1
|
Hayashi H, Abe A, Oguma T, Ito Y, Nakayama A. Sick sinus syndrome diagnosed after a sinus arrest during treatment for zygomatic fracture: a case report. BMC Oral Health 2023; 23:676. [PMID: 37726766 PMCID: PMC10507857 DOI: 10.1186/s12903-023-03413-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Intraoperative sinus arrest is rarely seen during zygomatic fracture treatment. The patient was diagnosed with sick sinus syndrome based on repeated postoperative sinus arrest, which could have resulted in death if diagnosed late, making this case very significant to report. CASE PRESENTATION Sick sinus syndrome is an arrhythmia associated with reduced automaticity of the sinoatrial node or impaired sinoatrial node conduction. We report the case of a 67-year-old man diagnosed with the syndrome after a sinus arrest that occurred during a zygomatic fracture treatment. The patient had cheek pain and mouth opening disorder, dizziness after fainting and sustaining a facial injury. Preoperative examination determined that the syncope was due to drug-induced arrhythmia, and surgery was authorized after drug withdrawal. During the operation, sinus arrest was observed due to trigeminal vagal reflex, and heart rate was restarted by stopping the operation and chest compressions. After the surgery, the patient showed symptoms of dizziness and palpitations, and sinus arrest following atrial fibrillation and supraventricular tachycardia, which was diagnosed as sick sinus syndrome, and a pacemaker was implanted. Currently, 8 years have passed since the surgery, and there are no symptoms of mouth opening disorder, dizziness, or palpitations. CONCLUSIONS In the case of maxillofacial injuries due to syncope, cardiogenic syncope is a possibility, and repeated syncope is a risk for death due to delayed diagnosis. There are no reports of maxillofacial trauma leading to a diagnosis of sick sinus syndrome. The purpose of this case report is to disseminate the importance of diagnosing the cause of syncope as well as injury treatment.
Collapse
Affiliation(s)
- Hiroki Hayashi
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Atsushi Abe
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan.
| | - Tetsushi Oguma
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
| | - Yu Ito
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
| | - Atsushi Nakayama
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
| |
Collapse
|
2
|
Murali SH, Gohil J, Easwer HV. A Sporadic Cisternal Cystic Oculomotor Schwannoma-Case Report and Review of Literature. J Neurosci Rural Pract 2022; 13:571-575. [PMID: 35946014 PMCID: PMC9357479 DOI: 10.1055/s-0042-1749456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Schwannoma arising from a pure motor cranial nerve in sporadic cases is a rare finding. We report adult female patient presented with a seizure without oculomotor palsy. On evaluation, she was diagnosed with cystic oculomotor schwannoma and underwent surgery. She developed oculomotor palsy postoperatively. Here, we describe a rare sporadic cystic oculomotor schwannoma.
Collapse
Affiliation(s)
- Sanjay Honavalli Murali
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences (SCTIMST), Trivandrum, Kerala, India
| | - Jaypalsinh Gohil
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences (SCTIMST), Trivandrum, Kerala, India
| | - H V Easwer
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences (SCTIMST), Trivandrum, Kerala, India
| |
Collapse
|
3
|
Lee YH, Hong JH, Shin HK. Gasserian ganglion radiofrequency thermoablation in a patient with aneurysm of the anterior communicating artery -A case report. Anesth Pain Med (Seoul) 2022; 16:382-386. [PMID: 35139620 PMCID: PMC8828629 DOI: 10.17085/apm.21019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022] Open
Abstract
Background Gasserian ganglion radiofrequency thermoablation is a good treatment option for the management of pain in trigeminal neuralgia. We report a case in which the patient of trigeminal neuralgia combined with anterior cerebral artery aneurysm was treated successfully by gasserian ganglion thermoablation without any complication. Case An 85-year-old female presenting with electric shock like sensation in the gum and molar teeth was diagnosed as trigeminal neuralgia. Carbamazepine medication and trigeminal nerve blockade relieved her pain partially, but severe side effects of carbamazepine occurred. Magnetic resonance angiography of the brain showed saccular aneurysm in inferior aspect of the anterior communicating artery. Gasserian ganglion thermoablation under sedation anesthesia using nicardipine was performed carefully without any rupture of the cerebral aneurysm. Conclusions Gasserian ganglion thermoablation could be performed safely in a patient with cerebral aneurysm without any inadvertent event.
