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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 17-25

Cardiac standstill and neurosurgery: A much-needed collaboration for complicated vascular procedures


1 Department of Anaesthesiology, GB Pant Institute of Post-Graduate Medical Education and Research, New Delhi, India
2 Department of Neurosurgery, GB Pant Institute of Post-Graduate Medical Education and Research, New Delhi, India

Date of Submission10-Aug-2022
Date of Decision20-Aug-2022
Date of Acceptance25-Aug-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Dr. Rachna Wadhwa
Department of Anaesthesiology, GB Pant Institute of Post-Graduate Medical Education and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_16_22

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  Abstract 


Complex intracranial aneurysm (ICA), large arteriovenous malformations and skull base tumours require absolute clean operative field and can be a battle of nerve testing at time due to torrential bleed. As such, there are various ways to reduce blood loss; however, maintaining cerebral perfusion during bleeding is a challenge. Currently, adenosine, hypothermia with cardiopulmonary bypass and rapid ventricular pacing (RVP) are options adopted at various places. Which one to choose may be a difficult preposition as there are several factors in its determinacy. This systematic review conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines evaluated 52 full-text articles for 2000–2022. A search of PubMed was done with keywords adenosine OR, hypothermia, OR RVP, OR cardiac stand still and ICA [All Fields]. Case reports and only abstracts were excluded. After exclusions, 26 articles were analysed. The relevant information for each modality has been tabulated. Adenosine produces short asystole as compared to RVP. Adenosine can be repeated if need arises. For hypothermia and RVP, one would need a good set-up with intense monitoring and complex logistics. There can be many complex situations where neurosurgeons may still need any of the above methods to choose for variable reasons or indications. Choosing any of the above methods is largely guided by individual set-ups; however, the use of adenosine seems to be simple and easy.

Keywords: Adenosine, cardiac standstill, cardiopulmonary bypass, hypothermia, rapid ventricular pacing


How to cite this article:
Wadhwa R, Singh D. Cardiac standstill and neurosurgery: A much-needed collaboration for complicated vascular procedures. J Cerebrovasc Sci 2022;10:17-25

How to cite this URL:
Wadhwa R, Singh D. Cardiac standstill and neurosurgery: A much-needed collaboration for complicated vascular procedures. J Cerebrovasc Sci [serial online] 2022 [cited 2022 Oct 4];10:17-25. Available from: http://www.jcvs.com/text.asp?2022/10/1/17/356698




  Introduction Top


Neurosurgery has passed through several tough terrains to establish itself as a safe branch of surgery which requires utmost dexterity. Unlike other parts of body, bleeding brain is an unforgiving organ which has limited scope to adjust and accommodate haematoma formation.

The gateway of clean and successful neurosurgery hinges upon minimal blood loss during surgery so that the fields are clearly visible. Any excessive bleeding can create panic even to experts, and it soon results in brain oedema and herniations which can add to more problems. At times, torrential intra-operative bleeding and inability to localize the exact site of bleed compels the neurosurgeon to apply clips blindly. Additionally, inadvertent coagulation and clipping can result in infarctions of brain tissue.

Some of the conditions of brain which can result in massive bleed are aneurysm, arteriovenous malformations (AVM), skull base tumours and certain other tumours. Site of lesions also plays a vital role in controlling bleeding, e.g., cavernous sinus and basilar artery.

In order to have a clean field during surgery, several options are available, e.g., pre-operative embolisation, exposure of common carotid artery and temporary clamp of carotid artery in neck and intraoperative hypotension.

Cardiac standstill is a method which can produce a near cardiac asystole so as to stop the circulation of blood to facilitate a surgeon to perform the required steps as indicated. It is a very challenging technique which has to keep a balance of no flow to the site of surgery as well as to prevent cerebral ischaemia. Intraoperative hypothermia, cardiac bypass machines, intraoperative adenosine and rapid ventricular pacing (RVP) are some of the methods being practiced to reduce bleeding and facilitate clipping.

The review article is to analyse the role of these techniques and to understand the current applications and merit of each for the larger benefit of patients. It also focuses on the merit of each such modality and the ease and complexity of each method.


