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Background Giant, previously coiled basilar tip aneurysms are difficult to cure. Case Description A 38-year-old woman with ruptured, giant, previously coiled basilar tip aneurysm was treated with clipping under hypothermic cardiac standstill and is doing excellently 15 years after surgery. Angiography did not show any recurrence. Conclusions Until endovascular treatment is proven on a long-term basis to cure similar aneurysms, surgery should remain an option.

We report a case of revascularization of the right coronary artery via the epicardial collateral, for which we used transcoronary rapid pacing to obtain cardiac standstill while puncturing the distal chronic total occlusion (CTO) cap. To our knowledge, this is the first case in which this technique has been used in CTO. (Level of Difficulty: Advanced.), Graphical abstract, We report a case of revascularization of the right coronary artery via the epicardial collateral, for which we used transcoronary rapid pacing to…

Vein of Galen malformations are congenital high-flow vascular malformations that often present with heart failure, hydrocephalus, developmental delay, and intracranial hemorrhage. Because open surgical treatment is associated with high morbidity and mortality, endovascular embolization is increasingly becoming the preferred method of intervention. However, embolization of these lesions can be difficult because of their high-flow nature. The use of adenosine-induced cardiac standstill for treatment of vein of Galen malformations has not been previously described in neonates. The authors describe 3 treatments in 2 patients that demonstrate that the use of adenosine is well tolerated and allows safe transarterial embolization of high-flow vein of Galen malformations in the pediatric population.

Background Potential cardiovascular benefits of precordial percussion pacing (PPP) during cardiac standstill are unknown.Methods and Results:A cardiac standstill model in amicrominipigwas created by inducing complete atrioventricular block with a catheter ablation technique (n=7). Next, the efficacy of cardiopulmonary resuscitation by standard chest compressions (S-CPR), PPP and ventricular electrical pacing in this model were analyzed in series (n=4). To assess the mechanism of PPP, a non-selective, stretch-activated channel blocker, amiloride, was administered during PPP (n=3). Peak systolic and diastolic arterial pressures during S-CPR, PPP and ventricular electrical pacing were statistically similar. However, the duration of developed arterial pressure with PPP was comparable to that with ventricular electrical pacing, and significantly greater than that with S-CPR. Amiloride decreased the induction rate of ventricular electrical activity by PPP in a dose-related manner. Each animal survived without any neurological deficit at 24, 48 h and 1 week, even with up to 2 h of continuous PPP. Conclusions In amicrominipigmodel of cardiac standstill, PPP can become a novel means to significantly improve physiological outcomes after cardiac standstill or symptomatic bradyarrhythmias in the absence of cardiac pacing. Activation of the non-selective stretch-activated channels may mediate some of the mechanophysiological effects of PPP. Further study of PPP by itself and together with S-CPR is warranted using cardiac arrest models of atrioventricular block and asystole.

Patients with cardiac arrest present as a relatively frequent occurrence in the Emergency Department. Despite the advances in our understanding of the pathophysiology of cardiac arrest, managing the condition remains a stressful endeavor and currently implemented interventions, while beneficial, are still associated with a disappointingly low survivability. The majority of modern Advanced Life Support algorithms employ a standardized approach to best resuscitate the ‘crashed’ patient. However, management during resuscitation often encourages a ‘one-size-fits-all’ policy for most patients, with lesser attention drawn towards causality of the disease and factors that could alter resuscitative care. Life support providers are also often challenged by the limited bedside predictors of survival to guide the course and duration of resuscitation. Over the recent decades, point-of-care ultrasonography (PoCUS) has been gradually proving itself as a useful adjunct that could potentially bridge the gap in the recognition and evaluation of precipitants and end-points in resuscitation, thereby facilitating an improved approach to resuscitation of the arrested patient. Point-of-care ultrasound applications in the critical care field have tremendously evolved over the past four decades. Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process. This article reviews the current literature on cardiac standstill and the application of bedside ultrasound in cardiac arrests.

This case describes and depicts cardiac standstill with thrombosed blood within the chambers of the heart. This was likely due to stasis of blood from a prolonged no-flow state. After viewing this ultrasound finding, the decision was made to halt resuscitative efforts in this case of a patient in cardiac arrest.

