A contribution to the controversy over dimethyl sulfoxide toxicity: anesthesia monitoring results in patients treated with Onyx embolization for intracranial aneurysms

Pamuk, Almıla Gülsün; Saatçi, Işıl; Cekirge, H Saruhan; Aypar, Ülkü

doi:10.1007/s00234-004-1323-y

Cited by 52 publications

(38 citation statements)

References 22 publications

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“…Research of anesthesia monitoring in patients treated with Onyx embolization for intracranial aneurysms showed no changes in heart rate or blood pressure following DMSO and Onyx injections, nor were any arrythmias observed. 5 We consider that this response was a TCR, which has been previously described in the literature as a reflexive response of bradycardia, hypotension, and gastric hypermobility seen upon mechanical stimulation in the distribution of the trigeminal nerve. 1 Clinically, TCR has been reported to occur during craniofacial surgery, 2 tumor resection in the cerebellopontine angle 3 and falx cerebri, 1 and trans-sphenoidal surgery for pituitary adenomas.…”

Section: Discussionmentioning

confidence: 89%

Trigeminocardiac Reflex in Embolization of Intracranial Dural Arteriovenous Fistula

Lv¹,

Li²,

Lv³

et al. 2007

American Journal of Neuroradiology

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SUMMARY:We report a case of immediate reproducible and reflexive response of asystole upon stimulation of Onyx injection during embolization of a tentorial dural arteriovenous fistula in a 53-yearold man. Upon recognition of the reflexive relationship between Onyx injection and increased vagal tone, the patient was given anticholinergic in an effort to block cholinergic hyperactivity. After atropine was given, no further dysrhythmias occurred. P revious articles have described trigeminocardiac reflex (TCR) during intracranial operations, ophthalmic surgery, and microcompression of the trigemimal ganglion. [1][2][3][4] We report a case of likely TCR seen upon mechanical stimulation of the middle meningeal artery in the spinosum foramen during embolization of a tentorial dural arteriovenous fistula (DAVF). This is the first case of TCR during transarterial embolization of DAVF. Case ReportA 53-year-old man presented with subarachnoid hemorrhage 2 years previously, and although conservative treatment was given at another hospital, headaches were still persistent. Cerebral angiograms were obtained and showed a DAVF fed by the right internal maxillary artery, the dorsal meningeal artery from the right meningohypophyseal trunk, and branches of the right posterior cerebral arteries. Venous outflow emptied into the right sigmoid sinus via the right dilated cerebellar cortical veins. Electrocardiogram (ECG) was normal. Recommendation was made for transarterial embolization of this lesion.Endovascular treatment was performed with the patient under standard anesthetic protocol. Anesthesia was induced with fentanyl (3 g/kg), followed by vecurium (1 mg/kg) and propofol (2 mg/kg). After the intubation of the trachea, the lungs were mechanically ventilated with a mixture of air and oxygen (FIO 2 ϭ 0.5). Anesthesia was maintained with renifentanyl (0.02 g/kg/min), and additional boluses of propofol (7 mg/kg/h) and vecurium (3 mg/h) were administered. A bilateral 6F femoral access was prepared, and the tip of a 6F guiding catheter was placed inside the right external carotid artery, while a 5F diagnostic catheter with continuous heparinized flush was positioned in the right vertebral artery for selective control angiograms. Using a road-mapping technique and fluoroscopic guidance, a Marathon microcatheter (ev3, Irvine, Calif.) was advanced over a 0.008-inch Mirage guidewire (ev3) in the right middle meningeal artery up to the fistula zone. Under biplane road-mapping, the catheter was slowly flushed with 0.25 mL of dimethyl-sulfoxide (DMSO) over 40 seconds, and this was followed by injection of Onyx 18 (ev3).The embolic material achieved antegrade filling of the malformation, but then formed a small reflux of several millimeters in length over the tip of the microcatheter. After waiting one minute for the reflux to solidify, the injection was continued gently. Again, some antegrade filling was achieved, but shortly, another short reflux was noted. This cycle was repeated until a plug of the embolic agent was obtained so that the ...