Collapse
Affiliation(s)
- Yong Ho Lee
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Ji Hee Hong
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Hye Kyung Shin
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| |
Collapse
|
4
|
Abstract
BACKGROUND A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination. METHODS World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response. RESULTS With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR. CONCLUSION Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.
Collapse
Affiliation(s)
- Robert W Arnold
- The Alaska OCR Study, Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA
| |
Collapse
|
5
|
Hoshijima H, Takeuchi R, Kikuchi K, Mizuta K. Asystole Triggered by the Mouth Opening With a Dental Mouth Gag Under General Anesthesia During Pediatric Oral Surgery: Report of a Rare Case. J Oral Maxillofac Surg 2021; 79:1862-1865. [PMID: 33939962 DOI: 10.1016/j.joms.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 11/18/2022]
Abstract
The trigeminovagal reflex manifests as a sudden onset of bradycardia, hypotension, and cardiac arrest in response to the stimulation of the trigeminal nerve. The incidence of trigeminovagal reflex in maxillofacial surgical procedures is approximately 1.6%. We report a case of asystole in a pediatric patient in whom a dental mouth gag triggered the trigeminovagal reflex during oral surgery. The patient was a 5-year-old boy who was scheduled to undergo extraction of maxillary supernumerary teeth. After tracheal intubation, anesthesia was maintained with sevoflurane and remifentanil. At the beginning of the surgery, his mouth was opened with a dental mouth gag, and electrocardigram showed asystole for 20 seconds. Thereafter, his heart rate spontaneously returned to basal value within 60 seconds. Since sufficient mouth opening was required to conduct the surgery, his mouth was opened again with the gag. When the interincisal distance exceeded about 40 mm, his heart rate suddenly decreased, but spontaneously returned to baseline within 60 second. The subsequent anesthetic course was uneventful.
Collapse
Affiliation(s)
- Hiroshi Hoshijima
- Associate Professor, Division of Dento-oral Anesthesiology, Tohoku University Graduate School of Dentistry Sendai, Miyagi, Japan.
| | - Risa Takeuchi
- Chief Anesthesiologist, Bunkoukai Special Needs Center, Sakura, Tochigi, Japan
| | - Kimiharu Kikuchi
- Chief Dentist, Bunkoukai Special Needs Center, Sakura, Tochigi, Japan
| | - Kentaro Mizuta
- Chief Professor, Division of Dento-oral Anesthesiology, Tohoku University Graduate School of Dentistry, Sendai, Miyagi, Japan
| |
Collapse
|
6
|
Khalifa GA, Abd-Elmoniem MF, Mohamed FI. The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures? J Craniomaxillofac Surg 2021; 49:394-402. [PMID: 33632536 DOI: 10.1016/j.jcms.2021.02.004] [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: 03/26/2020] [Revised: 11/18/2020] [Accepted: 02/07/2021] [Indexed: 10/22/2022] Open
Abstract
The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant. Out of 260 patients' files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type. There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated. 1Introduction.
Collapse
Affiliation(s)
- Ghada Amin Khalifa
- Maxillofacial Surgery and Diagnostic Science, College of Dentistry, Qassim University, Saudi Arabia; Dental Medicine for Girls, Al Azhar University, 11727, Nasr City, Cairo, Egypt.
| | - Manal Foad Abd-Elmoniem
- Anaesthesia, Intensive Care, and Pain, Faculty of Medicine for Girls, Al Azhar University, 11727, Nasr City, Cairo, Egypt.
| | - Fatma Ibrahim Mohamed
- Oral and Maxillofacial Surgery, Faculty of Dentistry, Deraya University, Minya, Egypt; Dental Medicine for Girls, Al Azhar University, 11727, Nasr City, Cairo, Egypt.
