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Al-Qiami A, Amro S, Sarhan K, Arafeh Y, Milad M, Omar I, Nashwan AJ. The protective role of lidocaine in surgeries involving trigeminal nerve manipulation: a meta-analysis of trigeminocardiac reflex prevention. Neurosurg Rev 2025; 48:310. [PMID: 40107993 PMCID: PMC11923009 DOI: 10.1007/s10143-025-03449-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Revised: 02/28/2025] [Accepted: 03/05/2025] [Indexed: 03/22/2025]
Abstract
The trigeminocardiac reflex (TCR) is activated when the trigeminal nerve is manipulated through mechanical pressure, traction, or irritation. This leads to a rapid increase in parasympathetic activity, resulting in a decrease in heart rate (HR) and blood pressure, which can potentially lead to bradycardia, and cardiac arrest, with a prevalence of 14.5% during neurointerventional procedures (8). The aim of this study was to assess the effect of lidocaine injection on preventing TCR during cranial surgeries. We conducted a comprehensive search of PubMed, Web of Science, and Cochrane CENTRAL electronic databases for clinical trials comparing the use of lidocaine versus placebo, or no intervention for TCR prevention during cranial surgeries up until 20 May 2024. Meta-analyses were performed using fixed-effects models, and heterogeneity was assessed using I-squared and Chi-square tests. A total of five studies involving 421 patients were included in this meta-analysis. The incidence of TCR was significantly lower in the lidocaine group compared to the control group, with a risk ratio of 0.05 (95% CI 0.01 to 0.37, P = 0.003). Additionally, the lidocaine group had a relatively small change in HR, with a mean difference of -10.56 (95% CI -13.30 to -7.83 beat per minute, P = 0.00001). No statistically significant difference in mean arterial pressure was observed between the two groups (MD -5.15, 95% CI [-10.38 to 0.08 mmHg], P = 0.09). Our results suggest that lidocaine may be effective in preventing TCR and stabilizing HR. The use of lidocaine could be considered a prophylactic measure during cranial surgeries. Further studies are needed to investigate the optimal dose and timing of lidocaine administration.
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Affiliation(s)
- Almonzer Al-Qiami
- Faculty of Medicine and Health Sciences, Kassala University, Kassala, Sudan
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, Egypt
| | - Sarah Amro
- Specialized Arab Hospital, Rafidia, Palestine
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, Egypt
| | - Khalid Sarhan
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, Egypt
| | - Yusra Arafeh
- Jordan University of Science and Technology, Amman, Jordan
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, Egypt
| | - Mina Milad
- Faculty of Medicine, Cairo University, Cairo, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, Egypt
| | - Islam Omar
- Faculty of Pharmacy, South Valley University, Qena, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, Egypt
| | - Abdulqadir J Nashwan
- Nursing & Midwifery Research Department (NMRD), Hamad Medical Corporation, Doha, Qatar.
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar.
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Cho SY, Jang BH, Jeon HJ, Kim DJ. Repeated ventricular bigeminy by trigeminocardiac reflex despite atropine administration during superficial upper lip surgery: A case report. World J Clin Cases 2022; 10:11967-11973. [PMID: 36405277 PMCID: PMC9669879 DOI: 10.12998/wjcc.v10.i32.11967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/15/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The trigeminocardiac reflex (TCR) is usually caused by an increased parasympathetic tone when pressure or traction is applied to the surrounding tissue of the trigeminal nerve. However, the inexperienced anesthesiologists may have challenges on the management of TCR patients.
CASE SUMMARY This is the case of an 18-year-old woman diagnosed with hemangioma of the upper lip. During the operation, about 1 h after surgery started, a constant 1:1 premature ventricular complex was detected, and blood pressure was decreased when approaching the deeper part with more strong traction for exposure of the part. Although the management of arrhythmias, such as lidocaine and atropine, was injected, arrhythmia induced by surgical stimulation could not be eliminated completely. As the traction repeated, bradycardia was also repeated, despite injecting additional atropine. Therefore, the anesthesiologist and the surgeon decided to perform the operation only to the extent that the vascular tissue was selectively removed only at the site without the reflex.
CONCLUSION With TCR, anesthesiologists should perform appropriate monitoring. In addition to proper drug administration, surgeons should be consulted to cope with stopping the surgery and setting the scope of the surgery even if the site is superficial.
