Intracranial aneurysm is a life-threatening condition that usually starts with little symptoms for years. And many patients only have sudden-onset symptoms when the aneurysm is ruptured. The mortality rate of ruptured intracranial aneurysm is very high. The intracranial aneurysm is mainly managed surgically by coil embolism or clipping. However, surgery itself is a risk factor for aneurysm rupture, and the rupture can occur in any stage of surgery. The size of aneurysm, the thickness of blood vessel wall, and BP are important factors to predict the risk of intraoperative rupture of aneurysm.[16–19] For intracranial aneurysm repair surgery, the key is to prevent aneurysm rupture, because rupture will cause blood loss and may lead to irreversible brain damage and other visceral organs and intraoperative bleeding will make it very difficult to have a clean surgical area to clip the aneurysm, and it may cause secondary damage during procedure. Therefore, to reduce the risk of aneurysm rupture is essential to increase survival rate of aneurysm repair surgery.
The size of aneurysm, the thickness of blood vessel wall, and BP are factors that correlated with the risk of aneurysm rupture. Big aneurysm, thinner blood vessel wall, and high BP are associated with higher risk of aneurysm rupture. However, among the three factors, BP is the only factor that can be managed in current clinical practice.
Adenosine-induced temporary cardiac arrest was widely used to lower BP in many cardiovascular surgeries. It was also used to control BP in the intracranial aneurysm surgery. A study found that patients whom induced temporary cardiac arrest during intracranial aneurysm repair needed less time to clipping, and slightly less intraoperative aneurysm rupture. This result supported that inducing temporary cardiac arrest was benefit to patients with aneurysm repair. However, adenosine may have safety issues, as some patients may response to adenosine differently, and patients who are sensitive to adenosine may be overdosed. Second, the duration of cardiac arrest and amplitude of blood pressure decrease was difficult to control when induced by adenosine.
RVP became a safer alternative to adenosine to control BP in many cardiac surgeries.[22–24] RVP enforced ventricular tachycardia and the ventricular filling was compromised because of the high HR and absent atrioventricular synchrony. Thus, reduced stroke volume and cardiac output lead to decreased BP. RVP had better control over the duration and amplitude of blood pressure than adenosine. In addition to general cardiovascular surgeries, recently RVP has been used to control BP during intracranial aneurysm repair surgery.
The benefits of RVP include: reducing the amount of bleeding and providing a clean surgical area; reducing the tension of aneurysm, which will decrease the chance of rupture during surgical isolation and clipping; and in cases of aneurysm rupture, RVP will induce a transient “very-low pressure” condition, and give a valuable time frame to clip the ruptured aneurysm. Therefore, RVP is a safe and effective method to provide transient reduction of cardiac output.
The complications of RVP usually are related with pacing probes, such as penetration of heart, cardiac tamponade, pneumothorax, and ventricular tachycardia. Therefore, it is suggested to thoroughly evaluate patients’ cardiac function, for example, Holter to exclude the sinus malfunctions, coronary computed tomography angiography to exclude coronary artery disease, and echocardiogram to exclude valve-related disease. Defibrillator and anti-arrhythmia drugs should be prepared before performing RVP.
In summary, here we presented a patient with large MCA aneurysm, and he was treated with aneurysm clipping with the assistance of RVP successfully, and discharged with no complications. RVP procedure may benefit intracranial aneurysm patients.
All authors contributed to the study design, collected the data, performed the data analysis, and prepared the manuscript.
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