During cardiopulmonary resuscitation, pulse checks must be rapid and accurate. Despite the importance placed on the detection of a pulse, several studies have shown that health care providers have poor accuracy for detection of central pulses by palpation. To date, the use of point-of-care ultrasound (POCUS) in cardiac arrest has focused on the presence of cardiac standstill and diagnosing reversible causes of the arrest.This case series highlights a simple, novel approach to determine whether pulses are present or absent by using POCUS compression of the central arteries.Using this technique, we found that a POCUS pulse check can be consistently performed in5 s and is clearly determinate, even when palpation yields indeterminate results.In this case series, the POCUS pulse check was a valuable adjunct that helped to change management for critically ill patients. Future prospective studies are required to determine the accuracy of this technique and the impact on patient outcomes in a larger cohort.

Transient cardiac standstill is a complementary procedure used with microsurgery to treat patients with particularly complex aneurysms, such as large or giant cerebral aneurysms. These procedures allow the aneurysms to be decompressed while maintaining a bloodless field and increased surgical exposure. Deep hypothermia combined with circulatory arrest provides cerebroprotection with optimal surgical conditions. However, its disadvantage is the relatively high risk of the procedure, which requires extensive expertise and infrastructure. Thus, its use is typically limited to patients with complex posterior circulation aneurysms. Adenosine-induced transient asystole is an easily applied technique in a variety of clinical situations. Its use requires minimal advanced preparation and no complex logistical coordination with other subspecialties. However, patient-specific dose-response relationships must be determined by exposure, so the relationship may not be known in an emergent situation. Persistent hypotension is a potentially major complication. Rapid ventricular pacing (RVP) has recently been reintroduced into cerebrovascular surgery. It is more predictable than adenosine in response time and, thus, can be used during unanticipated complications, such as aneurysmal rupture. It also induces a shorter period of hypotension compared with adenosine. However, RVP is more invasive and more complex from an anesthesia standpoint. Vascular neurosurgeons should be familiar with these techniques and know their applications and limitations.

AimsPaediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients.MethodsAn online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy.Results73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrest and the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation.ConclusionThis study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians.

Transvenous embolization (TE) has been increasingly applied for arteriovenous malformation (AVM) treatment. Transient cardiac standstill (TCS) has been described in cerebrovascular surgery but is uncommon for endovascular embolization. The authors present a patient with a ruptured thalamic AVM in whom both techniques were applied simultaneously. Surgery was considered, but the patient refused. Transarterial embolization was performed with an incomplete result. The deep-seated draining vein provided sole access to the AVM. A microcatheter was advanced into the draining vein. Under TCS, achieved with rapid ventricular pacing, complete AVM embolization was obtained. One-year magnetic resonance imaging and cerebral angiography demonstrated no residual AVM.The video can be found here: https://youtu.be/CAzb9md_xBU.

In pacemaker practice the occurrence of atrial / ventricular leads switch at the pacemaker box header is very rare and may cause confusion and possibly serious complications as failure of pacing and probably cardiac standstill, recognizing and managing this complication is highly vital for patient safety and even survival.

Intraoperative cerebral aneurysmal re-bleeding has a deleterious effect that is associated with high mortality and morbidity. Neurosurgeons and anesthesiologists should be familiar with all methods including hypothermia, cardiopulmonary bypass, pharmacologically-induced hypotension and cardiac standstill to manage intraoperative aneurysmal rupture or clip complex aneurysms. Specifically, adenosine induced profound hypotension or cardiac arrest has been used recently. We present our experience with the use of adenosine during a case of incidentally developed intraoperative cerebral aneurysmal rupture.

Sonographic cardiac standstill during adult cardiac arrest is associated with failure to get to return to spontaneous circulation. This report documents three children whose cardiac function returned after standstill with extracorporeal membranous oxygenation (ECMO). Sonographic cardiac standstill may not predict cardiac death in children.

