Adenosine-induced cardiac arrest as an alternative to temporary clipping during intracranial aneurysm surgery

Abstract

OBJECTIVE The purpose of this study was to analyze the impact of adenosine-induced cardiac arrest (AiCA) on temporary clipping (TC) and the postoperative cerebral infarction rate among patients undergoing intracranial aneurysm surgery. METHODS In this retrospective matched-cohort study, 65 patients who received adenosine for decompression of aneurysms during microsurgical clipping were identified (Group A) and randomly matched with 65 selected patients who underwent clipping but did not receive adenosine during surgery (Group B). The matching criteria included age, Fisher grade, aneurysm size, rupture status, and location of aneurysms. The primary outcomes were TC time and the postoperative infarction rate. The secondary outcome was the incidence of intraoperative aneurysm rupture (IAR). RESULTS In Group A, 40 patients underwent clipping with AiCA alone and 25 patients (38%) received AiCA combined with TC, and in Group B, 60 patients (92%) underwent aneurysm clipping under the protection of TC (OR 0.052; 95% CI 0.018-0.147; p < 0.001). Group A required less TC time (2.04 minutes vs 4.46 minutes; p < 0.001). The incidence of postoperative lacunar infarction was equal in both groups (6.2%). There was an insignificant between-group difference in the incidence of IAR (1.5% in Group A vs 6.1% in Group B; OR 0.238; 95% CI 0.026-2.192; p = 0.171). CONCLUSIONS AiCA is a useful technique for microneurosurgical treatment of cerebral aneurysms. AiCA can minimize the use of TC and does not increase the risk of IAR and postoperative infarction.

Low-dose adenosine-induced transient asystole during intracranial aneurysm surgery

“…The previous studies[ 2 , 5 , 9 , 11 , 13 , 18 ] have also reported relatively low incidences of transient cardiac arrhythmia and AF that resolved spontaneously and not related to the dose of adenosine. Postoperatively, elevated troponin T levels could also occur; however, it is unclear whether this finding is related to adenosine.…”

“…[ 8 , 10 , 14 , 17 ] More recently, AiTA has been used as an alternative to temporary clipping in patients without IAR. [ 2 , 5 , 9 , 11 , 13 , 15 ] There are no specific indications for adenosine use, but several authors have provided expert opinion on its use, such as in a large or deep-seated aneurysms in narrow corridors where temporary clip ligation is difficult or impossible, synergy with temporary clipping, and to improve visualization of adjacent perforating arteries. [ 7 ]…”

“…Many studies have demonstrated the safety of this technique with regard to perioperative cardiac morbidity. [ 2 , 5 , 11 , 12 , 20 ] However, no study has reported a difference in the dose recommendation between the use of AiTA for IAR versus without IAR, and few studies have evaluated the optimal dose of adenosine.…”

“…Intarakhao et al . [ 11 ] found that using AiTA as an alternative to temporary clipping could minimize the temporary clipping time without increasing the risk of IAR. Our findings demonstrate that low- dose adenosine (lower than 0.2 mg/kg) caused 8–12 s of asystole, which can adequately facilitate the placement of a permanent clip.…”

“…Several studies have demonstrated the utility of AiTA in facilitating intracranial aneurysm clip ligation and its safety regarding perioperative and postoperative outcomes. [ 2 , 3 , 5 , 8 , 9 , 11 - 14 , 16 , 17 , 19 , 21 ] There was no report on AiTA-related death. One serious complication was reported that the patient required closed cardiac chest compression due to prolonged extreme hypotension (>5.5 min) after the rapid redosing of adenosine due to IAR.…”