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Mazzaglia G, Bonomo G, Rubiu E, Murabito P, Amato A, Ferroli P, Gemma M. Anesthesia-induced Takotsubo cardiomyopathy in trigeminal neuralgia: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22424. [PMID: 36593670 PMCID: PMC9811571 DOI: 10.3171/case22424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Takotsubo syndrome (TS) represents a form of nonischemic cardiomyopathy characterized by sudden and temporary weakening of the myocardium. Many data suggest a primary role for sympathetic overstimulation in its pathogenesis. Nevertheless, these correlates are less easily identified during anesthesia. OBSERVATIONS A 50-year-old female patient with a 4-year history of drug-resistant left trigeminal neuralgia. She was scheduled for surgical microvascular decompression. In the operating room, after induction of general anesthesia and oral intubation, the electrocardiogram revealed a significant ST segment elevation along with a sudden decrease in systolic blood pressure and heart rate. Administration of atropine caused a conversion into ventricular tachycardia. The advanced cardiac life support protocols were applied with prompt defibrillation and rapid recovery at sinus rhythm. A transthoracic echocardiogram revealed apical akinesia with ballooning of the left ventricle with a reduction of systolic function. An emergency coronary arteriography was performed, showing normal epicardial coronary vessels. After 4 days, echocardiography revealed normalization of the left ventricular function with improvement of the ejection fraction. LESSONS In patients affected by trigeminal neuralgia, chronic pain can lead to a state of adrenergic hyperactivation, which can promote TS during the induction of general anesthesia, probably through the trigeminocardiac reflex.
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Affiliation(s)
| | - Giulio Bonomo
- Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy,University of Milan, Milan, Italy; and
| | - Emanuele Rubiu
- Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy,University of Milan, Milan, Italy; and
| | | | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Paolo Ferroli
- Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marco Gemma
- Departments of Neuroanesthesia and Intensive Care and
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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: 1.4] [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: 0.7] [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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Singh GP, Chowdhury T, Bindu B, Schaller B. Sudden Infant Death Syndrome - Role of Trigeminocardiac Reflex: A Review. Front Neurol 2016; 7:221. [PMID: 27994573 PMCID: PMC5136573 DOI: 10.3389/fneur.2016.00221] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 11/22/2016] [Indexed: 11/13/2022] Open
Abstract
Sudden infant death syndrome (SIDS) is an unexplained death in infants, which usually occurs during sleep. The cause of SIDS remains unknown and multifactorial. In this regard, the diving reflex (DR), a peripheral subtype of trigeminocardiac reflex (TCR), is also hypothesized as one of the possible mechanisms for this condition. The TCR is a well-established neurogenic reflex that manifests as bradycardia, hypotension, apnea, and gastric hypermotility. The TCR shares many similarities with the DR, which is a significant physiological adaptation to withstand hypoxia during apnea in many animal species including humans in clinical manifestation and mechanism of action. The DR is characterized by breath holding (apnea), bradycardia, and vasoconstriction, leading to increase in blood pressure. Several studies have described congenital anomalies of autonomic nervous system in the pathogenesis of SIDS such as hypoplasia, delayed neuronal maturation, or decreased neuronal density of arcuate nucleus, hypoplasia, and neuronal immaturity of the hypoglossal nucleus. The abnormalities of autonomic nervous system in SIDS may explain the role of TCR in this syndrome involving sympathetic and parasympathetic nervous system. We reviewed the available literature to identify the role of TCR in the etiopathogenesis of SIDS and the pathways and cellular mechanism involved in it. This synthesis will help to update our knowledge and improve our understanding about this mysterious, yet common condition and will open the door for further research in this field.
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Affiliation(s)
- Gyaninder Pal Singh
- Department of Neuro-Anesthesiology and Critical Care, All India Institute of Medical Sciences , New Delhi , India
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba , Winnipeg, MB , Canada
| | - Barkha Bindu
- Department of Neuro-Anesthesiology and Critical Care, All India Institute of Medical Sciences , New Delhi , India
| | - Bernhard Schaller
- Department of Research, University of Southampton , Southampton , UK
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Sandu N, Chowdhury T, Schaller BJ. How to apply case reports in clinical practice using surrogate models via example of the trigeminocardiac reflex. J Med Case Rep 2016; 10:84. [PMID: 27048202 PMCID: PMC4822233 DOI: 10.1186/s13256-016-0849-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 02/25/2016] [Indexed: 12/04/2022] Open
Abstract
Case reports are an increasing source of evidence in clinical medicine. Until a few years ago, such case reports were emerged into systematic reviews and nowadays they are often fitted to the development of clinical (thinking) models. We describe this modern progress of knowledge creation by the example of the trigeminocardiac reflex that was first described in 1999 by a case series and was developed over the cause-and-effect relationship, triangulation to systematic reviews and finally to thinking models. Therefore, this editorial not only underlines the increasing and outstanding importance of (unique) case reports in current science, but also in current clinical decision-making and therefore also that of specific journals like the Journal of Medical Case Reports.