| |
Collapse
|
7
|
Miranda Villasana JE, Ayala Gonzalez DA, Campos Ramírez LA, Hernández Sánchez EJ, Galindo Velázquez G. Reflejo trigémino cardíaco durante artroscopia de la articulación temporomandibular. Reporte de caso clínico. ACTA ODONTOLÓGICA COLOMBIANA 2020. [DOI: 10.15446/aoc.v10n2.88553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción: el reflejo trigémino cardíaco es una respuesta fisiológica parasimpática repentina, que ocasiona alteraciones cardiovasculares importantes durante la estimulación nerviosa en el trayecto del V par craneal, generalmente ocurre al realizar procedimientos quirúrgicos en cirugía oral y maxilofacial, neurocirugía, oftalmología y dermatología. La artroscopia de la articulación temporomandibular ha sido tradicionalmente considerada un procedimiento quirúrgico seguro, mínimamente invasivo, aun así, esta técnica no está exenta de complicaciones neuro y cardiovasculares. Objetivo: presentar un caso clínico que durante una artroscopia de la articulación temporomandibular en la fase de instrumentación del espacio articular superior, y que, bajo monitoreo continuo del anestesiólogo, reportó una bradicardia súbita. Conclusión: el diagnóstico intraoperatorio de reflejo trigémino cardíaco, fue descrito por el servicio de anestesiología recibiendo un tratamiento farmacológico temprano para esta condición, lo que permitió obtener una adecuada evolución trans y postoperatoria.La artroscopia de la articulación temporomandibular ha sido tradicionalmente considerada un procedimiento quirúrgico seguro, mínimamente invasivo, aun así, esta técnica no está exenta de complicaciones.El objetivo de este artículo es presentar un caso clínico que durante una artroscopia de la articulación temporomandibular en la fase de instrumentación del espacio articular superior sufrió una bradicardia súbita, con un diagnóstico intraoperatorio de reflejo trigémino cardíaco, recibiendo un tratamiento temprano por parte del servicio de anestesiología de esta condición, obteniendo una adecuada evolución trans y postoperatoria.
Collapse
|
8
|
Fowler SJ, Featherston M. Recurrent Atrial Tachyarrhythmia Triggered by Percutaneous Balloon Rhizotomy of the Trigeminal Nerve. Anaesth Intensive Care 2019; 32:410-2. [PMID: 15264739 DOI: 10.1177/0310057x0403200318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Stimulation of sensory branches of the trigeminal nerve is known to cause sudden bradycardia (trigeminocardiac reflex). However we report a case where percutaneous balloon rhizotomy of the trigeminal ganglion provoked atrial tachyarrhythmias during two separate treatments. On both occasions the patient was treated with antiarrhythmic drugs and reverted to sinus rhythm within days. Our case demonstrates that surgery involving the trigeminal nerve may cause variable cardiovascular effects that are often clinically significant. Possible mechanisms and management of arrhythmias in this setting are discussed.
Collapse
Affiliation(s)
- S J Fowler
- Department of Anaesthesia, Wellington Hospital, Wellington, New Zealand
| | | |
Collapse
|
9
|
Bhattacharjee A, Rajaram P, Khatua A, Rudresh KB, Krishnamurthy PB. Two Episodes of Trigeminocardiac Reflex During a Pan facial Fracture Surgery, a Rare Phenomenon - Case Report and Review of Literature. J Clin Diagn Res 2017; 11:ZD01-ZD03. [PMID: 29207845 DOI: 10.7860/jcdr/2017/29781.10570] [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: 05/02/2017] [Accepted: 08/08/2017] [Indexed: 11/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Abhishek Bhattacharjee
- Postgraduate Student, Department of Oral and Maxillofacial Surgery, Vokkaligara Sangha Dental College, Bengaluru, Karnataka, India
| | - Prashanth Rajaram
- Senior Lecturer, Department of Oral and Maxillofacial Surgery, Vokkaligara Sangha Dental College, Bengaluru, Karnataka, India
| | - Abhishek Khatua
- Postgraduate Student, Department of Oral and Maxillofacial Surgery, Vokkaligara Sangha Dental College, Bengaluru, Karnataka, India
| | - K B Rudresh
- Reader, Department of Oral and Maxillofacial Surgery, Vokkaligara Sangha Dental College, Bengaluru, Karnataka, India
| | | |
Collapse
|
10
|