Background: Cardiac standstill may be observedduring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Managementstrategies to decompress the heart include left-sided vent (LSV) insertion orhigh flows without LSV. However, evidence that either method reduces mortalityor neurological injury is unknown. In this study, we reviewed the outcomes ofpatients treated for cardiac standstill during ECMO with high flows instead ofLSV placement. Methods: Among 189 patients who underwent VAECMO from 2010 to 2016, a total of 188 patients continued VA ECMO without LVSwhile on ECMO. Retrospective chartreviews were performed focusing on cardiac standstill while on ECMO. Cardiacstandstill was defined as non-pulsatile arterial line tracing 6–8 hours aftercorrections of metabolic abnormalities. Patients who developed cardiacstandstill were studied for the duration of cardiac standstill and theirclinical outcomes. Results: Twenty-two patients (12%) developedcardiac standstill during VA-ECMO. Nine (41%) survived ECMO therapy and 6 (27%)survived to discharge with full neurological recovery. Of the ECMO survivors,cardiac standstill was observed over 7 (range, 3–10) days and ECMO flow wasincreased by an average of 32%. Causes of death for non-ECMO survivors wereanoxic brain injury (3, 23%), ischemic stroke (4, 31%), hemorrhagic stroke (2,15%), sepsis (1, 7.7%), bleeding/disseminated intravascular coagulation (2,15%) and malignant arrhythmias (1, 7.7%). Cardiac standstill persisted untildeath in all non-survivors. Intraventricular thrombi developed duringstandstill in 6 patients (27%) and resolved in 3 patients after 5.7±3.5 days.Causes of death were related to pre-existing conditions and anticoagulationregimen, not thrombus formation. Survival of patients with and without thrombiwere similar (33% vs. 44%, P=0.999). Conclusions: High ECMO flow adjustments can be aneffective alternative to LSV as a method of decompressing the heart, withoutincreasing neurological complications. With this strategy, patients diagnosedwith cardiac arrest during ECMO have reasonable survival outcomes (40%).

Gerard Guiot (1912–1998) was one of the most renowned and innovative neurosurgeons of the 20th century. His pivotal and revolutionary role in advancing transsphenoidal surgery has been recorded in many historical vignettes, yet his outstanding contributions to the advancement of neurosurgery outside the confines of the sella have not been described in a detailed fashion. In this article, the authors discuss the life and achievements of Professor Guiot and present a comprehensive description of his contributions to the field of neurosurgery, including cerebrovascular, spine, craniofacial, stereotactic functional, and endoscopic surgery.

Since the first surgery for an intracranial aneurysm in 1931, neurological surgeons have long strived to determine the optimal methods of surgical correction. Significant challenges of aneurysm clipping include intraoperative rupture and complex dome morphology. Hypothermia, cardiopulmonary bypass, pharmacologically induced hypotension, and cardiac standstill are a few of the methodologies historically and currently employed in the management of these issues. In the 1980s, significant advances in pharmacology and anesthesiology led to the use of agents such as adenosine for chemically induced hypotension and eventually complete circulatory arrest. Since the institution of the use of these agents, the traditional methods of circulatory arrest under conditions of hypothermia and cardiopulmonary bypass have fallen out of favor. However, there still exists a subset of technically difficult aneurysms for which cardiac standstill, both chemical and hypothermic, remains a viable therapeutic option. In this paper, the authors describe the history of cardiac standstill by both hypothermic and chemically induced means as well as provide examples in which these techniques are still necessary.

The surgical treatment of posterior circulation aneurysms, particularly basilar apex aneurysms, remains one of the most technically challenging neurosurgical procedures. Deep hypothermic circulatory arrest, or cardiac standstill, provides a bloodless surgical field in which giant or complex aneurysms of the posterior fossa can be safely collapsed to increase exposure without risking rupture during dissection. Visualization of the perforators is improved as is the ability to dissect them free from the clip. As endovascular techniques have evolved and alternate surgical techniques have been adopted, the indications for cardiac standstill have decreased.