  Historical Perspectives Top


Bleeding from vascular lesions, particularly during aneurysm surgery, has been a portal of resistance for successful clipping.[1] Since the first surgery for aneurysm by Norman McComish Dott by the method of ligating the carotid artery in 1931, there have been several advances.[2] Harry Botterell and William Lougheed used hypothermia in 1940–1950 on dogs.[13] Human application for aneurysm was utilised by William Sweet.[1] The first case of circulatory arrest was used in 1955 for large arteriovenous malformations. Surgical clipping along with hypothermia has been reported in a large series by Toronto General hospital in 1958. Later on, Charles Drake at Western Ontario used a combination of hypothermia and cardiopulmonary bypass in a series of 10 patients in the year 1963.[4] In addition, open chest circulatory arrest using Drew techniques gave impetus to vascular neurosurgery using deep hypothermia (12°C–14°C or 53.6°F–57.4°F).[5] The use of ventricular fibrillation (VF) by direct electrical stimulation of left ventricle was described by AaaronGissen which further added 4 min of circulatory arrest.[6] Open chest application of alternate current directly to heart-induced VF was later adopted by many. In 1988, Robert Spetzler from Barrow Neurological Institute used barbiturate in addition to hypothermia and complete circulatory arrest for neurological protection.[7]

Adenosine application for cardiac standstill emerged in 1999 by Michael Groff from Mr. Sinai School of Medicine.[8],[9] Later on, several series were reported for the benefits of adenosine by various authors.


  Materials and Methods Top


As per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search was made in PubMed for the recent articles of full-text review published between 2000 and 2022 using keywords: adenosine OR, hypothermia, OR Rapid ventricular pacing, OR cardiac stand still and intracranial aneurysm [All Fields]. Abstracts alone and where full-text articles could not be retrieved were excluded.

A total of 52 articles were retrieved for each pairing. Intracranial aneurysm (ICA) and adenosine revealed 13, ICA and RVP 3, ICA and hypothermia 28 and ICA and cardiopulmonary bypass 8 articles. Duplicate and unrelated articles were excluded (n = 26). Final analysis was performed on 26 relevant full-text review articles [Figure 1].
Figure 1: PRISMA Flow chart for search of articles and analysis. (ICA –Intracranial Aneurysm, RVP-Rapid Ventricular Pacing, CPB- Cardio-Pulmonary Bypass)

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The summary of various articles discussed in PRISMA has been arranged, and the highlights are discussed in [Table 1].
Table 1: Summary of selected articles reviewed

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The review found three common modalities to assist a surgeon in complex situation of clipping of ICA. RVP, hypothermia with cardiac bypass and adenosine have been used rather sparingly. Each modality has its benefit and limitation; therefore, the use of any one of the above warrants a complete understanding of concept and utilisation. Various authors have recommended various aspects, and therefore, there is no consensus which one to choose.


  Adenosine Standstill Top


Systemic use of adenosine has been reported in several reports.[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48] Because of its availability and easy to use, it has been established now at several neurosurgical units. One of it major advantages is its rapid action and short half-life (<10 secs).[35],[36]

It acts both on heart and peripheral vessels on different receptors.[37],[38] Primary action is on sinoatrial node where it binds with A1 receptors and decreases heart rate. In addition, it also acts on AV node producing negative chronotropic effect, produces vasodilatation and thus reduces blood pressure. It does not cause rebound hypertension that is a major advantage in neurosurgery.[39],[40],[41] Therefore, multiple injections can be given during the procedure. It takes about 30 s to induce asystole. The duration of asystole is dose dependent, but it varies amongst patients. Most authors record a starting dose of 6 mg as dose test.[35],[42] In some cases, a higher dose of 60mg may be needed. Adenosine produces asystole of 20–30 s and hence dose repetition may be required. In the event of intraoperative rupture, incremental dose administration cannot be used. Some authors have proposed bolus 0.4 mg/kg ideal body weight with a median dose of 30 mg to obtain to produce a median of 20 s asystole (5–30s).[35],[36] It is recommended to keep external defibrillator ready in all cases to manage any untoward incidence of unstable atrial fibrillation. Meling et al. have used it in intraoperative ruptures, to reduce the chances of dangerous drilling of clinoid process.[43] The role of adenosine has been documented to make the aneurysm soft, which helps in clipping a wide necked and partially thrombosed aneurysm. Almost all locations of aneurysm have been clipped using adenosine with safety, mostly in unruptured aneurysms.[44],[45],[46],[47]

Prolonged hypotension is one of the major concerns with adenosine, the period of which may last for about 30 min. It is also associated with profound reduction in systemic vascular resistance.[48] Restoration of hypotension after cessation of adenosine occurs within 3 minutes; however, it may be prolonged with repeated administration.[35],[36]

Sollevi et al. have used continuous infusion with effect coming in 1–2 min and restored after stopping within 1–5 min.[49] The mean arterial pressure (MAP) decreased to 46 mmHg within 1 min. Some of the relative contraindications are MI, wherein adenosine can produce regional ischaemia or previous heart blocks. Other relative contraindications include gout and bronchial asthma, as they may induce bronchospasm.