Shibao S, Kenawy K, Borghei-Razavi H, Yoshida K. The Trigeminocardiac Reflex During the Anterior Transpetrosal Approach. World Neurosurg 2017; 106:939-944. [PMID: 28739515 DOI: 10.1016/j.wneu.2017.07.086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The anterior transpetrosal approach (ATPA), during which the trigeminal nerve (TN) is manipulated, has a risk of eliciting the trigeminocardiac reflex (TCR). The aim of this study was to assess the risk of TCR during ATPA. METHODS Surgical records of 92 patients who had surgical treatment via ATPA at the Keio University Hospital between December 2005 and June 2015 were retrospectively analyzed. Patients were divided into 2 groups on the basis of the occurrence of TCR during surgery, and clinical and tumor characteristics were compared. Tumor characteristics were evaluated based on preoperative images and intraoperative findings and included the side of the lesion, size of the lesion, tumor size in Meckel cave, pathology of the disease, cavernous sinus invasion, extension into Meckel cave, and adhesion of lesion to TN. RESULTS TCR was observed in 14 of 92 patients (15.2%). TCR occurrence was significantly related to Meckel cave tumor size (P = 0.0264) and adhesion of the lesion to TN (P = 0.0002). CONCLUSIONS This study suggests that TCR is related to Meckel cave tumor size and tumor adhesion to TN in ATPA. To our knowledge, this is the first report describing TCR during ATPA.
Collapse
Affiliation(s)
- Shunsuke Shibao
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.
| | - Karam Kenawy
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan; Department of Neurosurgery, Sohag University, Sohag, Egypt
| | - Hamid Borghei-Razavi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
11
|
Vezina-Audette R, Benedicenti L, Castejon-Gonzalez A, Reiter AM. Anesthesia Case of the Month. J Am Vet Med Assoc 2017; 250:1104-1106. [DOI: 10.2460/javma.250.10.1104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
12
|
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: 0.3] [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.
Collapse
Affiliation(s)
- Monica Patadia
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | | | | |
Collapse
|
13
|
Joshi UM, Munnangi A, Shah K, Patil SG, Thakur N. Trigemino-Cardiac Reflex: A Phenomenon Neglected in Maxillofacial Surgery? J Maxillofac Oral Surg 2016; 16:181-185. [PMID: 28439158 DOI: 10.1007/s12663-016-0959-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 09/01/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Trigemino-cardiac reflex is a physiologic response of the body to pressure effects in the region of distribution of the trigeminal nerve. Oral and maxillofacial surgical procedures can induce the development of this reflex, which leads to significant changes in the heart rate and sinus rhythms. This study intends to evaluate the effects of this reflex in patients with facial fractures and its subsequent management. PATIENTS AND METHODS A total of thirty-seven patients with facial fractures who reported to the Department of Oral and Maxillofacial Surgery at Basaveswar Teaching and General Hospital, Gulbarga during a period from July 2015-March 2016 were considered for the study. RESULTS A male preponderance is observed with the most susceptible age group being 21-30 years. Twenty-three patients sustained mid-facial fractures alone, nine patients had isolated mandible fractures and five patients had fractures of both the mid-face and mandible. A relative bradycardia was observed in the patients with mid-facial trauma, both at the time of presentation and also during the surgical reduction of midfacial fractures which improved after completion of procedure in most of the patients. However, in two patients, the bradycardia progressed to a cardiac asystole during midface manipulation which required immediate halt of the procedure and intravenous administration of atropine. CONCLUSION Trigeminocardiac reflex though physiologic, which usually tends to subside without complications is not to be neglected in the surgeries of the maxillofacial skeleton. A propensity for unforeseen complications due to this reflex has to be avoided by meticulous monitoring of the ECG.
