2024 FSA Podium and Poster Abstracts

P068: INTRAOPERATIVE INTRACRANIAL ANEURYSM RUPTURE REQUIRING MULTIPLE DOSES OF ADENOSINE
Ethan T Lubanski, MD; Gisele Wakim, MD; Jackson Memorial Hospital

Inadvertent rupture of an intracranial aneurysm during an open clipping procedure is a rare but potentially devastating event. Adenosine-induced cardiac arrest can be performed to provide a bloodless surgical field. This is typically accomplished with a single 0.3-0.4mg/kg bolus of adenosine which should provide 30 to 60 seconds of profound hypotension and bradycardia. These circumstances often require management of potential arrythmias, profound blood loss, and postoperative neurological deficits. This case report details the perioperative management of an elective open intracranial aneurysm clipping of the posterior communicating artery complicated by a severe rupture requiring 4 doses of adenosine intraoperatively.

A 60-year-old 60kg female with no prior past medical history presented one month prior with mild vertigo symptoms and was found to have a 6mm aneurysm at the junction of the right ICA and PCom. The patient was then scheduled to undergo a right frontal craniotomy for aneurysm clipping to prevent spontaneous hemorrhage. Preoperative workup showed a starting hematocrit of 42% and EKG was unremarkable. Two units of pRBCs were available in the OR.

During placement of temporary clips, an incidental tear in the aneurysm neck led to hemorrhage. Adenosine was given to aid in visualization and bleeding control. An initial adenosine dose of 20mg was given followed by 3 more doses of 30mg for a total of 110mg. All four doses were given within 10 minutes. 3 units of pRBCs, 1mg of calcium, and 500mL of albumin were administered due to brisk blood loss and subsequent hypotension during the episode. The hemaocrit was 27% during this time, from a starting hematocrit of 34%. Blood loss was estimated to be 1L at this time. After each dose of adenosine, the patient remained hypotensive which responded to volume and product administration. No arrythmias or EKG changes were noted throughout. Hemodynamics and hematocrit returned to baseline after surgical control and resuscitation. Motor monitoring indicated new decreased amplitude in left foot at case conclusion.

The patient was extubated and taken to ICU. Postoperative exam was notable for a weak left lower extremity which resolved POD1. The patient had an uneventful inpatient course and was transferred to floor POD3 and rehab POD7. Patient was discharged home with full capabilities of performing all ADLs.

In cases involving aneurysm clipping, adenosine can be used in two different scenarios. The first involves using adenosine to simply facilitate clip placement in anatomically complex aneurysms without dissection or rupture.3-5 The second involves a more urgent scenario where adenosine is given to provide a bloodless surgical field in the setting of a rupture or dissection.6-8

In either setting, adenosine is given as a rapid intravenous bolus with a dose of 0.3-0.4 mg/kg with an expected decrease in SBP below 60mmHg for roughly 45 seconds.3 The use of adenosine for intracranial aneurysm clipping procedures appears safe with no difference found in neurologic outcomes.3,6,7 Potential side effects include arrythmias such as atrial fibrillation and asymptomatic troponinemia postoperatively. Interventions requiring defibrillation, pacing, or other invasive cardiac procedures are extremely rare.3,5,6