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Affiliation(s)
- Su-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
| | - Bo-Hyun Jang
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
| | - Hye-Jin Jeon
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
| | - Dong-Joon Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
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The Effect of Atropine on Trigeminocardiac Reflex-induced Hemodynamic Changes During Therapeutic Compression of the Trigeminal Ganglion. J Neurosurg Anesthesiol 2022; 34:e40-e45. [PMID: 32496449 DOI: 10.1097/ana.0000000000000702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Percutaneous compression of the trigeminal ganglion (PCTG) can induce significant hemodynamic perturbations secondary to the trigeminocardiac reflex (TCR). The aim of this study was to investigate the effect of atropine pretreatment on hemodynamic responses during PCTG for trigeminal neuralgia. MATERIALS AND METHODS A total of 120 patients who received PCTG were randomly assigned to control and atropine groups that were pretreated with saline (n=60) and atropine 0.004 mg/kg intravenously (n=60), respectively. Heart rate (HR) and mean arterial pressure (MAP) were measured at 9 timepoints from before induction of anesthesia until the end of the PCTG procedure; the incidence of TCR was also observed. RESULTS HR was higher in the atropine compared with control group from the time of skin puncture with the PCTG needle until after the procedure was completed (P<0.05). MAP was also higher in the atropine compared with control group, but only at entry of the needle into the foramen ovale until 1 minute after trigeminal ganglion compression (P<0.05). HR was reduced in both groups during entry of the needle into the foramen ovale and during ganglion compression, but less so in the atropine compared with the control group (P<0.05). MAP increased during PCTG compared with baseline in both groups, but with a larger increase in the atropine group (P<0.05). Two and 52 cases in the control group, and 6 and 1 cases in the atropine group, exhibited a TCR during entry of the needle into the foramen ovale and at ganglion compression, respectively (P<0.05). CONCLUSION Pretreatment with atropine was effective in most patients at minimizing abrupt reduction in HR during PCTG.
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Fiani B, Quadri SA, Farooqui M, D'Apuzzo M, Rosser RJ, Berman BW, Noel J, Xin XS, Badie B, Ramachandran A, Siddiqi J. A brainstem mass of Müllerian type Epithelial Origin without any primary cancer source. J Clin Neurosci 2018; 59:325-332. [PMID: 30337125 DOI: 10.1016/j.jocn.2018.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022]
Abstract
Brainstem tumors are rare, even rarer is a brainstem tumor containing tissues of an embryologic gynecologic origin. We report a very rare case of presence of a calcified heterogeneously contrast enhancing brainstem mass of Müllerian origin in a patient in a 38 year old female with no female genital tract cancer and past surgical history of ventriculoperitoneal (VP) shunt placement for congenital hydrocephalus. To our knowledge this is the very first and unusual case of a mass of gynecologic origin in the brainstem region especially in the setting of no history of gynecological tumor. The authors also reviewed the literature for all tumors reported for anterograde and retrograde dissemination of tumor cells through VP shunt. This case is a reaffirmation of the importance of brain tumor location and tissue diagnosis for the purpose of adjuvant treatment of neurosurgical lesions in the neurocritical care setting. It also highlights the role of catheters as potential routes of iatrogenic transmission not just in anterograde but also in a retrograde manner to the CNS, which is very unusual. This is the only second case to report retrograde flow of tumor cells from an extraneural source up the VP catheters. The authors suggest that intraperitoneal chemotherapy should be considered in the cases of known extraneural abdominal malignancies of high malignant potential with or without the presence of peritoneal infiltration in order to avoid dissemination through VP shunts.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Syed A Quadri
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA.