  Rapid Ventricular Pacing Top


RVP is a method which produces virtual asystole and transient hypotension. In this method, a pacemaker electrode is placed in right ventricle via internal jugular vein.

Tachycardia is induced which impedes ventricular filling and simultaneously reduces ventricular contraction. It results in reduced stroke volume and blood pressure without actually producing cardiac arrest or asystole. The procedure begins to keep heart rate of 150/min and eventually it is gradually increased to induce a MAP of under 50 mmHg. It can be combined with regular methods of intraoperative hypotension. After cessation of RVP, systolic blood pressure returns back to normal immediately, and contrary to adenosine, there is no prolonged hypotension.[23]

Unlike adenosine which can result in MAP of 0, the hypotension with RVP can be sustained around 40 mmHg for a longer duration and thus has a lesser risk of microembolism and infarct.

Although several episodes of RVP can be applied, most literature have used an average of 3 cycles of pacing.[24] Indication of pacing is largely to produce the slackness of aneurysm for clipping. Pacing is usually indicated when the sizes of aneurysm are large to giant. The majority of aneurysms are wide neck and located in intracavernous region.[50]

Reported complications are tachyarrhythmias (VF and atrial fibrillation) reversible with cardioversion. A small rise in troponin I levels is also reported. Rare procedural complications are cardiac tamponade, cardiac perforation, myocardial infarction and pneumothorax. Contraindications include prior myocardial infarction and severe left ventricular dysfunction.[51]


  Hypothermia and Cardiopulmonary Bypass Top


Hypothermia has been extensively used to treat neurosurgical conditions such as head injury. Its role in managing complex aneurysm and carotid-cavernous fistula has been sparingly used. It reduces the metabolic demand of brain and hence increases tolerance for tissue hypoxia during blood loss.


  Technical Aspects of Cardiopulmonary Bypass and Hypothermia Top


Selection of suitable case is definitely challenging and necessitates close-knit teamwork. Cardiovascular surgeons, neurosurgeons, anaesthesiologists and perfusionists have to work in close harmony for optimal conditions in the surgical field.

The technique involves placing creating extracorporeal circulation usually by placing two cannulas, one each in femoral artery and vein [Figure 2]a, [Figure 2]b and [Figure 3]. This can also be achieved by sternotomy and direct cannulation of aorta and right atrium.
Figure 2: Line diagram explaining cardiopulmonary bypass via femoral route

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Figure 3: (a) Exposed femoral artery and vein in an adult, (b) Cannulated artery and vein for bypass

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After assessing cardiovascular, pulmonary, renal and hepatic systems, it is essential to rule out peripheral vascular disease also. Oesophageal stricture, stenosis, surgery or trauma precludes the use of trans-oesophageal echocardiography (TEE). Baseline blood investigations, electrocardiography, chest X-ray and echocardiography (to rule out associated vascular anomaly, especially aortic valve pathology) are mandatory. Large-bore 16G intravenous cannula is secured and invasive arterial line is inserted under local anaesthesia. Standard general anaesthesia technique is used, keeping in mind suppression of haemodynamic response to laryngoscopy. The American Society of Anesthesiologists monitoring is instituted and additionally cerebral monitoring (bispectral index [BIS], near-infrared spectroscopy, etc.) is desirable/recommended. Central venous line is usually placed in right internal jugular vein. Some authors have also described the use of Swan-Ganz, P-A catheters. A mixture of air–oxygen is preferred for ventilation. Arterial blood gas (ABG) sample is analysed hourly for optimising ventilation and oxygenation. TEE probe is inserted and cardiac chambers and valves are assessed. Ejection fraction is documented, and associated lesions or pulmonary arterial hypertension if present are assessed for severity. The probe generally remains in situ for the entire procedure. It helps in guiding cannula positions in close chest cardiopulmonary bypass. It is essential to attach sticky defibrillator pads on both sides of chest, connected to defibrillator at all times.

