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Table of Contents    
ORIGINAL ARTICLE
Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 419-426

Adenosine-Induced Transient Asystole During Surgical Treatment of Basilar Artery Aneurysms


Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India

Date of Web Publication15-May-2020

Correspondence Address:
Vivek Raj
Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore - 560 066, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.284353

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 » 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.


Keywords: Adenosine-induced asystole, basilar bifurcation aneurysms, basilar trunk aneurysms, SCA aneurysms, subtemporal approach
Key Message: AITA is a simple technique of providing temporary flow arrest during aneurysm surgery when temporary clip placement is difficult. AITA is not popular in many centers due to apprehensions about the safety and efficacy of this technique. AITA enhances the safety of clipping basilar artery aneurysms as corridors for temporary clip application are very narr


How to cite this article:
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;68:419-26

How to cite this URL:
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 [serial online] 2020 [cited 2020 Jun 1];68:419-26. Available from: http://www.neurologyindia.com/text.asp?2020/68/2/419/284353




Adenosine-induced transient asystole (AITA) has emerged as a simple and safer alternative to complex techniques such as deep hypothermic cardiac arrest (DHCA) and rapid ventricular pacing (RVP) in providing temporary flow arrest during aneurysm surgery in carefully selected circumstances.[1],[2],[3] Despite reports of safe and effective use of adenosine during aneurysm surgery, this technique is not popular in many centers due to apprehensions about the safety and efficacy of this technique. Adenosine use in aneurysm surgery is mainly restricted to conditions where temporary clip application is difficult or for managing intraoperative aneurysm rupture.[4],[5],[6],[7],[8],[9],[10],[11] AITA enhances the safety of clipping basilar artery aneurysms as corridors for temporary clip application are very narrow and deep in these cases.[7],[8] The authors report their two years of experience with this technique in the surgical management of basilar artery aneurysms.


 » Materials And Methods Top


Patient population

All the patients with basilar artery aneurysms operated using AITA at our institute during two years (August 2013–July 2015) were included in this study. Approval of the ethical committee of the institute was taken for this study. Informed consent was taken from all the patients. AITA during surgery was tried only in those patients whose cardiac evaluation was normal. Preoperative complete cardiac evaluation including electrocardiogram and echocardiogram was done in all the patients. Coronary angiogram was done in patients when indicated to rule out coronary artery disease.

Technique

Surgery was performed in supine position, and transcutaneous pacemakers were placed in all the patients for managing complications such as prolonged asystole and bradycardia. All aneurysms were approached through subtemporal route. For managing inadvertent rupture of the aneurysm during dissection and clipping, proximal basilar artery was exposed in all the cases for temporary clip placement. Before inducing asystole, all the required clips were kept ready, and the preferred sequence of the clip application and alternative plans were informed to the assisting staff. Adenosine-induced asystole was used mainly during clip placement and during clip readjustment. Adenosine-induced asystole was also used during dissection of large aneurysms and for managing intraoperative aneurysm rupture. Adenosine 0.3–0.4 mg/kg was used for inducing asystole. From the injection of adenosine bolus till the restoration of normal rhythm, systolic blood pressure and heart rate were continuously informed to the operating team by the anesthetist. A minimum gap of 5 min was maintained between two adenosine-induced asystoles unless adenosine was used for managing intraoperative rupture of the aneurysm [Videos 1-3].


 » Results Top


AITA was used during surgery in 11 patients with 13 basilar artery aneurysms during the study period of 2 years. Patient characteristics and clinicoradiological features are summarized in [Table 1]. Based on the preliminary cardiac evaluation, preoperative coronary angiogram was considered necessary by cardiologists in two patients to rule out coronary artery disease. Coronary angiogram was normal in these two patients. Clip application/readjustment during AITA without temporary clip application was performed in 11 of these aneurysms with narrow corridor for temporary clip placement. AITA was found to be extremely useful in softening the aneurysm sac and safe clip application/readjustment in these 11 aneurysms [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. AITA in conjunction with temporary clip placement was useful in managing intraoperative aneurysm rupture and successful clipping of one aneurysm. AITA was not useful in circumferential dissection of a large partially thrombosed basilar top aneurysm as a significant portion of the aneurysm was filled with thrombus [Figure 6]. Circumferential dissection and clipping was performed in this patient after trapping the aneurysm with temporary clips and thrombectomy. A dosea of adenosine used and duration of asystole are summarized in [Table 2]. One patient had transient rebound hypertension (systolic blood pressure around 200 mmHg) for less than 1 min immediately following restoration of normal rhythm after asystole. None of the patients had any other complications such as arrhythmias, prolonged asystole/bradycardia, or bronchospasm related to adenosine. Three patients had additional aneurysms in the anterior circulation, which were also successfully clipped during the same admission.
Table 1: Patient characteristics and clinico radiological features ( 11 patients, 13 aneurysms)

