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A case report on middle cerebral artery aneurysm

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.
Abbreviations: ASA = American Society of Anesthesiologists, CCTA = coronary CT angiography, DSA = digital subtraction
angiography, GCS = Glasgow Coma Score, ICG = indocyanine green, MCA = middle cerebral artery, MRI = magnetic resonance
imaging, NYHA = New York Heart Association, PACU = post-anesthesia care unit, RVP = rapid ventricular pacing.
Keywords: case report, cerebral aneurysm, intraoperative aneurysm rupture, rapid ventricular pacing

1. Introduction

Editor: N/A.
Cerebral aneurysm is a common cause of intracranial hemor-
rhage, stroke, and death.[1] Rupture of aneurysm is a devastating
Ethics approval and consent to participate: Ethical approval was given by the
Ethics Committee of Huashan Hospital Fudan University, Shanghai, China. event with a high mortality. Treatment of cerebral aneurysm is
Informed written consent was obtained from the patient for publication of this mainly by two procedures under current clinical practice.[2] The
case report and accompanying images. first procedure is coil embolism, in which platinum coil is inserted
Consent for publication: Not applicable. into the lumen of the aneurysm, and a local thrombus then forms
Availability of data and material: The datasets used and/or analyzed during the around the coil, obliterating the aneurysmal sac.[3] The second
current study are all in the manuscript. one is surgical clipping which involves craniotomy and placement
The authors have no funding and conflicts of interest to disclose. of a clip on the blood vessel to exclude the weakened area. Both
Department of Anesthesiology, Huashan Hospital Fudan University, Shanghai, procedures are associated with different complications. For
China. example, coil embolism may lead to development of thrombo-
∗
Correspondence: Huahua Gu, Department of Anesthesiology, Huashan Hospital embolism,[4] and intraprocedural aneurysmal rupture.[5] The
Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China complications of surgical clipping include new or worse
(e-mail: [email protected]).
neurologic deficits caused by brain retraction, temporary arterial
Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc. occlusion, and intraoperative hemorrhage.[6–8] However, more
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-
and more clinical data support that surgical clipping has better
ND), where it is permissible to download and share the work provided it is safety and efficacy than coil embolism for treating unruptured
properly cited. The work cannot be changed in any way or used commercially MCA aneurysms.[9]
without permission from the journal. Rapid ventricular pacing (RVP) has been used in many
Medicine (2018) 97:48(e13320) cardiovascular surgeries as a reliable technique to control heart
Received: 28 June 2018 / Accepted: 24 October 2018 rate (HR) and blood pressure (BP). RVP enforces that ventricular
http://dx.doi.org/10.1097/MD.0000000000013320 tachycardia and ventricular filling are compromised because of