| | - Mudassir Farooqui
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Massimo D'Apuzzo
- Department of Pathology, City of Hope National Medical Center, Duarte, CA, USA
| | - Robert J Rosser
- Department of Pathology, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Blake W Berman
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Jerry Noel
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Xin S Xin
- Division of Neurosurgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Behnam Badie
- Division of Neurosurgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Anirudh Ramachandran
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
| | - Javed Siddiqi
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
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Leon-Ariza DS, Leon-Ariza JS, Nangiana J, Vargas Grau G, Leon-Sarmiento FE, Quiñones-Hinojosa A. Evidences in Neurological Surgery and a Cutting Edge Classification of the Trigeminocardiac Reflex: A Systematic Review. World Neurosurg 2018; 117:4-10. [DOI: 10.1016/j.wneu.2018.05.208] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/28/2018] [Indexed: 11/24/2022]
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Meuwly C, Chowdhury T, Gelpi R, Erne P, Rosemann T, Schaller B. The clinical surrogate definition of the trigeminocardiac reflex: Development of an optimized model according to a PRISMA-compliant systematic review. Medicine (Baltimore) 2017; 96:e9033. [PMID: 29245296 PMCID: PMC5728911 DOI: 10.1097/md.0000000000009033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmias including hemodynamic irregularities, apnea, and gastric hypermotility during stimulation of sensory branches of the trigeminal nerve. Since the first description of the TCR 1999, there is an ongoing discussion about a more flexible than the existing clinical definition. Aim of this work was to create a clinical surrogate definition through a systematic review of the literature. METHODS In this meta-analysis study, literature about TCR occurrences was, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, systematically identified through various search engines including PubMed (Medline), Embase (Ovid SP), and ISI Web of Sciences databases from January 2005 to August 2015. TCR was defined as a drop of heart rate (HR) below 60 bpm or 20% to the baseline. We extracted detailed data about hemodynamic changes and searched for connections between arterial blood pressure (BP) and HR changes during such episodes. RESULTS Overall 45 studies harboring 57 patients were included in the study but only 32 patients showed sufficient data for final analyze. HR showed a nonlinear behavior with a "tipping point" phenomena that differs in variance from the central/peripheral (20-30% drop) to ganglion (40-49% drop). BP showed a linear behavior with a "central limit" phenomena not differing in variance in the whole subgroup (30-39% drop). An analyzation of the correlation between BP and HR showed a trend to a linear correlation. CONCLUSIONS We can show for the first time that HR is the dominant variable in the TCR and present a new surrogate definition model. This model and the role of BP must be better investigated in further studies.
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Affiliation(s)
- Cyrill Meuwly
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba, Winnipeg, Canada
| | - Ricardo Gelpi
- Department of Pathology, Institute of Cardiovascular Physiopathology, University of Buenos Aires, Buenos Aires, Argentina
| | - Paul Erne
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Thomas Rosemann
- Department of Primary Care, University of Zurich, Zurich, Switzerland
| | - Bernhard Schaller
- Department of Primary Care, University of Zurich, Zurich, Switzerland
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Sandu N, Chowdhury T, Meuwly C, Schaller B. Trigeminocardiac reflex in cerebrovascular surgery: a review and an attempt of a predictive analysis. Expert Rev Cardiovasc Ther 2017; 15:203-209. [DOI: 10.1080/14779072.2017.1286983] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nora Sandu
- Department of Research, University of Southampton, Southampton, UK
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba (UOM)/Winnipeg Regional Health Authority (WRHA), Winnipeg, Manitoba, Canada
| | | | - Bernhard Schaller
- Department of Research, University of Southampton, Southampton, UK
- Department of Pathology, University of Buenos Aires, Buenos Aires, Argentina
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Dube S, Roy H, Singh G, Chaturvedi A. Hemodynamic disturbance during watertight dural closure? Mind the direction of saline irrigation!!! Saudi J Anaesth 2017; 11:122-123. [PMID: 28217074 PMCID: PMC5292838 DOI: 10.4103/1658-354x.197352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Patadia M, Bartindale M, Caballero N. Recurrent asystole as an electrocardiographic artifact during microdebrider use in functional endoscopic sinus surgery. Am J Rhinol Allergy 2016; 29:e220-3. [PMID: 26637574 DOI: 10.2500/ajra.2015.29.4256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Electrocardiographic (EKG) artifacts can lead to unnecessary treatment and costly diagnostic workup. Two previous studies reported a ventricular tachycardia artifact as a result of microdebrider malfunction. In this study, we report the first case of EKG artifacts that mimick asystole from microdebrider use during functional endoscopic sinus surgery (FESS). CASE A healthy 19-year-old woman presented with chronic rhinosinusitis, nasal polyposis, and a deviated nasal septum. She was scheduled for a bilateral FESS and septoplasty. During surgery, the microdebrider was changed after 1 hour. While using the second microdebrider, the EKG monitor showed three distinct asystolic events, all lasted approximately 3 seconds. The EKG tracing returned to normal sinus rhythm every time the microdebrider was stopped. The patient's oxygen saturation remained at 100%, and blood pressure remained stable during the episodes. The procedure was aborted, and an extensive cardiology workup was performed, which returned negative results. Biomedical engineering investigated the microdebrider and found a far greater than expected chassis leak, which likely caused electrical interference. Six months later, the patient underwent a right-sided FESS and revision left frontal FESS. There were no EKG abnormalities during the second surgery. DISCUSSION Although other EKG artifacts have been reported in the literature, this is the first case report of an artifact that mimicked asystole that stemmed from microdebrider use. Improved awareness of this potential EKG artifact for both the surgeon and the anesthesiologist may prevent an unnecessary costly workup.
