Trigemino-cardiac reflex may be refractory to conventional management in adults

Giuseppe Dagnini (1866-1928): Discoverer of the Trigemino-Cardiac Reflex and Practical Implications in Neurosurgery and Other Medical Specialties

The authors present the life and art of Giuseppe Dagnini, a renowned Italian physician who was born in Bologna in 1866. He was the chief of the Maggiore Hospital in Bologna and authored valuable scientific works on the trigemino-cardiac reflex which is still applied in modern clinical practice. Dr. Dagnini firstly described the reflex in 1908 postulating that stimulation of one of the 3 branches of the trigeminal nerve triggers the afferent pathway in lowering heart rate. The authors also provide a modern outlook on the clinical implications of the TCR in neurosurgery, neuroanesthesia, and other medical specialties.

A case report: A patient rescued by VA-ECMO after cardiac arrest triggered by trigeminocardiac reflex after nasal surgery

RATIONALE

Cardiac arrest (CA) caused by trigeminocardiac reflex (TCR) after endoscopic nasal surgery is rare. Hence, when a patient suffers from TCR induced CA in the recovery room, most doctors may not be able to find the cause in a short time, and standard cardiopulmonary resuscitation and resuscitation measures may not be effective. Providing circulatory assistance through venous-arterial extracorporeal membrane oxygenation (VA-ECMO) can help healthcare providers gain time to identify the etiology and initiate symptom-specific treatment.

PATIENT CONCERNS

We report a rare case of CA after endoscopic nasal surgery treated with VA-ECMO.

DIAGNOSES

We excluded myocardial infarction, pulmonary embolism, allergies, hypoxia, and electrolyte abnormalities based on the relevant examination results. Following a multidisciplinary consultation, clinical manifestation and a review of previous literature, we reasoned that the CA was due to TCR.

INTERVENTIONS

VA-ECMO was established to resuscitate the patient successfully during effective cardiopulmonary resuscitation.

OUTCOMES

ECMO was successfully evacuated a period of 190 minutes of therapy. The patient was discharged home on day 8.

LESSONS

TCR is notable during endoscopic nasal surgery. Our case indicates that CA in operating room is worth prolonged CCPR. The ideal time for ECPR implementation should not be limited within 20 minutes after CCPR.

Unusual Manifestations of the Trigeminocardiac Reflex During Awake Craniotomy: A Case Report and Review of the Literature

The trigeminocardiac reflex (TCR) is triggered by stimulation of a branch of the trigeminal nerve and results in vagally mediated bradycardia, hypotension, apnea, and gastrointestinal hypermotility. In the operating theatre, patients susceptible to TCR are typically under general anesthesia; thus, cardiac abnormalities are the most common manifestation. Our case highlights the less common intraoperative manifestations of gastric hypermotility and apnea in a patient undergoing awake craniotomy for tumor resection. Prompt recognition, removal of stimuli, and airway management prevented catastrophic complications while facilitating completion of the procedure.

Maxillomandibulocardiac reflex in a dog

Background

The trigeminocardiac reflex (TCR) is a brainstem reflex that may be observed in anaesthesia during surgical procedures stimulating the intracranial or peripheral portion of the trigeminal nerve. The peripheral TCR is divided into the oculocardiac reflex and the maxillomandibulocardiac reflex based on the affected sensory branches of the trigeminal nerve. In veterinary medicine the oculocardiac reflex has been described, however the maxillomandibulocardiac reflex has never been reported.

Case presentation

A 5-year-old male Epagneul Breton was presented for surgical management of an upper lip mass. During surgery, a sudden severe bradycardia and a decrease in systemic arterial blood pressure developed. The occurrence of a maxillomandibulocardiac reflex was suspected on the basis of the temporary link between surgical stimulation and haemodynamic changes. Three doses of atropine were given before starting a dopamine infusion due to lack of response. The dopamine infusion normalized heart rhythm and blood pressure. The dog recovered uneventfully and he was discharged 24 h later with a sinus rhythm and no sign of recurrence of arrhythmias.

Conclusion

The TCR is a rare but potentially life-threatening complication of procedures involving the sensory areas innervated by the three branches of the trigeminal nerve and it may cause bradycardia with hypotension. The use of a β1-adrenergic receptor agonist such as dopamine may be indicated in cases of a refractory response to the conventional treatment with atropine.

Two Episodes of Trigeminocardiac Reflex During a Pan facial Fracture Surgery, a Rare Phenomenon - Case Report and Review of Literature

Trigeminocardiac reflex is a sudden physiologic response due to mechanical manipulation of any of the branches of trigeminal nerve. Trigeminocardiac reflex occurs due to pressure effect or stretching of trigeminal nerve which causes fall in blood pressure and decrease in heart rate. In this reflex arc, the trigeminal nerve serves as afferent pathway and vagus nerve, which is cardio inhibitory in nature, serves as efferent pathway. Two episodes of trigeminocardiac reflex during maxillofacial trauma surgery is not a common phenomenon. The present case report describes a case of 40-year-old male patient, diagnosed with pan facial fracture in which two episodes of trigeminocardiac reflex were seen intraoperatively during fracture reduction and fixation of left zygomaticomaxillary complex fracture and inferior orbital rim fracture. Intraoperative management of trigeminocardiac reflex was done by withholding the stimulus and administration of atropine.

Comparative Study of Atropine Combined with Sodium Nitroprusside Pretreatment to Prevent Trigemino Cardiac Reflex after Trigeminal Ganglion Compression

INTRODUCTION

Manipulation of percutaneous compression of the trigeminal ganglion (PCTG) for trigeminal neuralgia (TN) can lead to significant haemodynamic changes, which were termed trigemino cardiac reflex (TCR). Nevertheless, many studies indicated that atropine pretreatment can reduce the incidence of bradycardia and cardiac arrest, but do not take precautions against abrupt rise of blood pressure.