Patients presenting in cardiac arrest frequently have poor outcomes despite heroic resuscitative measures in the field. Many emergency medical systems have protocols in place to stop resuscitative measures in the field; however, further predictors need to be developed for cardiac arrest patients brought to the emergency department (ED). Objective: To examine the predictive value of cardiac standstill visualized on bedside ED echocardiograms during the initial presentations of patients receiving cardiopulmonary resuscitation (CPR). Methods: The study took place in a large urban community hospital with an emergency medicine residency program and a high volume of cardiac arrest patients. As part of routine care, all patients arriving with CPR in progress were subject to immediate and brief subxiphoid or parasternal cardiac ultrasound examination. This was followed by brief repeat ultrasound examination during the resuscitation when pulses were checked. A 2.5-MHz phased-array probe was used for imaging. Investigators filled out standardized data sheets. Examinations were taped for review. Statistical analysis included descriptive statistics, positive and negative predictive values, and likelihood ratios. Results: One hundred sixty-nine patients were enrolled in the study. One hundred thirty-six patients had cardiac standstill on the initial echocardiogram. Of these, 71 patients had an identifiable rhythm on monitor. No patient with sonographically identified cardiac standstill survived to leave the ED regardless of his or her initial electrical rhythm. Cardiac standstill on echocardiogram resulted in a positive predictive value of 100% for death in the ED, with a negative predictive value of 58%. Conclusions: Patients presenting with cardiac standstill on bedside echocardiogram do not survive to leave the ED regardless of their electrical rhythms. This finding was uniform regardless of downtime. Although larger studies are needed, this may be an additional marker for cessation of resuscitative efforts.

Emergency physicians and intensivists are increasingly utilizing capnography and bedside echocardiography during medical resuscitations. These techniques have shown promise in predicting outcomes in cardiac arrest, and no cases of return of spontaneous circulation in the setting of sonographic cardiac standstill and low end-tidal carbon dioxide have been reported. This case report illustrates an example of such an occurrence. Our aims are to report a case of return of spontaneous circulation in a patient with sonographic cardiac standstill, electrocardiographic pulseless electrical activity, and low end-tidal carbon dioxide tensions and to place the case in the context of previous literature on this topic. Case report and brief review of the literature. In 254 cases reported, no patient has survived in the setting of sonographic cardiac standstill and low end-tidal carbon dioxide tension, making the reported case unique. This case should serve to illustrate the utility and limitations of combined cardiac sonography and end-tidal carbon dioxide measurement in determining prognosis during cardiac arrest.

Surgical management of giant cerebral aneurysms remains a major technical challenge for modern neurosurgeons. Endovascular approaches for giant aneurysms does not provide an acceptable alternative to direct surgical approaches. The use of deep hypothermic circulatory arrest as an adjunct during clipping of complex giant aneurysms shows promise as a treatment for otherwise incurable lesions. Patient selection and techniques of circulatory arrest surgery are discussed.

General anesthesia, which is cerebral arrest, and its cohorts respiratory arrest and cardiac arrest, are not singular effects peculiar to certain gases, vapors, or drugs, but reflex phenomena which can be triggered singly or in combination by a variety of stimuli acting extra/intra-integumentarily.

Stab wounds to the heart can present without clinical evidence of injury. Echocardiography has been advocated as an alternative to subxyphoid exploration in these cases. We present a case in which two serial echocardiography exams missed a diagnosis. Electrocardiographic changes and elevation of serial troponin I levels suggested the diagnosis, which was confirmed by thoracoscopy. Repair was facilitated by use of adenosine cardiac standstill.

The diagnosis of brain death should be based on a simple premise. If every possible confounder has been excluded and all possible treatments have been tried or considered, irreversible loss of brain function is clinically recognized as the absence of brainstem reflexes, verified apnea, loss of vascular tone, invariant heart rate, and, eventually, cardiac standstill. This condition cannot be reversed – not even partly – by medical or surgical intervention, and thus is final. Many countries in the world have introduced laws that acknowledge that a patient can be declared brain-dead by neurologic standards. The U.S. law differs substantially from all other brain death legislation in the world because the U.S. law does not spell out details of the neurologic examination. Evidence-based practice guidelines serve as a standard. In this chapter, I discuss the history of development of the criteria, the current clinical examination, and some of the ethical and legal issues that have emerged. Generally, the concept of brain death has been accepted by all major religions. But patients’ families may have different ideas and are mostly influenced by cultural attitudes, traditional customs, and personal beliefs. Suggestions are offered to support these families.

