Ragulojan Malavan, Krolczyk Gregory, Al Aufi Safa, Wang Alick P, McIsaac Daniel I, Hicks Shawn, Sinclair John, Budiansky Adele S
Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada.
Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON.
J Neurosurg Anesthesiol. 2025 Jul 1;37(3):288-295. doi: 10.1097/ANA.0000000000000988. Epub 2024 Aug 27.
Multiple strategies exist to facilitate microdissection and obliteration of intracranial aneurysms during microsurgical clipping. Rapid ventricular pacing (RVP) can be used to induce controlled transient hypotension to facilitate aneurysm manipulation. We report the indications and outcomes of intraoperative RVP for clipping of ruptured and unruptured complex aneurysms.
We completed a retrospective review of adult patients who underwent RVP-facilitated elective and emergent microsurgical aneurysm clipping by a single senior neurosurgeon between 2016 and 2023. Intraoperative RVP was performed at a rate of 150 to 200 beats per minute through a transvenous pacing wire and repeated as needed based on surgical requirements. Intraoperative procedural and pacing data and perioperative cardiac and neurosurgical variables were collected.
Forty patients were included in this study. The median (interquartile range) number of pacing episodes per patient was 8 (5 to 14), resulting in a median mean arterial pressure of 37 (30 to 40) mm Hg during RVP. One patient developed wide complex tachycardia intraoperatively, which resolved after cardioversion. Fifteen out of 36 (42%) patients who had postoperative troponin measurements had at least one troponin value above the 99th percentile upper reference limit. One patient had markedly elevated troponin with anterolateral ischemia in the context of massive postoperative intracranial hemorrhage. There were no other documented intraoperative or postoperative cardiac events.
This retrospective case series suggests that RVP could be an effective adjunct for clipping of complex ruptured and unruptured aneurysms, associated with transient troponin rise but rare postoperative cardiac complications.
在显微外科夹闭颅内动脉瘤的过程中，有多种策略可用于促进动脉瘤的显微分离和闭塞。快速心室起搏（RVP）可用于诱导控制性短暂低血压，以利于动脉瘤的操作。我们报告了术中RVP用于夹闭破裂和未破裂复杂动脉瘤的适应证及结果。
我们对2016年至2023年间由一位资深神经外科医生进行的RVP辅助下择期和急诊显微外科动脉瘤夹闭的成年患者进行了回顾性研究。术中通过经静脉起搏导线以每分钟150至200次的速率进行RVP，并根据手术需要重复进行。收集术中操作和起搏数据以及围手术期心脏和神经外科变量。
本研究纳入了40例患者。每位患者起搏发作的中位数（四分位间距）为8次（5至14次），导致RVP期间平均动脉压中位数为3�（30至40）mmHg。1例患者术中出现宽QRS波心动过速，复律后缓解。在36例进行术后肌钙蛋白测量的患者中，15例（42%）至少有一次肌钙蛋白值高于第99百分位数的参考上限。1例患者在术后大量颅内出血的情况下，肌钙蛋白明显升高并伴有前外侧心肌缺血。没有其他记录在案的术中或术后心脏事件。
这个回顾性病例系列表明，RVP可能是夹闭复杂破裂和未破裂动脉瘤有效的辅助手段，与肌钙蛋白短暂升高相关，但术后心脏并发症罕见。
