Adenosine‐induced transient hypotension for carotid artery injury during endoscopic skull‐base surgery: case report and review of the literature

Abstract

BackgroundAs the management of ventral skull‐base pathology has transitioned from open to endonasal treatment, there has been an increased focus on the prevention and endoscopic endonasal management of internal carotid artery (ICA) and major vascular injury. The use of adenosine to induce transient hypotension or flow arrest has been previously described during intracranial aneurysm surgery; however, there have been no reports of the technique being used during endonasal skull‐base surgery to achieve hemostasis following major vascular injury.MethodsCase report (n = 1) and literature review.ResultsA 25‐year‐old female underwent attempted endoscopic endonasal resection of an advanced right‐sided chondrosarcoma. During resection of the tumor, brisk arterial bleeding was encountered consistent with focal injury to the right cavernous ICA. Stable vascular hemostasis could not be achieved with tamponade. An intravenous bolus dose of adenosine was administered to induce a transient decrease in systemic blood pressure and facilitate placement of the muscle patch over the direct site of vascular injury. The patient subsequently underwent endovascular deconstruction of the right ICA.ConclusionThis is the first reported use of adenosine to induce transient hypotension for a major vascular injury sustained during endonasal skull‐base surgery. Based on well‐established safety data from neurosurgical application, adenosine has the potential to be used as a safe and effective adjunctive technique in similar endonasal circumstances and may represent an additional tool in the armamentarium of the skull‐base surgeon. Surgeons should consider having adenosine available when a risk of ICA injury is anticipated.

Use of Adenosine to Facilitate Localization and Repair of Internal Carotid Artery Injury during Skull Base Surgery: A Case Report and Literature Review

“…[17][18][19][20][21] Fastenberg et al noted 60s of hypotension with significantly reduced dosing of 0.056 mg/kg. 15 This is contrasted with our patient who required a nearly ten-fold larger dose of 0.42 mg/kg and experienced approximately 180s of hypotension. The exact reason for such varied effective dosing between our two cases remains unclear.…”

“…Fastenberg and colleagues recently published their report of utilization of adenosine to facilitate visualization and repair of an ICA injury encountered during EESBS. 15 It should be noted risk factors for ICA injury were present in both our case (patient undergoing revision surgery via an expanded endonasal approach, parasellar tumor involvement) and Fastenberg’s case (tumor mass effect on ICA). Furthermore, significant blood loss was encountered in both cases and ultimately, adenosine proved an integral measure for achieving hemostasis.…”

“…26 No side effects nor significant reflex hemodynamic derangements were encountered as consequence of adenosine administration in either our or Fastenberg's cases. 15 To the best of our knowledge, our case represents the second application of adenosine in the setting of carotid injury during EESBS. Given their rarity, amounting a large body of prospective data on ICA injury and adenosine use is challenging.…”

“…26 No side effects nor significant reflex hemodynamic derangements were encountered as consequence of adenosine administration in either our or Fastenberg’s cases. 15…”

Apohemoglobin-haptoglobin complexes attenuate the hypertensive response to low-molecular-weight polymerized hemoglobin

“…7 Although effective at controlling systemic hypertension, administration of adenosine and nitroglycerin must be carefully controlled to prevent hypotension. 15,16 Instead, we propose that using naturally occurring mechanisms of Hb detoxification is a potential strategy to mitigate systematic hypertension resulting from the presence of LMW PolyHb in the circulation. The naturally occurring Hb-scavenging protein, haptoglobin (Hp), plays a pivotal role in detoxifying stroma-free Hb in the blood.…”