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Figure 1: (a and b) DSA images (a – AP, b – lateral 3D reconstruction) showing large superiorly directed basilar bifurcation aneurysm. (c and d) Postoperative DSA images (c – AP, d – lateral) showing successful clip ligation of the aneurysm

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Figure 2: (a) 3D reconstruction DSA image showing small superiorly directed basilar bifurcation aneurysm. (b) Postoperative 3D reconstruction DSA image showing successful clip ligation of the aneurysm

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Figure 3: (a-c) DSA images (a and b – AP; c – oblique) showing superiorly directed small basilar bifurcation aneurysm. (d) CT angio showing low basilar bifurcation (11 mm below dorsum sellae). (e and f) Postoperative DSA images (e – AP, f – lateral) following clipping of aneurysm through modified Dolenc–Kawase's approcah showing successful clip ligation of aneurysm

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Figure 4: (a-d) DSA images (a and b – AP; c and d – lateral) showing superiorly directed small basilar bifurcation aneurysm and anteriorly directed small distal basilar trunk aneurysm. (e and f) Postoperative DSA images (e – AP; f – lateral) showing successful clip ligation of both aneurysms

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Figure 5: (a and b) 3D reconstruction DSA images (a – lateral, b – AP) showing large superiorly directed basilar bifurcation aneurysm. (c and d) Postoperative DSA images (c – lateral, d – AP) showing successful clip ligation of the aneurysm

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Figure 6: (a-f) DSA (a – AP, b – lateral, c – AP 3D recon) and CT angio images (d-f) showing superiorly directed partially thrombosed large distal basilar trunk fusosaccular aneurysm. Absent left P1 segment noted in CT angio image (e). Clipping of saccular component (red arrow) above the origin of Rt PCA and reconstruction of fusiform component (blue arrow) involving basilar trunk between the origin of Rt PCA and bilateral SCAs was planned (f). (g and h) Postoperative DSA images (g – AP, h – oblique 3D recon image) showing successful clip ligation of aneurysm except for small residual (arrow in h)

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Table 2: Dose of adenosine given, number of adenosine-induced asystoles, and the duration of AITA

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Check angiogram [digital subtraction angiography (DSA)] before discharge was performed in all the patients. Check DSA revealed complete obliteration of 11 aneurysms (84.6%, 11/13). In the remaining two aneurysms with small residual neck, successful coiling of the residual neck was performed in one case and regular follow-up was advised in another. One patient with intraoperative aneurysm rupture died secondary to severe vasospasm. Follow-up in the remaining patients ranged from 3 to 12 months (mean: 5.4 months). Six patients developed third nerve paresis after surgery which improved completely in five patients and partially in one patient. Five patients developed hemiparesis (Medical Research Council-MRC Grade:3-4/5) after surgery which subsequently improved completely in three patients. Two patients had persistent hemiparesis (MRC Grade 4/5) at a final follow-up of 3 months or more. Although postoperative computed tomography (CT) images in three of the five patients with postoperative hemiparesis did not reveal any obvious infarcts, small infarcts due to occlusion of perforators during clipping cannot be ruled out as postoperative magnetic resonance imaging was not done in these patients. Infarcts in posterior cerebral artery (PCA) territory in the postoperative CT images were noted in two of the remaining five patients with postoperative hemiparesis despite good flow on indocyanine green video angiography after clip application. DSA revealed kinking of ipsilateral PCA in one patient and normal flow in PCAs in other patient. Modified Rankin Scale at 3 months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. Good outcome (Modified Rankin Scale ≤2) at 3 months of follow-up was noted in 9 (82%, 9/11) of the 11 patients.


