gms | German Medical Science

Objective: The morphology of cerebral aneurysms is highly variable which may result in difficult surgical exposure for clip ligation in particular cases. Secure clip application is often not feasible without temporary intraaneurysmal pressure reduction. Such softening can be accomplished with transient adenosine-induced asystole. We here describe our experience with this technique in 72 patients.

Methods: We analyzed demographic data, aneurysm characteristics, application characteristics, radiological and clinical outcome, and procedure specific complications.

Results: Adenosine was applied in 72 patients (55 women, 17 men; mean age 56 years) who underwent microsurgical clipping of intracranial aneurysms: paraclinoid internal carotid artery (33 patients), anterior communicating artery (23 patients), middle cerebral artery (12 patients), and posterior inferior cerebellar artery (4 patients). 34 (47%) patients had suffered a subarachnoid hemorrhage from aneurysm rupture, 38 patients had carried incidental aneurysms. Mean aneurysm size was 10 mm (range 3-30 mm). Reasons for adenosine application were impracticality of temporary proximal vessel clipping (33 patients with paraclinoid internal carotid artery aneurysm), better visualization with softening of aneurysm (39 patients), and a very thin aneurysm neck (mycotic, blister like aneurysm) in 4 patients. Mean applied adenosine dosage was 21 mg (range 9-50 mg) with a mean cardiac flow arrest of 21 sec (range 0-69 sec). In 39 patients a single dose of adenosine was given, in 23 patients a repeated dose, in 7 patients a third, in 2 patients a fourth and in 1 patient a fifth dose. In 62 (86%) patients adenosine-induced asystole facilitated clip application but in 8 patients transient parent vessel clipping was additionally necessary, while in 2 patients aneurysm clipping was not possible (1 patient with a calcified aneurysm and 1 patient with blister like aneurysm). In 2 patients adenosine triggered transient atrial fibrilliation, in 1 patient it was self-limited, in the other cardioversion was required. Postoperative femoral angiography showed complete aneurysm occlusion in 70 (97%) patients. Postoperative cranial computed tomography revealed no cerebral infarction due to adenosine use.

Conclusion: In selected patients adenosine-induced transient cardiac arrest is a usesul technique to facilitate clip ligation. The use of adenosine is limited in patients with calcified, partially thrombosed and very thin walled (blister like, mycotic) aneurysms.