Transient Adenosine-Induced Asystole for the Management of Complex Aneurysms at the Skull Base

Background: Transient adenosine-induced asystole is a reliable method for producing a short period of relative hypotension during surgical and endovascular procedures. Although the technique has been described in the surgical treatment of aneurysms, little description of its use in large and giant aneurysms has been described.

Objective: The purposes of this study were to (1) assess the benefits of adenosine-induced transient asystole in large and giant aneurysms and (2) describe our experience in selected cases.

Methods: The adenosine-induced cardiac arrest protocol allows us to titrate the duration of cardiac arrest on the basis of individual patient responses. The operative setup is the same as with all aneurysm clippings, with the addition of the placement of transcutaneous pacemakers as a precaution for prolonged bradycardia or asystole. Escalating doses of adenosine are given to determine the approximate dose that results in 30 seconds of asystole. When requested by the surgeon, the dose of adenosine is administered for definitive dissection and clipping. We present nine large and giant cases in which this technique was used.

Results: Successful treatment of cerebral aneurysms requires circumferential visualization of the aneurysm neck, the parent vessel, branches, and perforators. Skull base techniques aid in the goal. We have also found that transient adenosine-induced asystole provides excellent and safe clip application, even in large and giant aneurysms. All patients did well neurologically and suffered no evidence of perioperative cerebral ischemia or delayed complication from the use of adenosine itself.

Conclusion: Transient adenosine-induced asystole is a safe and effective technique in select circumstances that may aid in safe and effective aneurysm clipping. Along with the traditional techniques of brain relaxation, skull base approaches, and temporary clipping, adenosine-induced asystole facilitates circumferential visualization of the aneurysm neck and is another technique available to cerebrovascular surgeons.