 » Discussion Top


Application of a temporary clip on vessel proximal to the aneurysm facilitates safe clipping of the aneurysm by reducing the pressure inside the aneurysm. Temporary clip placement may be difficult or not feasible in few conditions such as atherosclerotic proximal vessel, intraop aneurysm rupture, difficult exposure of proximal vessel in giant aneurysms, narrow corridor for temporary clip placement in basilar artery aneurysms, and clipping of contralateral ophthalmic segment aneurysms.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] Transient cardiac stand still is an important adjunct in aneurysm surgery where temporary clip placement is difficult or not feasible. DHCA, RVP, and AITA are various techniques used for achieving transient cardiac stand still or controlled hypotension during aneurysm surgery.[1],[2],[3],[12],[13],[14],[15] Recently, Kumar et al. have described a novel technique of endovascular pulmonary artery inflatable balloon-induced transient hypotensive circulatory flow arrest for clipping of a giant intracranial aneurysm.[16] DHCA is a high-risk procedure associated with complications such as coagulopathy-associated postoperative hematomas, aortic dissection, and myocardial infarction.[1],[6],[14] RVP is associated with complications such as cardiac perforation, ventricular fibrillation, and cardiac tamponade.[1],[12],[13] Potential complications of pulmonary artery inflatable balloon-induced transient circulatory arrest include pulmonary artery rupture/dissection and cardiac arrhythmias.[16] AITA is a simple, safe, and noninvasive alternative for providing transient flow arrest compared to the above invasive techniques.[2],[3],[14] However, the duration of flow arrest is short and more unpredictable with AITA.[1],[12],[14]

Adenosine is a commonly used drug for paroxysmal supraventricular tachycardia.[1],[4],[5],[6],[9] Rapid decrease in heart rate following intravenous bolus dose of adenosine results in systemic hypotension. Pharmacological effects of adenosine are transient as its half-life is around 10 s. The exact dose of adenosine required to produce asystole, duration of asystole, and the duration of profound hypotension (systolic blood pressure <60 mm Hg) following asystole in an individual are difficult to predict.[1],[4],[5],[6],[9] Adenosine by reducing the production of cyclic AMP can cause bronchospasm.[17] Use of adenosine should be avoided in patients with bronchospasm, second- or third-degree heart block, sick sinus syndrome, long QT syndrome, severe hypotension, decompensated heart failure and Wolff–Parkinson–White syndrome.[4],[5],[9],[17] As part of adenosine is eliminated by kidneys, caution is required in patients with renal failure and purine metabolism abnormalities like gout.[17]

AITA has been reported as a safe and effective technique for providing temporary flow arrest during embolization of intracranial arteriovenous malformations (AVMs), stent placement for aortic aneurysms and balloon dilatation procedures for congenital heart diseases,[18],[19],[20],[21],[22],[23],[24],[25] Sollevi et al. reported the use of adenosine infusion to provide controlled hypotension during cerebral aneurysm surgery in 1984.[26] Groff et al. first described AITA for clipping a basilar apex aneurysm in 1999.[7] Subsequently, various studies have reported the safety and efficacy of AITA in intracranial aneurysm surgeries.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[17],[27],[28],[29],[30] Hernesniemi popularized AITA for intracranial aneurysm surgery.[9],[11],[27] The dose of adenosine and duration of asystole reported in various series are summarized in [Table 3]. Hashimoto et al. described the technique of giving test doses of adenosine starting with 0.25–0.35 mg/kg and escalating the test dose by 10–20 mg every 3–10 min till the desired duration of profound hypotension is reached and determined the optimal dose of adenosine to be given during embolization of cerebral AVMs.[20] Establishing individual dose–response relationship with test doses to determine the optimal dose of adenosine in a patient exposes the patient to multiple periods of flow arrest or profound hypotension with possible risk of cerebral ischemia especially in patients with vasospasm.[4] Lee et al. compared the test incremental method (starting with 6 or 12 mg adenosine and additional doses based on the response) with the estimated dose injection method (0.3–0.4 mg/kg given in precalculated manner) and reported estimated dose injection method to be more convenient than the test incremental method.[17] Bebawy et al. reported that a dose of 0.3–0.4 mg/kg of ideal body weight is recommended as starting dose to achieve profound systemic hypotension (systolic blood pressure <60 mmHg) for approximately 45 s. In our study, we have used 0.3–0.4 mg/kg of adenosine for inducing AITA.[4]
Table 3: Comparison of the dose of adenosine given for AITA in various series