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Affiliation(s)
- Monica Patadia
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
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Aletaha M, Bagheri A, Roodneshin F, Mosallaei M, Yazdani S. Oculocardiac Reflex during Strabismus Surgery: Experience from a Tertiary Hospital. Strabismus 2016; 24:74-8. [DOI: 10.3109/09273972.2016.1170049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Lubnin AY, Israelyan LA, Shimanskiy VN, Odamanov DA. [Cardiac arrest after induction of anesthesia in neurosurgical patients]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:75-84. [PMID: 26529537 DOI: 10.17116/neiro201579375-84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper reports two clinical cases observed with a time lag of four years. In both cases, there were severe clinical symptoms of intracranial hypertension before the surgery. Prompt full-scale resuscitation was required in both cases due to asystole that developed immediately after induction of anesthesia and tracheal intubation. In one case, cardiac activity was successfully recovered by complex resuscitation with the emergency drainage of the cerebral ventricles. The possible causes of complications and preventive measures were discussed.
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Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - D A Odamanov
- Burdenko Neurosurgical Institute, Moscow, Russia
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Meuwly C, Chowdhury T, Sandu N, Reck M, Erne P, Schaller B. Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review. Medicine (Baltimore) 2015; 94:e807. [PMID: 25950688 PMCID: PMC4602521 DOI: 10.1097/md.0000000000000807] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmia including hypotension, apnea, and gastric hypermotility during stimulation of any branches of the trigeminal nerve. Previous publications imply a relation between TCR and depth of anesthesia. To gain more detailed insights into this hypothesis, we performed a systematic literature review.Literature about occurrence of TCR was systematically identified through searching in Cochrane Central Register of Controlled Trials (CENTRAL), PubMed (MEDLINE), EMBASE (Ovid SP), and the Institute for Scientific Information (ISI Web of Sciences) databases until June 2013, as well as reference lists of articles for risk calculation. In this study, TCR was defined as drop in mean arterial blood pressure and heart rate, both >20% to baseline. We calculated intraoperative cerebral state index (CSI) of each TCR-case using a newly developed method. These data were further divided into 3 subgroups: CSI <40 (deep anesthesia), CSI 40-60 (regular anesthesia), and CSI >60 (slight anesthesia).Including 45 studies with 910 patients, 140 (15%) presented with TCR, and 770 (85%) without TCR during operation. TCR occurrence showed a 1.2-fold higher pooled risk slighter anesthesia (CSI <40: 13%, at CSI 40-60: 21%, and at CSI >60: 27%) compared with deeper anesthesia. In addition, we could discover a 1.3-fold higher pooled risk of higher MABP drop with a strong negative correlation (r = -0.935; r = 0.89) and a 4.5-fold higher pooled risk of asystole during TCR under slight anesthesia compared with deeper anesthesia.Our work is the first systematic review about TCR and demonstrates clear evidence for TCR occurrence and a more severe course of the TCR in slight anesthesia underlying the importance of skills in anesthesia management during skull base surgery. Furthermore, we have introduced a new standard method to calculate the depth of anesthesia.
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Affiliation(s)
- Cyrill Meuwly
- From the University Hospital, 4031 Basel, Switzerland (CM, MR); Cardiology Luzerner Kantonsspital, 6000 Luzern, Switzerland (PE); Present address: Cardiology, St Anna Clinic, St Anna Strasse 32, 6006 Luzern, Switzerland (PE); Departments of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (TC); and Department of Research, University of Southampton, Southampton, UK (NS, BS)
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Cardiac emergencies in neurosurgical patients. BIOMED RESEARCH INTERNATIONAL 2015; 2015:751320. [PMID: 25692145 PMCID: PMC4321102 DOI: 10.1155/2015/751320] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 10/01/2014] [Accepted: 10/01/2014] [Indexed: 12/04/2022]
Abstract
Perioperative safety concerns are a major area of interest in recent years. Severe cardiac perturbation such as cardiac arrest is one of the most dreaded complications in the intraoperative period; however, little is known about the management of these events in the patients undergoing elective neurosurgery.