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Affiliation(s)
- Nora Sandu
- Departement of Research, University of Southampton, University Road, Southampton, SO17 1BJ, UK
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba, 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
| | - Bernhard J Schaller
- Departement of Research, University of Southampton, University Road, Southampton, SO17 1BJ, UK.
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Chowdhury T, Nöthen C, Filis A, Sandu N, Buchfelder M, Schaller B. Functional Outcome Changes in Surgery for Pituitary Adenomas After Intraoperative Occurrence of the Trigeminocardiac Reflex: First Description in a Retrospective Observational Study. Medicine (Baltimore) 2015; 94:e1463. [PMID: 26376385 PMCID: PMC4635799 DOI: 10.1097/md.0000000000001463] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Trigeminocardiac reflex (TCR) represents now a nearly ubiquitary phenomenon in skull base surgery. Functional relevance of the intrainterventional TCR occurrence is hitherto only proven for vestibular schwannoma. In a retrospective observational study, 19 out of 338 (8%) enrolled adult patients demonstrated a TCR during transsphenoidal/transcranial surgery for pituitary adenomas. The 2 subgroups (TCR vs non-TCR) had similar patient's characteristics, risk factors, and histology. Preoperatively, there was a similar distribution of normal pituitary function in the TCR and non-TCR subgroups. In this TCR subgroup, there was a significant decrease of that normal pituitary function after operation (37%) compared to the non-TCR group (60%) (P < 0.03). The TCR subgroup therefore demonstrated a 3.15 times (95%CI 1.15-8.68) higher risk for non-normalizing of postoperative pituitary function compared with the non-TCR subgroup (P < 0.03). It is presented, for the first time, an impact of TCR on the functional hormonal outcome after pituitary surgery and strongly underline again the importance of the TCR in clinical daily practice. As a consequence, TCR should be considered as a negative prognostic factor of hormonal normalization after surgery for pituitary adenomas that should be included into routine practice.
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Affiliation(s)
- T Chowdhury
- From the Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (CT); Department of Neurosurgery, University of Erlangen-Nuremberg, Germany (NC, FA, BM), and Department of Research, University of Southampton, Southampton, UK (SN, SB)
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Meuwly C, Golanov E, Chowdhury T, Erne P, Schaller B. Trigeminal cardiac reflex: new thinking model about the definition based on a literature review. Medicine (Baltimore) 2015; 94:e484. [PMID: 25654391 PMCID: PMC4602726 DOI: 10.1097/md.0000000000000484] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Trigeminocardiac reflex (TCR) is a brainstem reflex that manifests as sudden onset of hemodynamic perturbation in blood pressure (MABP) and heart rate (HR), as apnea and as gastric hypermotility during stimulation of any branches of the trigeminal nerve. The molecular and clinical knowledge about the TCR is in a constant growth since 1999, what implies a current need of a review about its definition in this changing context. Relevant literature was identified through searching in PubMed (MEDLINE) and Google scholar database for the terms TCR, oculocardiac reflex, diving reflex, vasovagale response. The definition of the TCR varies in clinical as well as in research studies. The main difference applies the required change of MABP and sometimes also HR, which most varies between 10% and 20%. Due to this definition problem, we defined, related to actual literature, 2 major (plausibility, reversibility) and 2 minor criteria (repetition, prevention) for a more proper identification of the TCR in a clinical or research setting. Latest research implies that there is a need for a more extended classification with 2 additional subgroups, considering also the diving reflex and the brainstem reflex. In this review, we highlighted criteria for proper definition and classification of the TCR in the light of increased knowledge and present a thinking model to overcome this complexity. Further we separately discussed the role of HR and MABP and their variation in this context. As another subtopic we gave attention to is the chronic TCR; a variant that is rarely seen in clinical medicine.
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Affiliation(s)
- C Meuwly
- From the University of Basel, Switzerland (CM); The Houston Methodist Research Institute, Houston, Texas, USA (EG); Department of Anesthesia and Perioperative Medicine. University of Manitoba, Winnipeg, Canada (TC); Cardiology, St Anna Clinic, Luzern, Switzerland and University of Basel, Switzerland (PE); Department of Research, University of Southampton, United Kingdom (BS); and Academic Editor, Medicine (BS)
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Sandu N, Chowdhury T, Sadr-Eshkevari P, Filis A, Arasho B, Spiriev T, Schaller B. Trigeminocardiac reflex during cerebellopontine angle surgery: anatomical location as a new risk factor. FUTURE NEUROLOGY 2015. [DOI: 10.2217/fnl.14.66] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
ABSTRACT Aim: Trigeminocardicac reflex (TCR), a brainstem reflex, can be manifested in almost all types of surgery in the head and neck region. Patients & methods: Retrospective review of 125 patients operated on cerebellopontine angle (CPA) tumors according to strict inclusion/exclusion criteria. Results: A total of 14 out of 125 patients showed TCR during CPA tumor operation. In total, 29% of those patients presented with a meningioma located exclusively premeatal, but not retromeatal in the CPA. There was significant relationship between meningiomas subgroups and TCR (Barnard test; p < 0.05). Conclusion: Anatomical location may represent an important, but not yet described risk factor for the TCR having therefore an important role in the understanding of the TCR.