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AITA is a safe technique and only very few complications have been reported.[2],[3] Al-Mousa et al., in their literature review, analyzed the data of 207 intracranial aneurysm surgeries performed using adenosine during surgery.[2] Various complications reported in this review were atrial fibrillation (6/207, 2.8%), bradyarrhythmia (2/207, 1%), tachyarrhythmia (1/207, 0.5%), and elevated troponin (4/207, 2%).[2] There were no mortalities related to AITA. All the arrhythmias were transient, and normal sinus rhythm was restored spontaneously in all except one patient with atrial fibrillation who required amiodarone for restoration of normal sinus rhythm.[2] Elevated troponin levels reported were not associated with any acute cardiac ischemic event or clinical/echocardiographic evidence of cardiac dysfunction. Guinn et al. reported prolonged hypotension requiring brief closed chest compressions till restoration of normal circulation in a patient following rapid redosing of adenosine given for managing intraoperative aneurysm rupture.[28] Kahn et al. reported self-limiting cardiac events such as transient myocardial ischemia (2%), atrial fibrillation requiring cardioversion (2%), transient left bundle branch block (1%), and prolonged period of asystole requiring temporary pacemaker activation (4.1%) in 98 patients with abdominal aortic aneurysm treated with stent grafts using AITA.[21] Considering the potential complications associated with AITA, it should be used only in conditions where temporary clip application is difficult or not feasible. Percutaneous pacemakers and surgery in supine position help in effectively managing complications such as prolonged asystole. Cardiac complications associated with AITA can be minimized by a complete preoperative cardiac workup.

AITA enhances the safety of clipping basilar artery aneurysms as corridors for temporary clip application are narrow. Short and unpredictable duration of flow arrest is the major limitation of this technique. AITA alone may not be sufficient in few circumstances as noted in the present series. Temporary clip application may be required along with AITA during premature rupture of aneurysm. Clipping of partially thrombosed large and giant aneurysms might require trapping with temporary clips and thrombectomy. Considering the limitations of AITA, basilar trunk proximal to the aneurysm was kept exposed for temporary clip placement when required in all our cases.

The best treatment for basilar artery aneurysms is controversial.[31] Endovascular treatment is preferred to microsurgery for basilar artery aneurysms at many centers. Good outcome with microsurgery comparable to endovascular treatment for basilar artery aneurysms has been reported in various series.[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44] The durability of aneurysm occlusion is superior with microsurgery.[31] As endovascular treatment is very expensive, microsurgery remains a very good, cheaper, and cost-effective treatment option for patients with intracranial aneurysms in developing countries.[45] Our institute is a charitable organization providing treatment free of cost to all the patients and the patient need not pay for either device (clips, coils, stents, etc.) or facilities (hospital bed, operation theater, intensive care unit, cath lab, etc.) (No-cost-to-patient health model).[46] For optimal utilization of available financial resources, clipping is the primary treatment modality for intracranial aneurysms at our institute as clipping is cost-effective compared with endovascular treatment. Expensive endovascular treatment is reserved for aneurysms not suitable for clipping and residual aneurysms following clipping. All the patients in this series were referred to our institute for microsurgery as these patients could not afford endovascular treatment. Good outcome (9/11, 82%) and high complete obliteration rates (11/13, 84.6%) of aneurysms reported in the present series indicate that microsurgical clipping is still a reasonably good option for basilar artery aneurysms and AITA enhances the safety of clipping these aneurysms.


 » Conclusion Top


Adenosine-induced transient asystole during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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