Following this, the patient is positioned for craniotomy as per neurosurgeons' requirement. In addition, chest and groin are also painted and draped, so that they are accessible for CPB. Depth of anaesthesia is ensured, and antibiotics and mannitol (0.5–1 g) are administered. Temperature, BIS, ABG and baseline ACT are recorded and documented. The neurosurgeon again assesses the aneurysm after craniotomy and gives a final nod whether to proceed for cardiopulmonary bypass. The most common technique is femorofemoral bypass.[52] CPB can be established by sternotomy and direct cannulation of aorta and right sternum, but in cases where open heart/chest surgery is not required, sternotomy should not be performed. In such cases, femorofemoral bypass is a preferred technique [Figure 2], though it is also popular for minimally invasive and redo cardiac surgeries.


  Technique for Femoral Cannulation Top


After exposing the groin area, under all aseptic precautions and adequately cleaning the area, fine surgical dissection is done to expose femoral vessels. Then, unfractionated heparin 300–400U/kg is administered. After administration of heparin, femoral artery and veins are cannulated [Figure 3]a and [Figure 3]b. ACT is measured after 3 min, and once ACT is >480 s, the patient can be safely taken on heart–lung machine [Figure 4]. Femoral venous cannula is advanced till right atrium under TEE guidance. In general, anaesthesia drugs such as fentanyl, rocuronium/pancuronium and midazolam are administered via pump and heparin in half dose is repeated hourly. Thiopentone or propofol infusions are administered to achieve electroencephalography (EEG) burst suppression till the time the patient goes on CPB and hypothermia is achieved. The cerebral rate of metabolism decreases by 7% for every 1°C fall in temperature.[53]
Figure 4: Image depicting cardiopulmonary bypass via femoral route

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Once the CPB is established, and optimal flows are achieved, MAP >50 mg (flow depends on BSA) cooling is initiated by an extracorporeal heat exchanger. Cooling should be done slowly and once target temperature is reached, it is maintained. Mild hypothermia refers to temperature of 32°C–35°C, moderate hypothermia is 28°C–32°C and deep hypothermia is <28°C. In general, moderate hypothermia is advocated on CPB. However, at times, deep hypothermic circulatory arrest (DHCA) is required for giant AVM and aneurysms.[54]

The surgeon exposes the surgical site and assesses the aneurysm once again. After confirming with a neurosurgeon, cardioplegia solution is administered to achieve cardiac standstill by the perfusionist, eventually leading to cerebral vascular relaxation. Such manoeuvres produce the slackness of aneurysm. Subsequently, aneurysm can be assessed with ease and the neurosurgeon can comprehend the anatomical complexities of aneurysm and proceed for clipping if possible. If there are issues with identification, flows are reverted and ICG may be performed in special circumstances. If the surgeon thinks vascularity and identification of collaterals is difficult, this is the time to decide if DHCA is required. If DHCA is planned, cerebroprotective agents are administered through CPB machine. The temperature monitoring site recommended is tympanic probe as it truly reflects brain temperature. The CPB time reported in the literature is 160 (117–215) min. However, the aim is to keep the duration of DHCA as minimal as possible, and many studies elaborate 30 min (15–45) to be safe and neurological complications are seen beyond 40–60 min.[53],[55] Besides hypothermia, other neuroprotective strategies are also important such as pharmacological agents, surface head cooling, glucose control, haemodilution and acid–base management.

Once surgical clipping/procedure has been completed, flows are established and the surgeon evaluates the surgical site for haemostasis. If the surgeon is confident that there is no bleeding, rewarming is initiated. Nitroglycerin infusion at low dose may be started to achieve uniform rewarming. Once cardiac activity is gained and electrolytes, ABG and haemodynamics are acceptable, the patient is weaned off cardiopulmonary bypass. Sometimes, minute doses of inotropes may be required to counter the efforts of cardioplegia. Hypothermia and rewarming are associated with rhythm disturbances; therefore, shock may be required in cases of refractory VF or pulseless ventricular tachycardia. Heparin is neutralised with almost equivalent dose of protamine. ACT is again measured and <140 s is considered safe.

It requires a proper infrastructure and set-up which generally exist in all cardiac operation theatres. Intra-operative monitoring with Electo-Encephalography (EEG), Somato-Sensory Evoked Potential (SSEP) and Brainstem Evoked Response Audiometry (BERA).