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Affiliation(s)
- Nora Sandu
- Department of Neurosurgery, University of Paris, Paris, France
| | - Tumul Chowdhury
- Department of Anesthesia, University of Manitoba, Winnipeg, Canada
| | | | - Andreas Filis
- Department of Neurosurgery, University of Erlangen, Erlangen, Germany
| | - Belachew Arasho
- Department of Neurosurgery, University of Paris, Paris, France
- Department of Neurology, University of Addis Ababa, Addis Ababa, Ethiopia
| | - Toma Spiriev
- Department of Neurosurgery, University of Paris, Paris, France
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
| | - Bernhard Schaller
- Department of Neurosurgery, University of Paris, Paris, France
- Department of Neurology, University of Addis Ababa, Addis Ababa, Ethiopia
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
- Department of Neuroanatomy, University of Pecs, Pecs, Hungary
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Trigeminocardiac reflex: a predictable event with unpredictable aspects. World Neurosurg 2012; 76:407-8. [PMID: 22152566 DOI: 10.1016/j.wneu.2011.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 03/02/2011] [Indexed: 11/22/2022]
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Hemmer LB, Afifi S, Koht A. Trigeminocardiac reflex in the Postanesthesia care unit. J Clin Anesth 2011; 22:205-8. [PMID: 20400008 DOI: 10.1016/j.jclinane.2009.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 02/27/2009] [Accepted: 03/07/2009] [Indexed: 11/30/2022]
Abstract
Bradycardia caused by the oculocardiac reflex is an anticipated occurrence during certain surgeries. The afferent pathway involves the trigeminal nerve's ophthalmic division. Reflex bradycardia from the trigeminocardiac reflex, via stimulation of maxillary or mandibular divisions of cranial nerve V, although less well known, has also been reported intraoperatively. Unstable bradycardia associated with stimulation of the mandibular division of cranial nerve V during trigeminal neuralgia pain episodes in the Postanesthesia Care Unit is presented.
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Affiliation(s)
- Laura B Hemmer
- Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
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Gorini C, Philbin K, Bateman R, Mendelowitz D. Endogenous inhibition of the trigeminally evoked neurotransmission to cardiac vagal neurons by muscarinic acetylcholine receptors. J Neurophysiol 2010; 104:1841-8. [PMID: 20719927 DOI: 10.1152/jn.00442.2010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Stimulation of the nasal mucosa by airborne irritants or water evokes a pronounced bradycardia accompanied by peripheral vasoconstriction and apnea. The dive response, which includes the trigeminocardiac reflex, is among the most powerful autonomic responses. These responses slow the heart rate and reduce myocardial oxygen consumption. Although normally cardioprotective, exaggeration of this reflex can be detrimental and has been implicated in cardiorespiratory diseases, including sudden infant death syndrome (SIDS). An essential component of the diving response and trigeminocardiac reflex is activation of the parasympathetic cardiac vagal neurons (CVNs) in the nucleus ambiguus that control heart rate. This study examined the involvement of cholinergic receptors in trigeminally evoked excitatory postsynaptic currents in CVNs in an in vitro preparation from rats. CVNs were identified using a retrograde tracer injected into the fat pads at the base of the heart. Application of the acetylcholinesterase inhibitor neostigmine significantly decreased the amplitude of glutamatergic neurotransmission to CVNs on stimulation of trigeminal fibers. Whereas nicotine did not have any effect on the glutamatergic responses, the muscarinic acetylcholine receptor (mAChR) agonist bethanechol significantly decreased the excitatory neurotransmission. Atropine, an mAChR antagonist, facilitated these responses indicating this trigeminally evoked brain stem pathway in vitro is endogenously inhibited by mAChRs. Tropicamide, an m4 mAChR antagonist, prevented the inhibitory action of the muscarinic agonist bethanechol. These results indicate that the glutamatergic synaptic neurotransmission in the trigeminally evoked pathway to CVNs is endogenously inhibited in vitro by m4 mAChRs.
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Affiliation(s)
- C Gorini
- George Washington University, Department of Pharmacology and Physiology, 2300 Eye St NW, Washington, DC 20037, USA
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Stavrinou P, Foroglou N, Patsalas I, Selviaridis P. Trigeminocardiac reflex and ipsilateral mydriasis during stereotactic brain tumor biopsy: an insight into the anatomical and physiological pathways involved. Acta Neurochir (Wien) 2010; 152:727-8. [PMID: 19787294 DOI: 10.1007/s00701-009-0509-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 09/03/2009] [Indexed: 11/26/2022]
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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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Schaller B, Filis A, Sandu N, Rasper J, Noethen C, Buchfelder M. Trigemino-cardiac reflex may be refractory to conventional management in adults. Acta Neurochir (Wien) 2008; 150:929-30; author reply 931. [PMID: 18726064 DOI: 10.1007/s00701-008-0010-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schaller BJ, Filis A, Buchfelder M. Detection and prevention of the trigeminocardiac reflex during skull base surgery. Acta Neurochir (Wien) 2007; 149:331. [PMID: 17342380 DOI: 10.1007/s00701-006-1088-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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