This special group needs further attention, as it is often neither feasible nor appropriate to apply conventional advanced cardiac life support algorithms in patients undergoing neurosurgery. Factors such as neurosurgical procedure and positioning can also have a significant effect on the occurrence of cardiac arrest.
Therefore, the aim of this paper is to describe the various causes and management of cardiac emergencies with special reference to cardiac arrest during elective neurosurgical procedures, including discussion of position-related factors and resuscitative considerations in these situations. This will help to formulate possible guidelines for management of such events.
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Brainstem surgery assisted by temporary trans-venous pacing to prevent severe bradycardia. Acta Neurochir (Wien) 2014; 156:431-2. [PMID: 24322585 DOI: 10.1007/s00701-013-1965-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 11/28/2013] [Indexed: 10/25/2022]
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Santhosh MCB, Pai RB, Rao RP, Byrappa V. Sudden sustained asystole during a cerebellopontine angle surgery. J Anaesthesiol Clin Pharmacol 2013; 29:402-3. [PMID: 24106373 PMCID: PMC3788247 DOI: 10.4103/0970-9185.117050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- M C B Santhosh
- Department of Anesthesiology, Shri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Dharwad, Karnataka, India
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Bhargava D, Thomas S, Chakravorty N, Dutt A. Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery. J Maxillofac Oral Surg 2013. [PMID: 26224999 DOI: 10.1007/s12663-013-0541-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology, risk factor assessment, presentation of the reflex, prevention, management with emphasis on the role of the attending anaesthetist and the maxillofacial surgeon. MATERIALS AND METHODS The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review published clinical papers, abstracts and evidence based reviews on trigeminocardiac reflex relevant to oral and maxillofacial surgery. RESULTS Sixty-five articles were found with the search term "trigeminocardiac reflex" in the literature searched. Eighteen articles met the inclusion criteria for this study. The relevant data was extracted, tabulated and reviewed to draw evidence based conclusions for the management of trigeminocardiac reflex. CONCLUSIONS Conclusions were drawn and discussed based on the reviewed maxillofacial literature with emphasis on the anaesthetist's and the surgeon's role in the management of this detrimental event in maxillofacial surgical practice.
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Affiliation(s)
- Darpan Bhargava
- Department of Oral and Maxillofacial Surgery, Peoples College of Dental Sciences and Research Center, Peoples University, Bhanpur, Bhopal, M.P. India
| | - Shaji Thomas
- Department of Oral and Maxillofacial Surgery, Peoples College of Dental Sciences and Research Center, Peoples University, Bhanpur, Bhopal, M.P. India
| | - Nupur Chakravorty
- Department of Anesthesiology, L.N Medical College and Research Center and J.K Hospital, J.K Town, Sarvdharm C-Sector, Kolar Road, Bhopal, M.P. India
| | - Ashutosh Dutt
- Department of Oral and Maxillofacial Surgery, Peoples College of Dental Sciences and Research Center, Peoples University, Bhanpur, Bhopal, M.P. India
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Chen CY, Luo CF, Hsu YC, Chen JF, Day YJ. Comparison of the effects of atropine and labetalol on trigeminocardiac reflex-induced hemodynamic alterations during percutaneous microballoon compression of the trigeminal ganglion. ACTA ACUST UNITED AC 2012; 50:153-8. [DOI: 10.1016/j.aat.2012.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 08/06/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022]
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Cho JM, Min KT, Kim EH, Oh MC, Kim SH. Sudden asystole due to trigeminocardiac reflex during transsphenoidal surgery for pituitary tumor. World Neurosurg 2012; 76:477.e11-5. [PMID: 22152579 DOI: 10.1016/j.wneu.2011.01.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 10/11/2010] [Accepted: 01/28/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND A sudden attack of an asystolic phenomenon is an extremely rare event during transsphenoidal surgery (TSS). It may be caused by an extreme type of trigeminocardiac reflex (TCR) during the manipulation of the trigeminal nerve or its innervated structures. CASE DESCRIPTION We report two cases of sudden asystole and a case of severe bradycardia due to TCR during TSS. All patients were managed successfully by cessation of the surgical manipulation or with the injection of an anticholinergic agent. CONCLUSIONS Although TCR occurs rarely and usually is self-limiting, surgeons should be cautious of its occurrence, especially when manipulating the cavernous sinus during TSS. This allows the early detection and appropriate treatment of this manifestation. Stopping the surgical procedure as soon as TCR occurs is likely to normalize the vital parameters. In addition, if further manipulations are inevitable, the administration of anticholinergic medication should be considered cautiously to improve surgical outcomes.
