Adenosine-induced Cardiac Pause for Endovascular Embolization of Cerebral Arteriovenous Malformations: Technical Case Report

Adenosine-induced Cardiac Pause for Endovascular Embolization of Cerebral Arteriovenous... ABSTRACTOBJECTIVE:Extremely high flow through arteriovenous malformations (AVMs) may limit the safety and effectiveness of endovascular glue therapy. To achieve a more controlled deposition of glue, we used transient but profound systemic hypotension afforded by an intravenously administered bolus of adenosine to induce rapidly reversible high-degree atrioventricular block.METHODS AND CASE REPORT:A patient with a large high-flow occipital AVM fed primarily by the posterior cerebral artery underwent n-butyl cyanoacrylate glue embolization. Nitroprusside-induced systemic hypotension did not adequately reduce flow through the nidus, as determined by contrast injection in the feeding artery. In a dose-escalation fashion, boluses of adenosine were administered to optimize the dose and verify that there was no flow reversal in the AVM and no other unexpected hemodynamic abnormalities by arterial pressure measurements and transcranial Doppler monitoring of the posterior cerebral artery feeding the AVM. Thereafter, 64 mg of adenosine was rapidly injected as a bolus to provide 10 to 15 seconds of systemic hypotension (∼ 20 mm Hg). Although there were conducted beats and some residual forward flow through the AVM during this time, the mean systemic and feeding artery pressures were roughly similar and remained relatively constant. A slow controlled injection of n-butyl cyanoacrylate glue was then performed, with excellent filling of the nidus.CONCLUSION:Adenosine-induced cardiac pause may be a viable method of partial flow arrest in the treatment of cerebral AVMs. Safe, deep, and complete embolization with a permanent agent may increase the likelihood of endovascular therapy's being curative or may further improve the safety of microsurgical resection. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Adenosine-induced Cardiac Pause for Endovascular Embolization of Cerebral Arteriovenous Malformations: Technical Case Report

Adenosine-induced Cardiac Pause for Endovascular Embolization of Cerebral Arteriovenous Malformations: Technical Case Report

TECHNICAL CASE REPORTS a t i e n t s h a r b o r i n g c e r e b r a l a r t e r i o ­ Adenosine-induced Cardiac Pause for v e n o u s m a l f o r m a t i o n s ( A V M s ) m a y b e n e f i t f r o m p r e o p e r a t i v e e n d o v a s c u l a r Endovascular Embolization of Cerebral e m b o l i z a t i o n , m o s t e f f e c t i v e l y w i t h c y a ­ n o a c r y l a t e g l u e s ( 2 ) . T h e g o a l o f t h e t h e r ­ Arteriovenous Malformations: Technical a p e u t i c e m b o l i z a t i o n i s t o o b l i t e r a t e a s m a n y o f t h e f i s t u l a s a n d t h e i r r e s p e c t i v e Case Report f e e d i n g a r t e r i e s a s p o s s i b l e , e s p e c i a l l y d e e p f e e d e r s t h a t a r e d i f f i c u l t t o c o n t r o l d u r i n g m i c r o s u r g i c a l r e s e c t i o n ( 1 4 ) . John Pile-Spellman, M .D ., W illiam L. Young, M.D., O n l y i n r a r e c a s e s i s e n d o v a s c u l a r t r e a t m e n t a i m e d a t t o t a l o b l i t e r a t i o n Shailendra Joshi, M .D ., D. Hoang Duong, M.D., ( 1 7 ) . O n e o f t h e m a j o r l i m i t a t i o n s o f e n ­ Meng C. Vang, M .D ., Andreas Hartmann, M.D., d o v a s c u l a r t r e a t m e n t i s t h a t t h e s o m e ­ Ronald A. Kahn, M .D ., David A. Rubin, M .D., t i m e s e x t r e m e l y h i g h f l o w t h r o u g h t h e A V M l i m i t s t h e s a f e t y a n d e f f e c t i v e n e s s Charles J. Prestigiacomo, M .D ., o f g l u e d e l i v e r y . T o a c h i e v e a m o r e c o n ­ Noeleen D. Ostapkovich, REEG/EPT t r o l l e d d e p o s i t i o n o f g l u e , s y s t e m i c h y ­ Departments of Radiology (JP-S, W L Y , D H D , M CV), Anesthesiology (W LY, SJ, N D O ), p o t e n s i o n c a n b e i n d u c e d t o a c h i e v e Neurological Surgery (JP-S, W L Y , CJP), Neurology (AH ), M edicine (DAR), College of w h a t i s t e r m e d flo w arrest ( 1 8 ) . M o s t Physicians and Surgeons, Colum bia U niversity, and...
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Publisher
Congress of Neurological Surgeons
Copyright
© Published by Oxford University Press.
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1097/00006123-199904000-00117
Publisher site
See Article on Publisher Site

Abstract

ABSTRACTOBJECTIVE:Extremely high flow through arteriovenous malformations (AVMs) may limit the safety and effectiveness of endovascular glue therapy. To achieve a more controlled deposition of glue, we used transient but profound systemic hypotension afforded by an intravenously administered bolus of adenosine to induce rapidly reversible high-degree atrioventricular block.METHODS AND CASE REPORT:A patient with a large high-flow occipital AVM fed primarily by the posterior cerebral artery underwent n-butyl cyanoacrylate glue embolization. Nitroprusside-induced systemic hypotension did not adequately reduce flow through the nidus, as determined by contrast injection in the feeding artery. In a dose-escalation fashion, boluses of adenosine were administered to optimize the dose and verify that there was no flow reversal in the AVM and no other unexpected hemodynamic abnormalities by arterial pressure measurements and transcranial Doppler monitoring of the posterior cerebral artery feeding the AVM. Thereafter, 64 mg of adenosine was rapidly injected as a bolus to provide 10 to 15 seconds of systemic hypotension (∼ 20 mm Hg). Although there were conducted beats and some residual forward flow through the AVM during this time, the mean systemic and feeding artery pressures were roughly similar and remained relatively constant. A slow controlled injection of n-butyl cyanoacrylate glue was then performed, with excellent filling of the nidus.CONCLUSION:Adenosine-induced cardiac pause may be a viable method of partial flow arrest in the treatment of cerebral AVMs. Safe, deep, and complete embolization with a permanent agent may increase the likelihood of endovascular therapy's being curative or may further improve the safety of microsurgical resection.

Journal

NeurosurgeryOxford University Press

Published: Apr 1, 1999

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