Author: Budiansky AS et al.
Journal of Neurosurgical Anesthesiology 37(4):335–340, October 2025. doi:10.1097/ANA.0000000000001046
This focused review examined the principal techniques for temporary blood flow reduction during complex neurovascular procedures. Historically, deep hypothermic circulatory arrest (DHCA) provided a bloodless surgical field but carried prohibitive morbidity and mortality, making it largely obsolete. Intravenous adenosine remains a commonly used method due to ease of administration and rapid onset, though interindividual variability and risks of arrhythmia or bronchospasm limit predictability.
Rapid ventricular pacing (RVP) has emerged as a reliable alternative, offering precise, controlled hypotension with immediate recovery, but requiring advance planning and specialized expertise. Endovascular balloon-assisted occlusion provides localized control in anatomically challenging lesions and can be combined with systemic techniques during hybrid procedures. No single technique has shown clear superiority; choice depends on lesion characteristics, institutional resources, and multidisciplinary expertise. The review emphasizes the need for individualized strategies and further prospective data to refine safety, efficacy, and potential neuroprotective adjuncts.
What You Should Know
• Flow reduction is essential in managing aneurysms, AVMs, and other complex neurovascular lesions.
• DHCA is nearly obsolete due to high perioperative morbidity and mortality.
• Adenosine is simple and accessible but unpredictable in response.
• RVP offers precise control and predictability, though requires advanced planning.
• Endovascular balloon-assisted occlusion provides localized control in complex anatomical sites.
• No technique is universally superior — strategies should be individualized.
References
American Heart Association/American Stroke Association
2023 Guideline for Management of Aneurysmal Subarachnoid Hemorrhage. Stroke. 2023;54:e10–e58.
Bebawy JF, Gupta DK, Bendok BR, et al.
Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile. Anesth Analg. 2010;110:1406–1411.
Waqas M, Vakharia K, Dossani RH, et al.
Rapid ventricular pacing for flow reduction during neuroendovascular procedures: case series and literature review. J Neurointerv Surg. 2021;13:672–676.
Thank you to the Journal of Neurosurgical Anesthesiology for making this work available.