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Section: Discussionmentioning

confidence: 89%

Trigeminocardiac Reflex in Embolization of Intracranial Dural Arteriovenous Fistula

Lv¹,

Li²,

Lv³

et al. 2007

American Journal of Neuroradiology

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“…At our institution, NBCA glue is preferred over Onyx, because Onyx utilization typically extends the embolization 29 and requires more fluoroscopic time, 49 which potentially increases the detrimental effects of ionizing radiation on children's developing nervous systems. Furthermore, the potentially large doses of Onyx required for embolization of these fistulas increases the risk for the rare complication of DMSO (dimethyl sulfoxide)-related pulmonary toxicity 39,46 associated with Onyx. This pulmonary toxicity may exacerbate the preexisting cardiovascular and pulmonary comorbidities often seen in this group of children.…”

Section: 40mentioning

confidence: 99%

An institutional series and literature review of pial arteriovenous fistulas in the pediatric population

Madsen¹,

Lang²,

Pisapia³

et al. 2013

PED

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Object Pial arteriovenous fistulas (PAVFs) are a rare form of cerebrovascular disease that tend to be overrepresented in the pediatric population. There have been limited studies of the clinical features and outcomes in this group of patients. Here, the authors attempt to better delineate this clinical entity with institutional cases and a review of the literature. Methods A retrospective review of cases at our institution was performed to identify all pediatric patients treated for a PAVF between 2000 and 2012. Results Five patients treated for a PAVF were identified. Patients had a mean age of 1.9 years at diagnosis, and the most common presenting symptoms were seizure and macrocephaly. Patients were treated primarily with embolization, and 3 patients required both N-butyl cyanoacrylate (NBCA) glue and coiling. Four of the patients had complete obliteration of the PAVF and had a pediatric overall performance category score of either 1 (n = 3) or 2 (n = 1) at follow-up. There was 1 death due to heart failure. Analysis of the literature review suggested that a younger age or presence of intracerebral hemorrhage (ICH) or congestive heart failure (CHF) at presentation likely predicts a worse prognosis. Older patients presented more often with ICH, whereas younger patients presented significantly more often in CHF. The majority of pediatric patients reported on in the literature were treated with endovascular embolization, most commonly with NBCA glue alone. Most patients (65.4%) in the literature had an excellent outcome without neurological deficit. Conclusions Pial AVFs represent a serious yet rare form of cerebrovascular disease. Pediatric patients with ICH or CHF at presentation or those who are very young are likely to have a worse prognosis. Endovascular management of these patients has greatly changed the natural history of this disease, but the complication and mortality rates suggest the need for continued insights and advances in treatment.

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“…Injection of DMSO has been shown to induce vessel necrosis and vasospasm when injected too quickly. 18,[29][30][31] In addition, there have been reports of electrocautery-induced ignition of Onyx. 32 In order to overcome the drawbacks of commercially available embolic materials, we have developed a liquid, in situ gelling polymeric material that can potentially be used as an embolic agent for intracranial aneurysms.…”

Section: Introductionmentioning

confidence: 99%

Gelling process differences in reverse emulsion, in situ gelling polymeric materials for intracranial aneurysm embolization, formulated with injectable contrast agents

et al. 2010

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The use of liquid-to-solid curing materials for brain aneurysm embolization has become increasingly attractive, as liquid embolics can be delivered noninvasively and can potentially achieve a higher degree of aneurysm volume occlusion. This study was aimed at characterizing differences in the gelling process of a reverse emulsion, crosslinking polymer system formulated with different types of injectable contrast agents. The polymeric system consists of poly(propylene glycol) diacrylate (PPODA) and pentaerythritol tetrakis(3-mercaptopropionate) (QT). These monomers undergo Michael-type addition upon initiation by a basic, aqueous solution. Conray™ and Omnipaque™ 300, commercially available contrast agents, were pH-adjusted to basic conditions and used as initiating solutions with the PPODA-QT system. Material characteristics were identified through rheology and scanning electron microscopy (SEM). Results showed that Conray- and Omnipaque-formulated materials progress through the gelling process uniquely, evidenced by distinctly different viscosity profiles and droplet distributions. These results indicate that Conray is more miscible with the PPODA-QT organic phase. Greater solubility in the organic phase allows Conray-formulated gels to have faster and more widespread reaction initiation kinetics when Conray and Omnipaque have the same pH. Omnipaque-formulated gels require a higher pH for the material to solidify in a time frame comparable to Conray-formulated gels. This discrepancy arises because the majority of reaction initiation sites in Omnipaque-formulated gels occur at phase boundaries via hydroxide ion flux from emulsified droplets rather than from hydroxide ions that are solubilized and integrated within the PPODA-QT organic phase.

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A contribution to the controversy over dimethyl sulfoxide toxicity: anesthesia monitoring results in patients treated with Onyx embolization for intracranial aneurysms

Cited by 52 publications

References 22 publications

Trigeminocardiac Reflex in Embolization of Intracranial Dural Arteriovenous Fistula

Trigeminocardiac Reflex in Embolization of Intracranial Dural Arteriovenous Fistula

An institutional series and literature review of pial arteriovenous fistulas in the pediatric population

Gelling process differences in reverse emulsion, in situ gelling polymeric materials for intracranial aneurysm embolization, formulated with injectable contrast agents

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