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the high HR and absent atrioventricular synchrony. Thus, Anesthesiologists (ASA) classification was grade I. The patient
reduced stroke volume and cardiac output lead to decreased BP. had normal ECG, pulmonary function, echocardiography,
Recently, there were several reports of using RVP in the surgery Holter, and coronary CT angiography (CCTA) tests.
to treat cranial aneurysms.[10–13] There are no major safety issues Considering the size of this MCA aneurysm was large, and
in those reports. However, because this procedure requires patient had good cardiac and pulmonary functions, it was
extensive preoperative cardiological workup of the patient and therefore decided to use RVP to reduce BP during MCA
an experienced neurosurgery and neuroanesthesiology team with aneurysm repair, and to lower the risk of intracranial hemorrhage
much cerebrovascular expertise, actually it remains reserved for during procedure.
selected elective cases and highly specialized centers.
Here we presented a case report of a patient with large MCA
aneurysm. The risk of aneurysm rupture in this patient is 3. Therapeutic intervention
relatively high due to the size of lesion. Since RVP has been used 3.1. Anesthesia procedure, probe placement, and RVP
to reduce BP during aneurysm repairs successfully,[10–13] the
testing
preoperative cardiological evaluation of this patient supported us
to choose RVP procedure to reduce the risk of intraoperative General anesthesia was performed by a team consisting of an
aneurysm rupture. anesthesiologist and nurses with experience in cardiac
intervention and surgery. The patient was given 1 mg
midazolam, 0.5 g fentanyl, 1.0 mg/mL propofol (target-con-
2. Patient information and clinical findings
trolled infusion), and levetiracetam to induce anesthesia. The
The patient was a 46-year-old man. He had intermittent right- respiratory rate and cardiac function were closely monitored.
side headache for 5 years, and he complained left lower limb Local anesthesia was performed by injecting 2% lidocaine
numbness for 3 months. Physical examination found no sensory around left radial artery. A 4-French introducer sheath was
loss in both upper and lower extremities. The patient had normal placed in radial artery to set up A-line. On examination, the BP
muscle tone and deep tendon reflex. Magnetic resonance imaging was 106/56 mm Hg, HR was 56 bpm, and oxygen saturation
(MRI) of the head, performed without the administration of was 99%. A 6Fr catheter was put into left axillary vein under
intravenous contrast material, revealed an aneurysm at right ultrasound guidance to set up C-line. A 5Fr flow directed
MCA M1 segment, (5  4  4 cm3) (Fig. 1). Digital subtraction pacing catheter was inserted into right ventricle, and the probe
angiography (DSA) confirmed the diagnosis of right MCA was inserted around 45 cm and reached the right ventricular
aneurysm (Fig. 2). apex. Correct positioning of the pacing electrode was
The patient had no history of hypertension, diabetic mellitus, confirmed via continuous ECG monitoring under pacer
and coronary artery disease. New York Heart Association stimulation with a low pacing threshold. External defibrillation
(NYHA) classification was grade I, and American Society of pads were placed on the chest wall.

Figure 1. Head CT scan and MRI of patient before surgery. (A–B) Head CT scan. Right temporal area has a high-dense round lesion. The edge of lesion is sharp
and no sign of edema. (C–D) Head MRI contrast-enhanced T1-weighted scan. The lesion has strong signal in contrast-enhanced T1-weighted MRI, suggesting it
may be an aneurysm. (E–F) Head MRI T2-weighted. (G–H) Head MRI T1-weighted. MRI = magnetic resonance imaging.

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Figure 2. Digital subtraction angiography (DSA) confirmed the MCA aneurysm. MCA = middle cerebral artery.

3.2. Surgical procedure RVP significantly reduced the tension of aneurysm when
The patient was put in supine position, and his head was turn isolating the MCA M1 fragment, and decreased the risk of
toward left side around 20°. Cut skin and temporalis, and rupture. Once the aneurysm was fully exposed, we induced
exposed frontal bone and temporal bone, and opened a window another two episodes of RVP to clip the aneurysm. Intra-
in this area. Incised the dura, and started to dissect the aneurysm. operatively, indocyanine green (ICG) video angiography was
When the aneurysm was fully exposed, the RVP was started to used to verify aneurysm occlusion as well as parent vessel
reduce BP. RVP was induced totally four times during the entire perfusion after each clip placement.
procedure. Twice was induced when isolating aneurysm and The patient was in very stable condition during the entire
twice was started during clip placement. The first RVP lasted 120 procedure. No vasoactive and anti-arrhythmia drugs were used,
s and maximum HR was 130 bpm, and lowest BP reached 58/38 and no adjustment of doses of fentanyl and propofol as well. The
mm Hg. The second RVP lasted 50 s, and maximum HR was 150 MCA aneurysm was clipped successfully. The temporary pacing
bpm, and lowest BP reached 39/21 mm Hg. The third RVP lasted was removed after the surgery. The surgery lasted 6 h and 40 min,
50 s, and the maximum HR was 160 bpm, and lowest BP reached and total RVP time was less than 5 min.
29/26 mm Hg. The last RVP lasts 50 s and the maximum HR was
165 bpm, and the lowest BP reached 28/23 mmHg (Fig. 3). There
3.3. Follow-up and outcomes
were at least 3 min gap period between each RVP episodes. Every
time RVP was induced, the HR reached the maximum HR in 5 s, The patient was transferred to post-anesthesia care unit (PACU)
and the average BP dropped to the lowest level. After that the BP for observing around 2.5 h. After the patient woke up and the
increased gradually in 50 s, and eventually it reached to 58%– Glasgow Coma Score (GCS) was more than 6, the patient was
80% of BP before RVP induction. transferred to ICU. CT scan confirmed no intracranial bleeding,