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Affiliation(s)
- Jin Mo Cho
- Department of Neurosurgery, Pituitary Tumor Clinics, Yonsei Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Puri AS, Thiex R, Zarzour H, Rahbar R, Orbach DB. Trigeminocardiac reflex in a child during pre-Onyx DMSO injection for juvenile nasopharyngeal angiofibroma embolization. A case report. Interv Neuroradiol 2011; 17:13-6. [PMID: 21561553 DOI: 10.1177/159101991101700103] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 11/07/2010] [Indexed: 11/17/2022] Open
Abstract
We describe the occurrence of the trigeminocardiac reflex (TCR) during DMSO pre-flushing of the microcatheter in preparation for Onyx embolization via the internal maxillary artery. TCR has not been previously associated with embolization of extradural entities. Familiarity with this clinical reflex and its proper management may help in planning neurointerventional procedures involving DMSO injection in the trigeminal territory.
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Affiliation(s)
- A S Puri
- Neurointerventional Service, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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22
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Is prevention or knowledge better than a cure for the trigeminal cardiac reflex? J Oral Maxillofac Surg 2010; 68:2035; author reply 2035. [PMID: 20638594 DOI: 10.1016/j.joms.2010.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 04/14/2010] [Indexed: 11/20/2022]
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Bohluli B, Bayat M, Sarkarat F, Moradi B, Tabrizi MHS, Sadr-Eshkevari P. Trigeminocardiac reflex during Le Fort I osteotomy: a case-crossover study. ACTA ACUST UNITED AC 2010; 110:178-81. [PMID: 20382052 DOI: 10.1016/j.tripleo.2009.12.054] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 12/12/2009] [Accepted: 12/28/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The present study aimed to assess the occurrence of trigeminocardiac reflex (TCR) during Le Fort I osteotomies. STUDY DESIGN This case-crossover study included 25 Le Fort I osteotomy candidates without systemically compromising conditions. Mean arterial blood pressure and pulse rate values were recorded before downfracture (DF) (MABP1, PR1), during DF (MABP2, PR2), and after DF (MABP3, PR3). The data were analyzed using repeated measure ANOVA tests (alpha = 0.05). RESULTS PR1 and PR3 were significantly higher than PR2 (P < .001). MABP2 value was significantly lower compared with MABP1 and MABP3 values (P < .001). PR2 and MABP2 showed a mean decrease of 6.5% and 9.7% compared with PR1 and MABP1, respectively. CONCLUSION Different values have been suggested for TCR. Considering the limitations, the present study may suggest a revision of the values or descriptions for TCR, at least in maxillofacial Le Fort I osteotomy.
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Affiliation(s)
- Behnam Bohluli
- Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Azad University of Tehran, Tehran, Iran
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Lv X, Li Y, Jiang C, Wu Z. The incidence of trigeminocardiac reflex in endovascular treatment of dural arteriovenous fistula with onyx. Interv Neuroradiol 2010; 16:59-63. [PMID: 20377980 PMCID: PMC3277960 DOI: 10.1177/159101991001600107] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Accepted: 02/20/2010] [Indexed: 02/05/2023] Open
Abstract
This paper reports the incidence of tri-geminocardiac reflex (TCR) in endovascular treatment of dural arteriovenous fistulas (DAVFs) with Onyx. The consecutive case histories of 45 patients with DAVFs, treated with Onyx transarterially and transvenously, from February 2005 to February 2008 at Beijing Tiantan Hospital, China, were retrospectively reviewed. The time period was limited as the anesthetic and intravascular procedure was performed under the same standardized anesthetic protocol and by the same team. The TCR rate was subsequently calculated. Of the 45 patients, five showed evidence of TCR during transarterial Onyx injection and transvenous DMSO injection. Their HR fell 50% during intravascular procedures compared with levels immediately before the stimulus. However, blood pressure values were stable in all cases. The TCR rate for all patients was 11.1% (95% CI, 4 to 24%), 7.7% (95% CI, 2 to 21%) in patients treated intraarterially and 33.3% (4 to 78%) in patients treated intravenously. Once HR has fallen, intravenous atropine is indicated to block the depressor response and prevention further TCR episodes. TCR may occur due to chemical stimulus of DMSO and Onyx cast formation under a standardized anesthetic protocol and should be blunted by atropine.
