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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: 2.3] [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: 1.4] [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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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: 43] [Impact Index Per Article: 4.8] [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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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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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: 1.9] [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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Jeon DG, Kang BJ, Hur TW. Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report. Korean J Anesthesiol 2014; 67:209-12. [PMID: 25302098 PMCID: PMC4188768 DOI: 10.4097/kjae.2014.67.3.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/16/2013] [Accepted: 05/16/2013] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Dae Geun Jeon
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Bong Jin Kang
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Tae Won Hur
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
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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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Radvansky BM, Husain Q, Cherla DV, Choudhry OJ, Eloy JA. In-office vasovagal response after rhinologic manipulation. Int Forum Allergy Rhinol 2012. [PMID: 23193039 DOI: 10.1002/alr.21121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advances in endoscopic sinus surgery have led to a greater number of in-office procedures away from the traditional operating room setting. Rhinologists acting independently of anesthesiologists must be prepared for potential complications, such as vasovagal response (VVR), that may arise during in-office rhinologic manipulations. In this study, we review our experience with this condition and discuss risk factors and a management algorithm for in-office VVR. METHODS A retrospective analysis at a large tertiary referral center was performed on all patients undergoing in-office endoscopic procedures with rhinologic manipulation between July 2008 and June 2012. A total of 4973 patients underwent in-office endoscopic procedures and 8 patients with VVR were identified. Demographic data, diagnosis, procedure performed, and outcomes were reviewed. RESULTS Eight patients out of 4973 (0.16%) experienced VVR during in-office endoscopic procedures. Seven (87.5%) of these 8 patients recovered from the VVR within 30 minutes and subsequently completed their scheduled procedure. One (12.5%) of the 8 patients did not fully recover after 30 minutes and was sent to the Emergency Department, where he was stabilized and subsequently discharged. The most common comorbidities in these 8 patients with VVR were hypercholesterolemia in 3 patients (37.5%), and hypertension and benign prostatic hyperplasia, each found in 2 patients (25.0%). CONCLUSION Although the incidence of VVR during rhinologic procedures is low, rhinologists should be familiar with this condition and be prepared for its management.
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Affiliation(s)
- Brian M Radvansky
- Department of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ 07103, USA
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Levine JM, Bisker E, Galetta SL, Kumar MA. The oculocardiac reflex may mimic signs of intracranial hypertension in patients with combined cerebral and ocular trauma. Neurocrit Care 2011; 16:151-3. [PMID: 21607785 DOI: 10.1007/s12028-011-9560-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND In the setting of head trauma, progressive bradycardia may raise suspicion for intracranial hypertension, especially when accompanied by pupillary abnormalities or systemic hypertension. METHODS We describe the case of a patient with concomitant cerebral and ocular trauma who presented with a fixed and dilated pupil and progressive bradycardia due to an oculocardiac reflex. RESULTS The oculocardiac reflex is an unusual cause of bradycardia due to stimulation of the ophthalmic division of the trigeminal nerve and has been described in a variety of clinical settings. CONCLUSIONS Clinicians should be aware that the oculocardiac reflex might mimic signs of intracranial hypertension in patients with combined facial and cerebral trauma.
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Affiliation(s)
- Joshua M Levine
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Trigeminocardiac reflex, bilateral sagittal split ramus osteotomy, Gow-Gates block: a randomized controlled clinical trial. J Oral Maxillofac Surg 2011; 69:2316-20. [PMID: 21511380 DOI: 10.1016/j.joms.2011.01.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 01/15/2011] [Accepted: 01/20/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The behavior of trigeminocardiac reflex (TCR) during maxillofacial surgeries has not yet been sufficiently studied and knowledge of its behavior is limited to some case reports. The present study aimed to assess the occurrence of TCR in bilateral sagittal split ramus osteotomy and to determine the possible effect of Gow-Gates block on its incidence. MATERIALS AND METHODS Twenty candidates for bilateral sagittal split ramus osteotomy (included were American Society of Anesthesiologists I Class III patients with a prognathism of 3 to 5 mm) were given routine general anesthesia after at least 12 hours of fasting. All patients received Gow-Gates mandibular nerve block on 1 random side (case ramus; the other side was used as the control) after induction of general anesthesia before surgery. Pulse rate was recorded at baseline, soft tissue cutting, bone cutting, sagittal splitting, setback manipulation, and recovery. Mean pulse rate values were compared statistically using t test for the 2 sides in patients. RESULTS No statistically significant differences were found between the blocked and control sides except during ramus sagittal splitting and setback manipulation (P < .0001), when a significantly decreased pulse rate was recorded for the control ramus compared with the blocked ramus. CONCLUSIONS The present study provides further evidence for the complex neurophysiologic mechanism and probable prevention of peripheral TCR. The results of the present study should be further validated through future studies but already provide strong evidence that peripheral and central TCR may act differently based on slightly different pathways.
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Cornelius JF, Sadr-Eshkevari P, Arasho BD, Sandu N, Spiriev T, Lemaitre F, Schaller B. The trigemino-cardiac reflex in adults: own experience. Expert Rev Cardiovasc Ther 2010; 8:895-8. [PMID: 20602549 DOI: 10.1586/erc.10.74] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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