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Figure 3. Record of vital sign monitoring during procedure. a, b, c, and d indicated four RVP during surgery. RVP = rapid ventricular pacing.

and there were no arterial blood gas changes during or after RVP, factors, BP is the only factor that can be managed in current
compared with before RVP. The biomarkers for cardiac muscle clinical practice.
damages, including CK-MB, troponin T, and ProBNP, were Adenosine-induced temporary cardiac arrest was widely used
increased at 24 h after surgery (Table 1). Seven weeks after to lower BP in many cardiovascular surgeries. It was also used to
surgery, the patient was fully conscious and cooperative. Muscle control BP in the intracranial aneurysm surgery.[20] A study
tone of right side extremities were grade V and left side found that patients whom induced temporary cardiac arrest
extremities were grade IV. CTA confirmed no MCA aneurysm during intracranial aneurysm repair needed less time to clipping,
(Fig. 4), and the patient was discharged. and slightly less intraoperative aneurysm rupture.[20] This result
supported that inducing temporary cardiac arrest was benefit to
patients with aneurysm repair. However, adenosine may have
4. Discussion
safety issues, as some patients may response to adenosine
Intracranial aneurysm is a life-threatening condition that usually differently, and patients who are sensitive to adenosine may be
starts with little symptoms for years. And many patients only overdosed. Second, the duration of cardiac arrest and amplitude
have sudden-onset symptoms when the aneurysm is ruptured.
The mortality rate of ruptured intracranial aneurysm is very
high.[14] The intracranial aneurysm is mainly managed surgically
by coil embolism or clipping. However, surgery itself is a risk
factor for aneurysm rupture,[15] 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

Table 1
Level of cardiac biomarkers before and after RVP.
Before RVP After RVP
Biomarkers 2h 4h 24 h Reference
ProBNP <100 53.9 55.4 188.4↑ <100 (pg/mL)
Myoglobulin <21 200.7↑ 943.7↑ 125↑ 28–72 (ng/mL)
CK-MB 0.46 1.17 7.28↑ 9.35↑ <4.87 (ng/mL)
Troponin T <0.01 <0.01 <0.01 <0.01 0.013–0.025 (ng/mL) Figure 4. Computed tomography angiography confirmed the MCA aneurysm
is clipped. MCA = middle cerebral artery.
CK-MB = creatine kinase isoenzyme MB, ProBNP = pro b-type natriuretic peptide.

