45:1-25. [PMID: 33891216 PMCID: PMC8827391 DOI: 10.1007/s10143-021-01543-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 01/06/2023]
Abstract
Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.
Collapse
Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK. .,Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.
| | - John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vincent Nguyen
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.,Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Julian Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Ramez Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK
| |
Collapse
|
6
|
Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
Collapse
|
7
|
Intarakhao P, Thiarawat P, Tewaritrueangsri A, Pojanasupawun S. Low-dose adenosine-induced transient asystole during intracranial aneurysm surgery. Surg Neurol Int 2020; 11:235. [PMID: 32874738 PMCID: PMC7451161 DOI: 10.25259/sni_79_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022] Open
Abstract
Background Few studies have evaluated the adenosine dose that induces cardiac arrest during intracranial aneurysm surgery. We present our experiences with adenosine-induced transient asystole (AiTA) during intracranial aneurysm surgery and dosage recommendations. Methods We retrospectively reviewed the medical records of all patients who underwent intracranial aneurysm surgery between July 2016 and December 2018. Patients who experienced AiTA during intracranial aneurysm surgery were included in the study. Results Our study included nine intracranial aneurysm surgeries performed in eight patients. Thirteen episodes of AiTA were reported. Five of these were performed to facilitate bleeding control due to intraoperative aneurysm rupture (IAR), and adenosine doses were 9 mg (0.20 mg/kg), 12 mg (0.25 mg/kg), 12 mg (0.26 mg/kg), 18 mg (0.34 mg/kg), and 18 mg (0.39 mg/kg), resulted in transient asystole for 12, 14, 9, 44, and 18 s, respectively. For episodes without IAR, adenosine doses ranging from 6 to 18 mg (0.11-0.39 mg/kg) caused asystole for 8-33 s. In five episodes without IAR, low-dose adenosine (lower than 0.2 mg/kg) was used and caused asystole ranging from 8 to 12 s. Postoperatively, two patients had elevated cardiac troponin T levels but normal electrocardiograms. Conclusion AiTA can facilitate the clipping of intracranial aneurysms at low-risk of serious cardiac complications. An adenosine dose of 0.2-0.4 mg/kg is safe and effective in both IAR and non IAR situations. In non IAR cases, we propose that low-dose AiTA is an option to facilitate aneurysm clipping. A starting dose of 6 mg or 0.1-0.2 mg/kg can adequately induce brief asystole by softening the aneurysmal sac during clip application.
Collapse
Affiliation(s)
- Patcharin Intarakhao
- Departments of Anesthesiology, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| | - Peeraphong Thiarawat
- Departments of Surgery, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| | - Apirak Tewaritrueangsri
- Departments of Anesthesiology, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| | - Surachart Pojanasupawun
- Departments of Anesthesiology, Naresuan University, Tambon Thapho, Muang Phitsanulok, Thailand
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Sai Kiran NA, Mohan D, Sivaraju L, Raj V, Vidyasagar K, Hegde AS. Adenosine-Induced transient asystole during surgical treatment of basilar artery aneurysms. Neurol India 2020; 68:419-426. [PMID: 32415018 DOI: 10.4103/0028-3886.284353] [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] [Indexed: 11/04/2022]
Abstract
Aim To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms. Materials and Methods All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study. Results Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. Conclusion AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.
Collapse
Affiliation(s)
- Narayanam A Sai Kiran
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Dilip Mohan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Laxminadh Sivaraju
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Vivek Raj
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Kanneganti Vidyasagar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Alangar S Hegde
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| |
Collapse
|