Lawton et al. studied 60 patients over a span of 12 years, where majority of posterior circulation aneurysms were managed successfully with hypothermic circulatory arrest.[56] Various authors have found DHCA to be quite helpful in complex and giant ICA s including basilar artery aneurysms.[56],[57],[58],[59]

Hypothermia can be of immense use in large and giant aneurysm which currently is viewed as a challenging task. Surgery for complex aneurysm and intracranial bypass procedures are some useful indications for hypothermia and cardiac standstill. Although DHCA confers many surgical advantages, still issues such as coagulopathy, cerebral microembolism, increased plasma viscosity and erythrocyte rigidity, metabolic acidosis, hyperglycaemia and altered drug metabolism must be managed simultaneously.[53] Some of the other complications due to hypothermia include sepsis, myocardial infarction, transfusion-related issues and pulmonary embolism. Mortality related to technique is reported 8%–13%, which may be related to subarachnoid haemorrhage itself.[56]

In the current scenario, exclusive indications for DHCA practically include complex posterior circulation and giant aneurysms not amenable to be treated using conventional techniques or that recur after endovascular coiling. Therefore, inspite of decreasing trend for the use of DHCA because of newer technology-driven endovascular methods, it still remains in the armamentarium for managing complex vascular neurosurgery. However, DHCA requires complex infrastructure and a multidisciplinary expert team for optimal management.

After having discussed the existing techniques, all the methods have been analysed detailing on uses, techniques, doses, advantages and disadvantages, as tabulated in [Table 2].
Table 2: Advantages and disadvantages of various methods for cardiac standstill

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  Conclusions Top


Several ICAs, because of size, location and complexity, mandate a surgical approach. Despite technical assistance and advanced techniques, surgical management of ICA becomes a nightmare some time, more so when endovascular options are also difficult for a particular case.

Various authors have described adenosine, RVP and CPB with hypothermia for the management of such complex and difficult situations. Each one has its merit and limitation; hence, there is no consensus to use only a particular method. Whereas hypothermia and cardiac standstill and RVP seem a reasonable option, it requires hybrid theatre, infrastructure and a dedicated team. In comparison, adenosine seems to be simpler and safer modality to choose in limited resources.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wright JM, Huang CL, Sharma R, Manjila S, Xu F, Dabb B, et al. Cardiac standstill and circulatory flow arrest in surgical treatment of intracranial aneurysms: A historical review. Neurosurg Focus 2014;36:E10.  Back to cited text no. 1
    
2.
Todd NV, Howie JE, Miller JD. Norman Dott's contribution to aneurysm surgery. J Neurol Neurosurg Psychiatry 1990;53:455-8.  Back to cited text no. 2
    
3.
Lougheed WM, Sweet WH, White JC, Brewster WR. The use of hypothermia in surgical treatment of cerebral vascular lesions; a preliminary report. J Neurosurg 1955;12:240-55.  Back to cited text no. 3
    
4.
Lougheed WM, Kahn DS. Circumvention of anoxia during arrest of cerebral circulation for intracranial surgery. J Neurosurg 1955;12:226-39.  Back to cited text no. 4
    
5.
Drake CG, Barr HW, Coles JC, Gergely NF. The use of extracorporeal circulation and profound hypothermia in the treatment of ruptured intracranial aneurysm. J Neurosurg 1964;21:575-81.  Back to cited text no. 5
    
6.
Gissen AJ, Matteo RS, Housepian EM, Bowman FO Jr. Elective circulatory arrest during neurosurgery for basilar artery aneurysms. JAMA 1969;207:1315-8.  Back to cited text no. 6
    
7.
Dobell AR, Bailey JS. Charles drew and the origins of deep hypothermic circulatory arrest. Ann Thorac Surg 1997;63:1193-9.  Back to cited text no. 7
    
8.
Spetzler RF, Hadley MN, Rigamonti D, Carter LP, Raudzens PA, Shedd SA, et al. Aneurysms of the basilar artery treated with circulatory arrest, hypothermia, and barbiturate cerebral protection. J Neurosurg 1988;68:868-79.  Back to cited text no. 8
    
9.
Groff MW, Adams DC, Kahn RA, Kumbar UM, Yang BY, Bederson JB. Adenosine-induced transient asystole for management of a basilar artery aneurysm. Case report. J Neurosurg 1999;91:687-90.  Back to cited text no. 9
    
