High-Dose Adenosine Administration in an Asynchronously Paced Patient During Intracranial Aneurysm Clipping: A Case Report

A patient with a high ventricular pacing burden managed by a Cardiac Resynchronization Therapy with Defibrillation (CRT-D) device, undergoing cerebral aneurysm clipping, required a strategy for brief, controlled reductions in cerebral perfusion pressure. Because adenosine cannot induce asystole in paced patients, its usefulness for neurosurgical flow control is uncertain. After reprogramming the device to dual pace, no sense, no response (DOO) mode with defibrillation therapies disabled, adenosine boluses were administered during clip application and produced predictable hypotension despite uninterrupted pacing. This case demonstrates that adenosine can be an effective and predictable hypotensive agent even in continuously paced patients, expanding available techniques for temporary flow control in complex cerebrovascular surgery.