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Affiliation(s)
- X Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China.
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Trigeminocardiac reflex: a cause of sudden asystole during cerebellopontine angle surgery. J Clin Neurosci 2010; 17:641-4. [PMID: 20188568 DOI: 10.1016/j.jocn.2009.07.117] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 07/02/2009] [Accepted: 07/07/2009] [Indexed: 11/17/2022]
Abstract
We present a patient with an unusual, exaggerated trigeminocardiac reflex response during surgery for vestibular schwannoma and its successful management.
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Electrocardiographic changes due to vagosympathetic coactivation during the trigeminocardiac reflex. J Neurosurg Anesthesiol 2009; 21:270. [PMID: 19543008 DOI: 10.1097/ana.0b013e31819f1cf4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The trigemino-cardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity, sympathetic hypotension, apnea, or gastric hypermotility during central or peripheral stimulation of any of the sensory branches of the trigeminal nerve. Clinically, the TCR has been reported to occur during craniofacial surgery, manipulation of the trigeminal nerve/ganglion and during surgery for lesion in the cerebellopontine angle, cavernous sinus, and the pituitary fossa. Apart from the few clinical reports, the physiologic function of this brainstem reflex has not yet been fully explored. The manifestation of the TCR can vary from bradycardia and hypotension to asystole. From the experimental findings, the TCR represents an expression of a central reflex leading to rapid cerebrovascular vasodilatation generated from excitation of oxygen-sensitive neurons in the rostral ventro-lateral medulla oblongata. By this physiologic response, the systemic and cerebral circulations may be adjusted in a way that augments cerebral perfusion. This review summarizes the current state of knowledge about TCR.
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Prabhakar H, Ali Z, Singh GP. Asystole may be the most severe sequela of the trigeminocardiac reflex: a comment on "Asystole due to trigemino-cardiac reflex: A rare complication of trans-sphenoidal surgery for pituitary adenoma". J Clin Neurosci 2009; 16:1508. [PMID: 19632118 DOI: 10.1016/j.jocn.2009.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 02/25/2009] [Indexed: 11/17/2022]
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Schaller B, Sandu N, Ottoviani G, Filis A, Noethen C, Buchfelder M. Transient asystole during endoscopic transsphenoidal surgery: an example of trigeminocardiac reflex. Pituitary 2009; 12:271-2. [PMID: 18587648 DOI: 10.1007/s11102-008-0132-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy. Clin Neurol Neurosurg 2008; 110:1064-7. [PMID: 18845385 DOI: 10.1016/j.clineuro.2008.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 05/30/2008] [Accepted: 07/13/2008] [Indexed: 02/07/2023]
Abstract
The trigeminocardiac reflex occurs from manipulation or stimulation of peripheral branches or the central component of the trigeminal nerve and consists of bradycardia, hypotension, apnea, and increased gastric motility. The efferent limb of the response is mediated by the vagus nerve. This 65-year-old Caucasian male suffered an episode of bradycardia progressing to transient asystole during the course of an awake-craniotomy procedure for tumor resection. The cardiac rhythm changes resolved with administration of intravenous atropine, removal of the precipitating stimulus, and application of topical anesthetic on the dura of the middle cranial fossa. The trigeminocardiac response may complicate the course of a craniotomy and may place an awake, unintubated patient at increased risk for morbidity. The reflex may be prevented by anesthetizing the dura innervated by the trigeminal nerve via injection or topical application of local anesthetic. If encountered, removal of the stimulus, airway protection, and administration of vagolytic medications are measures that need to be considered.