10.
Hishikawa T, Murai S, Hiramatsu M, Haruma J, Nishi K, Ebisudani Y, et al. An evaluation of the safety and feasibility of adenosine-assisted clipping surgery for unruptured cerebral aneurysms: Study protocol. Neurol Med Chir (Tokyo) 2021;61:393-6.  Back to cited text no. 10
    
11.
Nussbaum ES, Burke E, Nussbaum LA. Adenosine-induced transient asystole to control intraoperative rupture of intracranial aneurysms: Institutional experience and systematic review of the literature. Br J Neurosurg 2021;35:98-102.  Back to cited text no. 11
    
12.
Fastenberg JH, Garzon-Muvdi T, Hsue V, Reilly EK, Jabbour P, Rabinowitz MR, et al. Adenosine-induced transient hypotension for carotid artery injury during endoscopic skull-base surgery: Case report and review of the literature. Int Forum Allergy Rhinol 2019;9:1023-9.  Back to cited text no. 12
    
13.
Al-Mousa A, Bose G, Hunt K, Toma AK. Adenosine-assisted neurovascular surgery: Initial case series and review of literature. Neurosurg Rev 2019;42:15-22.  Back to cited text no. 13
    
14.
Wang X, Feletti A, Tanaka R, Yamada Y, Suyama D, Kawase T, et al. Adenosine-induced flow arrest to facilitate intracranial complex aneurysm clip ligation: Review of the literature. Asian J Neurosurg 2018;13:539-45.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Yoon NK, Scoville JP, Taussky P. Adenosine-induced cardiac standstill for endovascular treatment of pediatric vein of Galen malformations. J Neurosurg Pediatr 2018;21:380-3.  Back to cited text no. 15
    
16.
Intarakhao P, Thiarawat P, Tewaritrueangsri A, Pojanasupawun S. Low-dose adenosine-induced transient asystole during intracranial aneurysm surgery. Surg Neurol Int 2020;11:235.  Back to cited text no. 16
    
17.
Desai VR, Rosas AL, Britz GW. Adenosine to facilitate the clipping of cerebral aneurysms: Literature review. Stroke Vasc Neurol 2017;2:204-9.  Back to cited text no. 17
    
18.
Bendok BR, Gupta DK, Rahme RJ, Eddleman CS, Adel JG, Sherma AK, et al. Adenosine for temporary flow arrest during intracranial aneurysm surgery: A single-center retrospective review. Neurosurgery 2011;69:815-20.  Back to cited text no. 18
    
19.
Britz GW. Adenosine-induced transient asystole. Methodist Debakey Cardiovasc J 2014;10:220-3.  Back to cited text no. 19
    
20.
Chowdhury T, Petropolis A, Wilkinson M, Schaller B, Sandu N, Cappellani RB. Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract 2014;2014:595837.  Back to cited text no. 20
    
21.
Shiiya N. Aortic arch replacement for degenerative aneurysms: Advances during the last decade. Gen Thorac Cardiovasc Surg 2013;61:191-6.  Back to cited text no. 21
    
22.
Zhao ZX, Wu C, He M. A systematic review of clinical outcomes, perioperative data and selective adverse events related to mild hypothermia in intracranial aneurysm surgery. Clin Neurol Neurosurg 2012;114:827-32.  Back to cited text no. 22
    
23.
Saldien V, Menovsky T, Rommens M, Van der Steen G, Van Loock K, Vermeersch G, et al. Rapid ventricular pacing for flow arrest during cerebrovascular surgery: Revival of an old concept. Neurosurgery 2012;70:270-5.  Back to cited text no. 23
    
24.
Konczalla J, Platz J, Fichtlscherer S, Mutlak H, Strouhal U, Seifert V. Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: Results of an interdisciplinary prospective trial. J Neurosurg 2018;128:1741-52.  Back to cited text no. 24
    
25.
Mackensen GB, McDonagh DL, Warner DS. Perioperative hypothermia: Use and therapeutic implications. J Neurotrauma 2009;26:342-58.  Back to cited text no. 25
    
26.
Mack WJ, Ducruet AF, Angevine PD, Komotar RJ, Shrebnick DB, Edwards NM. Deep hypothermic circulatory arrest for complex cerebral aneurysms: Lessons learned. Neurosurgery 2008;62:1311-23.  Back to cited text no. 26
    
27.
Levati A, Tommasino C, Moretti MP, Paino R, D'Aliberti G, Santoro F. Giant intracranial aneurysms treated with deep hypothermia and circulatory arrest. J Neurosurg Anesthesiol 2007;19:25-30.  Back to cited text no. 27
    