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of blood pressure decrease was difficult to control when induced treatment complications in a series of 782 patients (CLARITY study).
Radiology 2010;256:916–23.
by adenosine.[21]
[5] Elijovich L, Higashida RT, Lawton MT, et al. Predictors and outcomes of
RVP became a safer alternative to adenosine to control BP in intraprocedural rupture in patients treated for ruptured intracranial
many cardiac surgeries.[22–24] RVP enforced ventricular tachy- aneurysms: the CARAT study. Stroke 2008;39:1501–6.
cardia and the ventricular filling was compromised because of the [6] Andrews RJ, Bringas JR. A review of brain retraction and recommen-
high HR and absent atrioventricular synchrony. Thus, reduced dations for minimizing intraoperative brain injury. Neurosurgery
1993;33:1052–63.
stroke volume and cardiac output lead to decreased BP. RVP had [7] Samson D, Batjer HH, Bowman G, et al. A clinical study of the
better control over the duration and amplitude of blood pressure parameters and effects of temporary arterial occlusion in the manage-
than adenosine. In addition to general cardiovascular surgeries, ment of intracranial aneurysms. Neurosurgery 1994;34:22–8.
recently RVP has been used to control BP during intracranial [8] Fridriksson S, Saveland H, Jakobsson KE, et al. Intraoperative
complications in aneurysm surgery: a prospective national study. J
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Neurosurg 2002;96:515–22.
The benefits of RVP include: reducing the amount of bleeding [9] Alreshidi M, Cote DJ, Dasenbrock HH, et al. Coiling versus
and providing a clean surgical area; reducing the tension of microsurgical clipping in the treatment of unruptured middle cerebral
aneurysm, which will decrease the chance of rupture during artery aneurysms: a meta-analysis. Neurosurgery 2018;83:879–89.
surgical isolation and clipping; and in cases of aneurysm rupture, [10] Konczalla J, Platz J, Fichtlscherer S, et al. Rapid ventricular pacing for
clip reconstruction of complex unruptured intracranial aneurysms:
RVP will induce a transient “very-low pressure” condition, and results of an interdisciplinary prospective trial. J Neurosurg
give a valuable time frame to clip the ruptured aneurysm. 2018;128:1741–52.
Therefore, RVP is a safe and effective method to provide transient [11] Nimjee SM, Smith TP, Kanter RJ, et al. Rapid ventricular pacing for a
reduction of cardiac output. basilar artery pseudoaneurysm in a pediatric patient: case report. J
Neurosurg Pediatr 2015;15:625–9.
The complications of RVP usually are related with pacing probes,
[12] Khan SA, Berger M, Agrawal A, et al. Rapid ventricular pacing
such as penetration of heart, cardiac tamponade, pneumothorax, assisted hypotension in the management of sudden intraoperative
and ventricular tachycardia. Therefore, it is suggested to thoroughly hemorrhage during cerebral aneurysm clipping. Asian J Neurosurg
evaluate patients’ cardiac function, for example, Holter to exclude 2014;9:33–5.
the sinus malfunctions, coronary computed tomography angiogra- [13] Whiteley JR, Payne R, Rodriguez-Diaz C, et al. Rapid ventricular pacing:
a novel technique to decrease cardiac output for giant basilar aneurysm
phy to exclude coronary artery disease, and echocardiogram to surgery. J Clin Anesth 2012;24:656–8.
exclude valve-related disease. Defibrillator and anti-arrhythmia [14] Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med
drugs should be prepared before performing RVP. 2006;355:928–39.
In summary, here we presented a patient with large MCA [15] Estevao IA, Camporeze B, Araujo ASJr, et al. Middle cerebral artery
aneurysms: aneurysm angiographic morphology and its relation to pre-
aneurysm, and he was treated with aneurysm clipping with the
operative and intra-operative rupture. Arq Neuropsiquiatr 2017;75:523–32.
assistance of RVP successfully, and discharged with no complica- [16] Park YK, Yi HJ, Choi KS, et al. Intraprocedural rupture during
tions. RVP procedure may benefit intracranial aneurysm patients. endovascular treatment of intracranial aneurysm: clinical results and
literature review. World Neurosurg 2018;e605–15.
[17] Talari S, Kato Y, Shang H, et al. Comparison of computational fluid
Author contributions dynamics findings with intraoperative microscopy findings in unruptured
intracranial aneurysms: an initial analysis. Asian J Neurosurg 2016;11:
All authors contributed to the study design, collected the data, 356–60.
performed the data analysis, and prepared the manuscript. [18] Kadasi LM, Dent WC, Malek AM. Cerebral aneurysm wall thickness
Conceptualization: Huahua Gu. analysis using intraoperative microscopy: effect of size and gender on
Data curation: Yi Ping, Huahua Gu. thin translucent regions. J Neurointerv Surg 2013;5:201–6.
[19] Suzuki T, Takao H, Suzuki T, et al. Determining the presence of thin-
Formal analysis: Yi Ping, Huahua Gu. walled regions at high-pressure areas in unruptured cerebral
Investigation: Yi Ping. aneurysms by using computational fluid dynamics. Neurosurgery
Writing – original draft: Yi Ping, Huahua Gu. 2016;79:589–95.
Writing – review & editing: Huahua Gu. [20] Intarakhao P, Thiarawat P, Rezai Jahromi B, et al. Adenosine-induced
cardiac arrest as an alternative to temporary clipping during intracranial
aneurysm surgery. J Neurosurg 2017;129:1–7.
[21] Fishberger SB, Mehta D, Rossi AF, et al. Variable effects of adenosine on
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