A case report on middle cerebral artery aneurysm treated by rapid ventricular pacing

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Abstract

Rationale:

Cerebral aneurysm is a common cause of intracranial hemorrhage, stroke, and death. It is treated with vascular surgeries, such as coil embolism and artery clipping. However, surgery itself is a risk factor that may cause rupture of aneurysm, and leads to irreversible brain damage, and even death. Rapid ventricular pacing (RVP) is a procedure that temporarily lowers blood pressure by increasing heart rate and reducing ventricular filling time. RVP has been widely used to reduce blood vessel tension in many cardiovascular surgeries.

Patient concerns:

A 46-year-old man came to our hospital with intermittent right-side headache for 5 years, and left lower limb numbness for 3 months.

Diagnoses:

Magnetic resonance imaging (MRI) of the head and digital subtraction angiography confirmed the diagnosis of right middle cerebral artery (MCA) aneurysm.

Interventions:

Considering the large size of this MCA aneurysm, RVP was used to reduce blood pressure during MCA aneurysm repair, and to lower the risk of intracranial hemorrhage during procedure.

Outcomes:

Post procedure, there was no abnormality detected. Seven weeks after surgery, the patient's muscle tone of right side extremities were grade V and left side extremities were grade IV. Computed tomography angiography confirmed no MCA aneurysm.

Lessons:

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 in intracranial aneurysm patients.

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Most cited references 23

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Cerebral aneurysms.

J Brisman, Evan Newell, J. Song (2006)

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Ruptured intracranial aneurysms: factors affecting the rate and outcome of endovascular treatment complications in a series of 782 patients (CLARITY study).

F Ricolfi, Laurent Pierot, Christophe Cognard … (2010)

To analyze the clinical and anatomic factors that affect the occurrence and outcome of complications (thromboembolic events and intraoperative rupture) in the endovascular treatment of ruptured intracranial aneurysms in a large multicenter series, the CLARITY study (Clinical and Anatomic Results in the Treatment of Ruptured Intracranial Aneurysms). This study was approved by the institutional review boards of the participating centers, and written informed consent was obtained from all patients. In the CLARITY series, 782 patients (314 men, 468 women; age range, 19-80 years, mean age, 51.3 years +/- 13.2 [standard deviation]) with 782 ruptured aneurysms underwent endovascular treatment for ruptured intracranial aneurysms at 20 institutions. Uni- and multivariate analyses were performed to determine factors (demographic characteristics, risk factors, anatomic factors, and therapeutic factors) that affect the occurrence of treatment-related complications. A higher rate of thromboembolic events was observed in patients with aneurysms larger than 10 mm (28.0% vs 10.7% in patients with aneurysms < or =10 mm, P < .001), in smokers (16.1% vs 10.1% in nonsmokers, P = .015), and in patients with aneurysms with a neck larger than 4 mm (20.8% vs 11.0% in aneurysms with a neck < or =4 mm, P = .004).The frequency of intraoperative rupture was higher in patients with middle cerebral artery (MCA) aneurysms (8.5% vs 3.7% in patients without MCA aneurysms, P = .029), in patients younger than 65 years (5.0% vs 0.8% in patients older than 65 years, P = .032), and in patients without hypertension (5.4% vs 1.5% in patients with hypertension, P = .017). The rate of thromboembolic events in the endovascular treatment of ruptured aneurysms is significantly affected by aneurysm size and neck size but not by aneurysm location. Conversely, the rate of intraoperative rupture is significantly affected by aneurysm location but not aneurysm size.

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Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study.

Lucas Elijovich, Steven Giannotta, Michael Lawton … (2008)

Intraprocedural rupture (IPR) is a well known complication of intracranial aneurysm treatment. Risks and predictors of IPR and its impact on outcome have not been clearly established. Potential predictors of IPR were evaluated in patients treated in the Cerebral Aneurysm Rerupture After Treatment (CARAT) study using multivariate logistic regression with stepwise elimination stratified by treatment modality. Periprocedural death or disability was defined as death or a change of >or=2 points on the Modified Rankin Scale at discharge compared to before treatment. IPR occurred in 14.6% of 1010 patients (299 coiled, 711 clipped): 19% with clipping and 5% with coiling (P<0.001). Among those clipped, 31% with IPR had periprocedural death or disability compared to 18% without IPR (P=0.001); among those coiled, 63% with IPR had periprocedural death or disability compared to 15% without IPR (P<0.001). Overall, coronary artery disease and initial lower Hunt and Hess Grade were independent predictors of IPR. For those undergoing coiling, independent predictors of IPR were Asian race, black race, COPD, and lower initial Hunt and Hess Grade. Among those undergoing clipping, hyperlipidemia and lower initial Hunt and Hess Grade were both independent predictors of IPR. IPR was common in patients undergoing treatment of ruptured aneurysms, particularly with surgical clipping. The frequency of IPR with new disability was similar in the surgical and endovascular treatment groups. Coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess Grade were associated with greater risk of IPR, which may reflect differences in vessel fragility but requires further confirmation.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: November 2018

Publication date (Electronic): 30 November 2018

Volume: 97

Issue: 48

Electronic Location Identifier: e13320

Affiliations

Department of Anesthesiology, Huashan Hospital Fudan University, Shanghai, China.

Author notes

[∗ ]Correspondence: Huahua Gu, Department of Anesthesiology, Huashan Hospital Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China (e-mail: 13918121092@ 123456163.com ).

Article

Publisher ID: MD-D-18-04467 Accession ID: 13320

DOI: 10.1097/MD.0000000000013320

PMC ID: 6283198

PubMed ID: 30508924

SO-VID: 99d44ce3-42cf-429d-bd00-8cb2bf7d4303

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

History

Date received : 28 June 2018

Date accepted : 24 October 2018

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Keywords: case report,cerebral aneurysm,intraoperative aneurysm rupture,rapid ventricular pacing

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Keywords: case report, cerebral aneurysm, intraoperative aneurysm rupture, rapid ventricular pacing

A case report on middle cerebral artery aneurysm treated by rapid ventricular pacing : A CARE compliant case report

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Abstract

Rationale:

Patient concerns:

Diagnoses:

Interventions:

Outcomes:

Lessons:

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ScienceOpen Clinical Case Reports Collection

Most cited references 23

Cerebral aneurysms.

Ruptured intracranial aneurysms: factors affecting the rate and outcome of endovascular treatment complications in a series of 782 patients (CLARITY study).

Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study.

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