28.
Young WL, Lawton MT, Gupta DK, Hashimoto T. Anesthetic management of deep hypothermic circulatory arrest for cerebral aneurysm clipping. Anesthesiology 2002;96:497-503.  Back to cited text no. 28
    
29.
Demaria R, Fortier S, Bédard A, Sinquet JC, Albat B, Frapier JM, et al. Extracorporeal circulation: An extraordinary tool that is not just for cardiac surgeons. J Chir (Paris) 2002;139:232-5.  Back to cited text no. 29
    
30.
Zimmer DL, Martin KM. Giant intracranial aneurysm obliteration using deep hypothermic circulatory arrest. AACN Clin Issues 1997;8:196-204.  Back to cited text no. 30
    
31.
Taylor CL, Selman WR, Kiefer SP, Ratcheson RA. Temporary vessel occlusion during intracranial aneurysm repair. Neurosurgery 1996;39:893-905.  Back to cited text no. 31
    
32.
Koch F, Thompson J, Chung RS. Giant cerebral aneurysm repair. Incorporating cardiopulmonary bypass and neurosurgery. AORN J 1991;54:224-7.  Back to cited text no. 32
    
33.
White DC. Deliberate interruption of the cerebral circulation. Int Anesthesiol Clin 1969;7:687-99.  Back to cited text no. 33
    
34.
Chawla R, Tempe DK. Cardiopulmonary bypass for management of intracranial aneurysms: Anaesthetic considerations. Ann Card Anaesth 2005;8:171-9.  Back to cited text no. 34
[PUBMED]  [Full text]  
35.
Lee SH, Kwun BD, Kim JU, Choi JH, Ahn JS, Park W, et al. Adenosine-induced transient asystole during intracranial aneurysm surgery: Indications, dosing, efficacy, and risks. Acta Neurochir (Wien) 2015;157:1879-86.  Back to cited text no. 35
    
36.
Bebawy JF, Gupta DK, Bendok BR, Hemmer LB, Zeeni C, Avram MJ, et al. Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: Dose-response data and safety profile. Anesth Analg 2010;110:1406-11.  Back to cited text no. 36
    
37.
Meling TR. Adenosine-assisted clipping of intracranial aneurysms. Acta Neurochir Suppl 2018;129:11-8.  Back to cited text no. 37
    
38.
Shryock JC, Belardinelli L. Adenosine and adenosine receptors in the cardiovascular system: Biochemistry, physiology, and pharmacology. Am J Cardiol 1997;79:2-10.  Back to cited text no. 38
    
39.
Hashimoto T, Young WL, Aagaard BD, Joshi S, Ostapkovich ND, Pile-Spellman J. Adenosine-induced ventricular asystole to induce transient profound systemic hypotension in patients under going endovascular therapy. Dose-response characteristics. Aneasthesiology 2000;23:998-1001.  Back to cited text no. 39
    
40.
Guinn NR, McDonagh DL, Borel CO, Wright DR, Zomorodi AR, Powers CJ, et al. Adenosine-induced transient asystole for intracranial aneurysm surgery: A retrospective review. J Neurosurg Anesthesiol 2011;23:35-40.  Back to cited text no. 40
    
41.
Owall A, Gordon E, Lagerkranser M, Lindquist C, Rudehill A, Sollevi A. Clinical experience with adenosine for controlled hypotension during cerebral aneurysm surgery. Anesth Analg 1987;66:229-34.  Back to cited text no. 41
    
42.
Luostarinen T, Takala RS, Niemi TT, Katila AJ, Niemelä M, Hernesniemi J, et al. Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture. World Neurosurg 2010;73:79-83.  Back to cited text no. 42
    
43.
Meling TR, Romundstad L, Niemi G, Narum J, Eide PK, Sorteberg AG. Adenosine-assisted clipping of intracranial aneurysms. Neurosurg Rev 2018;41:585-92.  Back to cited text no. 43
    
44.
Powers CJ, Wright DR, McDonagh DL, Borel CO, Zomorodi AR, Britz GW. Transient adenosine-induced asystole during the surgical treatment of anterior circulation cerebral aneurysms: Technical not. Neurosurgery 2010;67 2 Suppl Operative: 461-70.  Back to cited text no. 44
    