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Trigemino-cardiac reflex may be refractory to conventional management in adults. Acta Neurochir (Wien) 2008. [DOI: 10.1007/s00701-008-0011-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Meng Q, Yang Y, Zhou M, Li X. Trigemino-cardiac reflex: the trigeminal depressor responses during skull base surgery. Clin Neurol Neurosurg 2008; 110:662-6. [PMID: 18514393 DOI: 10.1016/j.clineuro.2008.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 03/16/2008] [Accepted: 03/26/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To observe and analyze the occurrence and management of the trigemino-cardiac reflex (TCR) defined as the phenomenon of abrupt drops in heart rate (HR) and blood pressure during skull base surgery. METHOD One hundred patients underwent skull base surgery for various lesions were recruited and great attention was paid to heart rate and blood pressure throughout the surgical procedure to screen intraoperative TCR. RESULT Twelve patients had TCR intro-operatively, all patients showed abrupt drops in HR of 38% from a mean of 78 beats/min to a mean of 49 beats/min, mean arterial blood pressure (MABP) decreased 33% from a mean of 93 mmHg to a mean of 60 mmHg, respectively. TCR was resolved spontaneously in eight patients, but had to be offset by intraoperative administration of relatively higher dose atropine in another four patients. CONCLUSION (1) Manipulation at or near the trigeminal nerve during the skull base surgery may cause TCR, even if premedication with anticholinergic drug is used; (2) cessation of irritation from surgical manipulation to disrupt the reflex is the most important step to offset TCR; (3) continuous, especially repeated TCR in some rare cases occasionally necessitates the administration of high dose atropine.
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Affiliation(s)
- Qingli Meng
- Department of Neurosurgery, Qilu Hospital, Shandong University, Jinan, Shandong, PR China
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Prabhakar H, Ali Z, Rath GP. Trigemino-cardiac reflex may be refractory to conventional management in adults. Acta Neurochir (Wien) 2008; 150:509-10. [PMID: 18465091 DOI: 10.1007/s00701-008-1516-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cardiovascular Responses During Percutaneous Radiofrequency Thermocoagulation Therapy in Primary Trigeminal Neuralgia. J Neurosurg Anesthesiol 2008; 20:131-5. [DOI: 10.1097/ana.0b013e3181628305] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim JY, Park JS, Baek DJ, Lee SI, Kim KT, Choe WJ, Kim JW. Asystole via Trigeminocardiac Reflex during Skin Flap Elevation in a Patient Undergoing Craniotomy for Cerebral Aneurysm Clipping - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.2.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ji Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
| | - Jang Su Park
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
| | - Dong Jin Baek
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
| | - Sang Il Lee
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
| | - Kyung Tae Kim
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
| | - Won Joo Choe
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
| | - Jung Won Kim
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University Collge of Medicine, Goyang, Korea
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Gharabaghi A, Acioly de Sousa MA, Tatagiba M. Detection and prevention of the trigeminocardiac reflex during cerebellopontine angle surgery. Acta Neurochir (Wien) 2006; 148:1223. [PMID: 17102925 DOI: 10.1007/s00701-006-0894-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
MESH Headings
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/prevention & control
- Bradycardia/etiology
- Bradycardia/physiopathology
- Bradycardia/prevention & control
- Brain Neoplasms/pathology
- Brain Neoplasms/surgery
- Cerebellopontine Angle/anatomy & histology
- Cerebellopontine Angle/surgery
- Hearing Loss, Sensorineural/etiology
- Hearing Loss, Sensorineural/physiopathology
- Hearing Loss, Sensorineural/prevention & control
- Humans
- Hypotension/etiology
- Hypotension/physiopathology
- Hypotension/prevention & control
- Monitoring, Intraoperative/standards
- Neuroma, Acoustic/pathology
- Neuroma, Acoustic/surgery
- Postoperative Complications/etiology
- Postoperative Complications/physiopathology
- Postoperative Complications/prevention & control
- Reflex, Abnormal
- Trigeminal Nerve/physiopathology
- Trigeminal Nerve/surgery
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Schaller BJ, Buchfelder M. Trigemino-cardiac reflex in skull base surgery: from a better understanding to a better outcome? Acta Neurochir (Wien) 2006; 148:1029-31; discussion 1031. [PMID: 16944048 DOI: 10.1007/s00701-006-0889-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 04/25/2006] [Indexed: 10/24/2022]
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