Adenosine -Induced Flow Arrest and Microsurgerical Clipping in Difficult Cerebral Aneurysm Surgeries
Mannará Francisco Alberto1,2*, Alonso Soledad1, Gonza Hernán1, Fernández Javier1, Stupka Sara3, Civilotti Roman3 and Gardella Javier1,2
1Department of Neurological Surgery, Hospital of High Complexity Juan D Perón, Argentina
2Department of Neurological Surgery, Hospital Fernández, Argentina
33Department of Anaesthesic, Hospital of High Complexity Juan D Perón, Argentina
Submission: October 24, 2016; Published: December 01, 2016
*Corresponding author: Mannará Francisco Alberto, Avalos 1536, (1431), Buenos Aires, Argentina, Tel:5491154996753; Email:[email protected]
How to cite this article: Mannará F Al, Alonso S, Gonza H, Fernández J, et al. Adenosine -Induced Flow Arrest and Microsurgerical Clipping in Difficult Cerebral Aneurysm Surgeries. Open Access J Neurol Neurosurg. 2016; 1(5): 555574 DOI: 10.19080/OAJNN.2016.01.555574
Transient flow arrest caused by induced Adenonsine administration has been used to facilitate microsurgical clipping in some cases of cerebral aneurysms. Here, we described our experience in two cases where adenosine induced flow arrest facilitate to place the clip in the neck of aneurysm without any complication, in cases where proximal control is not possible.
Endovascular techniques in the treatment of cerebral aneurysms had evolved advances in the field, however, microsurgery with clip occlusion of the aneurysm´s neck is still a mainstay in definitive treatment. Intraoperative rupture of the cerebral aneurysm can have undesired consequences. To avoid rupture, proximal temporary arterial occlusion is used to decrease the turgor of the aneurysm neck, thereby facilitating clip occlusion of the aneurysm or clip reconstruction of the carotid artery. Sometimes, it is difficult to find an anatomically suitable place for temporary arterial occlusion for carotid paraclinoid aneurysms or giant aneurysms, even with clinoidectomy performed. In such cases, the use of adenosine can facilitate surgery, producing reversible flow‑arrest. This helps in decompressing the aneurysm sac and improve visualisation to facilitate clip application. We present two cases where the use of induced adenosine flow arrest facilitate to place the clip in the prompt positition without any complication.
51 years old female patient, antecedent of endovascular coiled left paraclinoid aneurysm 2 years before, with posterior amaurosis. She was admitted at hospital with a ruptured carotid ophthalmic on the right side (Figure 1). She was scheduled for surgical clipping of the aneurysm. In anticipation of intra- operative rupture, we planned administration of intravenous adenosine. The patient was placed with external defibrillator paddles in position. We performed a right frontotemporal craniotomy with intradural clinoidectomy. When we exposed the neck, we confirmed a great tension on wall of the artery, with the optic nerve displaced uprighted, so it was difficult to clip the aneurysm with safety (Figure 2). We administered 18 mg (0.3 mg/kg)adenosine via central venous catheter in a quick bolus with 20 ml of normal saline flush, which resulted in flow‑arrest and transient asystole lasting for 20 seconds .This facilitated further dissection, softing the walls of the dome and neck, (Figure 3) and application of permanent clip . Exclusion of aneurysm was confirmed with Doppler ultrasonographic device. (20 MHZ Mizuho Doppler). Sinus recovery occurred after about 20 s and normal sinus rhythm was recovered. The patient did not suffer any cardiological or neurological consecuence. We repeated electrocardiograms (ECGs), echocardiograms and Troponin I assay post‑operatively at 6 and 24 h, respectively, which were within normal limits.
35 years old patient with subarachnoid haemorraghe, Hunt
and Hess grade IV, Fisher 4, with left giant supraclinoid carotid
aneurysm (Figure 4, Figure 5). We planned treatment by clip
reconstruction and anticipated the use of adenosine to facilitate
dissection and deal with a possible intra‑operative rupture.
During dissection, the aneurysm ruptured.
Adenosine 18 mg IV was administered as a quick bolus
through the central line with 20 ml of normal saline flush.
Asystole was achieved for 25 seconds, during which, we could
reconstructed with fenestrated multiclipping technique the
parent artery, with exclusion of aneurysm. With Mizuho Doppler
we confirmed patency of internal carotid artery. Following
asystole, the patient heart rate recovered spontaneously without
any haemodynamic sequelae.
Adenosine is an endogenously occurring nucleoside analogue,
which reduces heart rate and prolongs conduction through
the sinoatrial and atrioventricular nodes, acting on cardiac A1
receptor to decrease cyclic adenosine monophosphate. It has an
ultra‑short half‑life <10 s, secondary to reuptake by red blood
cells and vascular endothelial cells .
Due the very short negative dromotropic and chronotropic
effect on cardiac sinoatrial and atrioventricular nodes,
Adenosine is usually indicated in paroxysmal supraventricular
tachyarrhythmia. The administration of adenosine in patients
with normal sinus rhythm induces a rapidly reversible cardiac
arrest. The intravascular half-life of adenosine at the physiologic
level is less than a second [1-3].
Adenosine-induced flow arrest offers a unique method to
reduce cerebral perfusion pressure briefly and controllably
and can facilitate the clip ligation of many aneurysms that
were previously treated with deep hypothermic circulatory
arrest, temporary occlusion of the extracranial carotid artery,
or endovascular balloon catheter retrograde suction deflation
In the case number 1 we used adenosine because the great
tension on the wall of the aneurysm. Sometimes, we had opened
the aneurism and, deflate it to perform the clipping, but this
option we used it when the wall is calcified or with thrombosis.
The patient was young, and didn´t have calcified wall, so
adenosine induced flow arrest facilitate the clipping, softing the
walls without the need to retract optic nerve.
In a case of an aneurysm rupture, adenosine has been
used successfully to induce transient cardiac arrest to stop the
bleeding when suction fails to clear the operative field, allowing
the surgeon to place temporary or permanent clip under visual
In our experience, when we deal with an intraoperative
aneurysm rupture, we try to gain proximal control, and transient clip is used. Furthermore, lowering systolic pression facilitate to
face this situation. In such circumstances, maybe we don´t need
to use adenosine. In the case number 2, we didn´t have proximal
control to manage the bleeding. In such circumstance, adenosineinduced
flow arrest was useful to clip aneurysm. However, the
surgeon should think in this possibility to prepare the patient
prior to perform the surgery, considering the placement of
external defibrillator pads on all patients who might receive
adenosine, to provide external pacing capability if prolonged
asystole/ bradycardia were to develop, or cardioversion in the
face of hemodynamically unstable atrial fibrillation. In addition,
monitoring all these patients for biochemical evidence of
myocardial injury (e.g., troponin I) in the postoperative period
has now become our standard practice to perform appropriate
subsequent evaluation for those with a positive response.