45.
Meling TR, Sorteberg A, Bakke SJ, Slettebø H, Hernesniemi J, Sorteberg W. Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: Treatment and outcome. J Neurosurg 2008;108:662-71.  Back to cited text no. 45
    
46.
Andrade-Barazarte H, Luostarinen T, Goehre F, Kivelev J, Jahromi BR, Ludtka C, et al. Transient cardiac arrest induced by adenosine: A tool for contralateral clipping of internal carotid artery-ophthalmic segment aneurysms. World Neurosurg 2015;84:1933-40.  Back to cited text no. 46
    
47.
Benech CA, Perez R, Faccani G, Trompeo AC, Cavallo S, Beninati S, et al. Adenosine-induced cardiac arrest in complex cerebral aneurysms surgery: An Italian single-center experience. J Neurosurg Sci 2014;58:87-94.  Back to cited text no. 47
    
48.
Lagerkranser M, Bergstrand G, Gordon E, Irestedt L, Lindquist C, Stånge K, et al. Cerebral blood flow and metabolism during adenosine-induced hypotension in patients undergoing cerebral aneurysm surgery. Acta Anaesthesiol Scand 1989;33:15-20.  Back to cited text no. 48
    
49.
Sollevi A, Lagerkranser M, Irestedt L, Gordon E, Lindquist C. Controlled hypotension with adenosine in cerebral aneurysm surgery. Anesthesiology 1984;61:400-5.  Back to cited text no. 49
    
50.
Saldien V, Schepens T, Van Loock K, Vermeersch G, Wildemeersch D, Van Hoof V, et al. Rapid ventricular pacing for neurovascular surgery: A study on cardiac and cerebral effects. World Neurosurg 2018;119:e71-7.  Back to cited text no. 50
    
51.
Khan SA, Berger M, Agrawal A, Huang M, Karikari I, Nimjee SM, et al. Rapid ventricular pacing assisted hypotension in the management of sudden intraoperative hemorrhage during cerebral aneurysm clipping. Asian J Neurosurg 2014;9:33-5.  Back to cited text no. 51
[PUBMED]  [Full text]  
52.
Massad MG, Charbel FT, Chaer R, Geha AS, Ausman JI. Closed chest hypothermic circulatory arrest for complex intracranial aneurysms. Ann Thorac Surg 2001;71:1900-4.  Back to cited text no. 52
    
53.
Conolly S, Arrowsmith JE, Klein AA. Deep hypothermic circulatory arrest. Contin Educ Anaesth Crit Care Pain 2010;10:138-142.  Back to cited text no. 53
    
54.
Schebesch KM, Proescholdt M, Ullrich OW, Camboni D, Moritz S, Wiesenack C, et al. Circulatory arrest and deep hypothermia for the treatment of complex intracranial aneurysms – Results from a single European Center. Acta Neurochir (Wien) 2010;152:783-92.  Back to cited text no. 54
    
55.
Aebert H, Brawanski A, Philipp A, Behr R, Ullrich OW, Keyl C, et al. Deep hypothermia and circulatory arrest for surgery of complex intracranial aneurysms. Eur J Cardiothorac Surg 1998;13:223-9.  Back to cited text no. 55
    
56.
Lawton MT, Raudzens PA, Zabramski JM, Spetzler RF. Hypothermic circulatory arrest in neurovascular surgery: Evolving indications and predictors of patient outcome. Neurosurgery 1998;43:10-20.  Back to cited text no. 56
    
57.
Sullivan BJ, Sekhar LN, Duong DH, Mergner G, Alyano D. Profound hypothermia and circulatory arrest with skull base approaches for treatment of complex posterior circulation aneurysms. Acta Neurochir (Wien) 1999;141:1-11.  Back to cited text no. 57
    
58.
Ponce FA, Spetzler RF, Han PP, Wait SD, Killory BD, Nakaji P, et al. Cardiac standstill for cerebral aneurysms in 103 patients: An update on the experience at the Barrow Neurological Institute. Clinical article. J Neurosurg 2011;114:877-84.  Back to cited text no. 58
    
59.
Santiago B, Gradil C, Cunha E Sa M. The role of deep hypothermic cardiac arrest in the surgical treatment of complex intracranial aneurysms. Eur Neurol Rev 2011;6:204.  Back to cited text no. 59
    


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Abstract
Introduction
Historical Persp...
Materials and Me...
Adenosine Standstill
Rapid Ventricula...
Hypothermia and ...
Technical Aspect...
Technique for Fe...
Conclusions
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