Cardiac arrest remains a common problem throughout the world. This article explores several factors that aid in determining prognosis after cardiac arrest. It is broadly divided into prearrest factors, intra-arrest factors, and postarrest factors. Prearrest factors predominantly concern the presence or absence of a shockable rhythm. Intra-arrest factors look at the partial pressure of end-tidal CO2 and the presence of cardiac standstill on ultrasound. Postarrest factors include early outcome measures as well as a more comprehensive algorithmic approach to predicting neurologic outcome.

G 60-YEAR-OLD MAN was scheduled for aortic valve replacement because of severe aortic regurgitation. A preperative 12-lead electrocardiogram showed normal sinus hythm. At the time of aortic declamping, the serum potassium as 5.6 mEq/L. Cardiac standstill followed the release of the ortic cross-clamp, and therefore atrioventricular (AV) sequenial pacing (DOO) using a Swan-Ganz Pacing-TD catheter Edwards Life Sciences, Tokyo, Japan) was initiated (atrial and entricular output: 10 V, pulse duration: 0.75 milliseconds, 1 illisecond, respectively, pacing rate: 90 beats/min, AV delay: 50 milliseconds). As shown in Figure 1, AV sequential pacing as successful. However, soon after, the electrocardiogram hanged to the rhythm as shown in Figure 2. What is the iagnosis?

I NITIAL experience using high doses of esmolol hydrochloride in beating hearts while undergoing coronary revascularization is presented. Although the authors set out to stay within the drug manufacturer's recommended doslng guidelines, it was not possible to obtain satisfactory surgical conditions and, therefore, the dose was increased to provide optimal working conditions. The surgical technique of coronary artery bypass grafting on nonarrested hearts with ventrlcular support devices has been previously described from this restitution. 1 The first patient (of three) underwent cardiopulmonary bypass (CPB) and the latter patients were supported with an lnvestigational ventrlcular assist device, the Sternotomy Hemopump (Johnson and Johnson Interventional Systems Company, Rancho Cordova, CA). These two patients are part of a multlcenter, randomized, prospective, FDAapproved study, which has been reviewed by the Committee for Protection of Human Subjects (CPHS) of the University of Texas Health Science Center at Houston. Consent included the use of esmolol and sodium nitroprusside, if required.

Technical refinements, improved immunosuppression and long-term care have transformed transplantation from an experimental procedure to an established life-saving and life-prolonging treatment with good survival rates in both the short- and long-term. However, the issues surrounding organ donation remain one of the most difficult areas in transplantation and the shortage of donor organs is the major limiting factor, with growing numbers of patients on waiting lists world-wide. A variety of factors including improved road safety and changes in neurosurgical management have led to a decreased number of conventional heart-beating brain-stem-dead donors in some countries and has prompted a resurgence of interest in donation from donors after cardiac standstill - originally called ‘non heart beating’ donation but now more commonly referred to as ‘donation after cardiac death’ as in the title of this book. This volume is, therefore, extremely timely, addressing a rapidly developing field. Both editors have long track records in this area and they have chosen a wide range of international experts as contributors. On the whole, they have succeeded in covering the field comprehensively. Like any multi-author volume there is some degree of repetition of material from chapter to chapter but this leaves the virtue that chapters can be read as a complete source by those only wishing to dip into the volume for specific topics. Areas covered include techniques of retrieval, organ preservation, resuscitation after retrieval, organ assessment and the outcomes of transplantation in kidneys, livers and lungs retrieved from such donors. The commonest (but not the only) form of donation after cardiac death is retrieval of organs from patients where supportive treatment has been withdrawn in an intensive-care setting. Some of the thorniest issues in such donations arise in the management of these patients prior to their death and in the immediate period after cardiac standstill. These issues are remarkably well rehearsed and reviewed in the chapter on legal and ethical issues by Sam Shemie and Michael DeVita, who have managed to put together an impressive review of the situation and the relevant legal framework across the world. This book will be of interest and value to all working in the area of solid-organ transplantation. It contains information relevant to established consultants in transplantation, trainees and both recipient and donor-transplant co-ordinators.