AIM

The purpose of our study was to compare control group {patients receiving Sodium Nitro-Prusside (SNP) pretreatment before PCTG} with study groups (patients receiving different doses of atropine combined with SNP pretreatment before PCTG) in cardiovascular parameters {Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Heart Rate (HR)} at 5 periods during Total Intravenous Anaesthesia (TIVA).

MATERIALS AND METHODS

In total, 120 patients, who underwent PTCG, were enrolled and randomly assigned into control group {group A (SNP pretreatment before PCTG, n=29)} and study groups {group B (0.002mg /kg atropine combined with SNP pretreatment before PCTG, n=30), C (0.004mg/kg atropine pretreatment before PCTG, n=31) and D (0.006mg/kg atropine combined with SNP pretreatment before PCTG, n=30)}, the relationship between haemodynamic changes and using atropine pretreatment or not was compared. Cardiovascular parameters were measured at five periods: preoperative (T0); before puncture (T1); during compression (T2); 1 min after the compression ended (T3); and 1 min after the procedure ended (T4). Multivariate analysis of variance (MANOVA) and Pearson's χ(2) test were used, and a value of p < 0.05 was considered statistically significant.

RESULTS

Compared with the group A, means of SBP and DBP in the study groups (group B, C and D) were not observed significant differences at all time points (p>0.05), the mean values of HR showed significant differences, when compared to group C and group D at T2 and T3 (p<0.001). Meanwhile, means of SBP, DBP and HR comparison in the same group were observed between T1 and T2, to the group A, B and D, means of HR (p>0.05 vs. T1) indicated significant differences, however, there was no significant difference in group C (p>0.05). Furthermore, the incidence of post-compression tachycardia was observed in each group.

CONCLUSION

By comparison, it seemed that 0.004mg/kg atropine pretreatment before PCTG was more reasonable for preventing significant haemodynamic changes.

Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review

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.

Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report

The trigemino-cardiac reflex has been reported to occur during various craniofacial surgeries or procedures including manipulation of the trigeminal ganglion, tumor resection in the cerebellopontine angle, various facial reconstructions and trans-sphenoidal adenomectomy. Regarding risk factors during trans-sphenoidal adenomectomy, invasiveness closely related to the size of tumor and the degree of manipulation of cavernous sinus wall have been reported. We report the case of a 40-year-old female patient who had a relatively small-sized (< 10 mm) pituitary adenoma. Repetitive asystoles occurred during microscopic trans-sphenoidal operation of the wall of the cavernous sinus, which strongly suggests the importance of careful manipulation of the cavernous sinus wall. In addition to reporting this rare complication of trans-sphenoidal adenomectomy, we reviewed its clinical management by performing a literature search.

Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery

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.

Sudden asystole due to trigeminocardiac reflex during transsphenoidal surgery for pituitary tumor

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.

Measured outcomes with hypnosis as an experimental tool in a cardiovascular physiology laboratory

The authors detail their multidisciplinary collaboration of cardiologists, physiologists, neurologists, psychologists, engineers, and statisticians in researching the effects of hypnosis on the cardiovascular system and their additions to that incomplete literature. The article details their results and provides guidelines for researchers interested in replicating their research on hypnosis' effect on the cardiovascular system.

Trigemino-cardiac reflex during orbital floor reconstruction: a case report and review

Trigemino-cardiac reflex is occurrence of hypotension and bradycardia upon surgical manipulation of areas supplied by the trigeminal nerve, and has been reported during craniofacial maxillofacial and ocular surgeries. Communication between the anaesthetic and surgical team is essential, and cessation of the precipitating stimulus is the first and most important therapeutic step. We report a case of immediate, reproducible, and reflexive response of Bradycardia and dysrhythmia upon manipulation of orbital fracture during orbital floor reconstruction in a 65-year-old man. Upon recognition of the reproducible relationship between falcine stimulation and increased vagal tone, the patient was given atropine in an effort to block cholinergic hyperactivity. After atropine administration, no further dysrhythmias occurred and surgery was carried uneventfully.

Trigeminocardiac reflex in the Postanesthesia care unit

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.

Trigemino-cardiac reflex and antecedent transient ischemic attacks

OBJECTIVES

The trigemino-cardiac reflex (TCR) is a brainstem reflex that has gained enormous interest in recent years and was initially described by Schaller and coworkers as a centrally inducible reflex during skull-base surgery. In the meantime, parts of its functional consequences have been described. Here, we present a study that gives special reference to preventive factors of the TCR and investigates the hypothesis linking preceding transient ischemic attacks (TIAs) to the occurrence of TCR.

METHODS

We retrospectively reviewed 338 consecutive patients with the histological diagnosis of a pituitary adenoma, who were operated on from 2000 to 2006 in the Neurosurgery department of the University of Gottingen in Germany. Depending on the occurrence of intraoperative TCR, patients were divided into TCR and non-TCR groups. In 19 of these patients (6%), we found the intraoperative occurrence of the TCR. The patient characteristics between the two subgroups were comparable.

RESULTS

There was a statistically significant difference between the subgroups of precedent TIA (TCR: 11% vs non-TCR: 4%) versus nonprecedent TIA (TCR: 89% vs non-TCR: 96%) regarding the intraoperative occurrence of the TCR (chi(2): p < 0.01).

CONCLUSION

A precedent TIA less than 6 weeks before operation represents a significant risk factor for subsequent intraoperative occurrence of the TCR. Our data may indicate, for the first time, the existence of an oxygen-conserving reflex not only in animals but also in humans. Its neuroprotective effect in the context of the TCR is discussed.

The trigemino-cardiac reflex: an update of the current knowledge

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.