Clipping of DACA ANEURYSM: In search for perfection

Uploaded On : 14th August 2019

DACA aneurysms accounts for 6% of all intracranial aneurysms. They are smaller (median 8 mm), more frequently associated with multiple aneurysms (18%), and presents more often with intracerebral hematomas (26%) than ruptured aneurysms in general. Their microsurgical treatment showed the same complication rates as for other ruptured aneurysms.

Temporary clip ligation of a proximal vessel has risks of stroke, dissection or rupture and decreases visualisation. In instances where temporary arterial occlusion is difficult for anatomical reasons or impractical, adenosine use can be beneficial.

Ideal criteria for flow arrest in vascular surgery include the following:

  • Predictable effects (especially degree and duration of hypotension)
  • Few pharmacological side effects
  • Titratability
  • Technical feasibility and simplicity
  • Low risk for procedure-related complications [1]

In this review article, we provide background on adenosine use in intracranial aneurysm surgery.

Indication

  • Large and/or deep aneurysms in narrow corridors where temporary clip ligation is difficult or not possible. In these situations, adenosine-induced cardiac arrest relaxes the brain and may improve visualisation in narrow corridors.Moreover, temporary clip ligation only decreases blood flow from one direction, while adenosine-induced hypotension is more global and, in certain instances, can more effectively decompress the aneurysmal dome
  • In synergy with temporary clipping, especially during intraoperative aneurysmal rupture
  • Instances in which temporary clipping fails
  • To improve visualisation of adjacent perforating arteries

Adenosine has been used successfully for ruptured and unruptured aneurysms in anterior and posterior circulations with a rare incidence of clinically significant side effects. Its rapid onset and offset and predictable action make it a valuable tool in cerebrovascular surgery. Most evidence to date has been in the form of cases series or retrospective reviews, signifying the need for a prospective, randomised trial of adenosine usage.

Surgical Nuances

We operated on a case of H&H Grade 2 SAH with ruptured DACA aneurysm. Pre-operative CT angio showed vasospasm of proximal A3 vessel on both sides. Also, as is the case with most DACA aneurysms ,the aneurysm comes in the way of proximal artery due to the curve along corpus callosum.

Hence it was decided to for AiCA instead of temporary clipping and to decrease the CMrO2 an electrical standstill of brain was induced with Barbiturates just prior to AiCA and confirmed with intra operative EEG.

After successful clipping, distal flow and adequacy of clipping was confirmed with micro Doppler and intra operative microscope integrated ICG.

Post operatively patient had no evidence of clinical or radiological vasospasm.

Conclusion

[2]AiCA is a useful technique for micro neurosurgical treatment of cerebral aneurysms. AiCA can minimize the use of TC and does not increase the risk of IAR and postoperative infarction if combined with barbiturate induced electrical slowing/ standstill.

References

  1. Virendra R Desai,1 Alejandro L Rosas,2 and Gavin W Britz1, Adenosine to facilitate the clipping of cerebral aneurysms: literature review , Stroke Vasc Neurol. 2017 Dec; 2(4): 204–209.
  2. Patcharin Intarakhao MD 1 , 2 , Peeraphong Thiarawat MD 1 , 3 , Behnam Rezai Jahromi MB 1 , Danil A. Kozyrev MD 1 , Mario K. Teo MD, FRCS(SN) 4 , Joham Choque-Velasquez MD 1 , Teemu Luostarinen MD, PhD 5 and Juha Hernesniemi MD, PhD 1 ; Adenosine-induced cardiac arrest as an alternative to temporary clipping during intracranial aneurysm surgery; Volume 129: Issue 3 (Sep 2018): Pages 567-851 in Journal of Neurosurgery.

    Dr. Amit chakrabarty
    Sr. Consultant – Neuro Surgery

    RBH Department of Neurosciences

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