Collapse
Affiliation(s)
- Udupikrishna M Joshi
- Department of Oral and Maxillofacial Surgery, HKES S. Nijalingappa Institute of Dental Science and Research, Gulbarga, India
| | - Ashwini Munnangi
- Department of Oral and Maxillofacial Surgery, HKES S. Nijalingappa Institute of Dental Science and Research, Gulbarga, India
| | - Kundan Shah
- Department of Oral and Maxillofacial Surgery, HKES S. Nijalingappa Institute of Dental Science and Research, Gulbarga, India
| | - Satishkumar G Patil
- Department of Oral and Maxillofacial Surgery, HKES S. Nijalingappa Institute of Dental Science and Research, Gulbarga, India
| | - Nitin Thakur
- Department of Oral and Maxillofacial Surgery, HKES S. Nijalingappa Institute of Dental Science and Research, Gulbarga, India
| |
Collapse
|
14
|
Abstract
BACKGROUND Trigeminocardiac reflex (TCR) consists of bradycardia or asystole along with hypotension and apnea coinciding with stimulation of the trigeminal nerve. During rhinoplasty procedures, we noticed that local anesthetic solution (LAS) application to the columellar area results in bradycardia. We planned to conduct a randomized prospective study on 47 patients undergoing rhinoplasty to demonstrate the characteristics of TCR arising from the columella. METHOD Local anesthetic solution containing 2% prilocaine with 1:80,000 adrenaline was applied under standard general anesthesia protocol. In group 1 (study group, n = 24), 2 mL of LAS was applied to the columella. In group 2 (control group, n = 23), 2 mL of LAS was applied to the nasal dorsum. In group 3 (control group, n = 20), after LAS was applied to nasal dorsum in group 2, we waited for 10 minutes. Then, 2 mL of LAS was applied to the columella. Here, recordings were taken for the columella.Heart rate (HR) and blood pressure (BP) were recorded just before needle insertion (baseline level), at the time of needle insertion (NIT) to the columella or dorsum, and after the 1st, 5th, 10th, 30th, and 60th seconds. RESULTS Transient bradycardia (≥20% drop in HR) was observed in 33% of the patients in group 1.Decrease in HR compared to the baseline level in group 1 was significantly greater than that of groups 2 and 3 at all times (P ≤ 0.05).Systolic BP in NIT and in 60th second in group 1, only in NIT in group 2 was significantly lower than that of baseline levels (P ≤ 0.05). CONCLUSIONS We concluded that stimulation of a sensory branch of the trigeminal nerve in the columellar area leads to TCR under general anesthesia by eliciting clinical hypotension with a drop in systolic BP and in HR of more than 20% compared to the baseline level.Knowing the existence of a certain TCR area will be helpful to the surgeon and anesthesiologist to exercise extra vigilance and to make continuous and meticulous monitoring of the electrocardiogram, HR, and BP during which the TCR may be precipitated such as local anesthetic infiltration to the columellar area in rhinoseptoplasty operations.
Collapse
|
15
|
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.
Collapse
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)
| | | | | | | | | | | |
Collapse
|
16
|
Amirjamshidi A, Abbasioun K, Etezadi F, Ghasemi SB. Trigeminocardiac reflex in neurosurgical practice: Report of two new cases. Surg Neurol Int 2013; 4:126. [PMID: 24233130 PMCID: PMC3815044 DOI: 10.4103/2152-7806.119053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/13/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Systemic hypotension, cardiac dysrhythmia especially bradycardia, apnea, and gastric hypermotility occurring presumably after stimulation of any of the sensory branches of trigeminal nerve are coined as trigeminocardiac reflex (TCR). Neither enough is known about the predisposing factors in relation with the intraoperative occurrence of this life threatening reflex, nor about the exact pathophysiology of its brain stem pathway. ENCOUNTERING TWO CASES OF BRADYCARDIA AND HYPOTENSION DURING SURGERY ENCOURAGED THE AUTHORS TO: (1) report these two cases and review similar reports in the relevant literature, (2) discuss the suggested mechanisms for such an event, and (3) report the result of a prospective cohort of precisely checked cases in a sister article, to remind the younger neurosurgical community of a possible and bothering even mortal, but avoidable complication in their everyday practice. CASE DESCRIPTION The first case was a 71-year-old male who developed bradycardia and hypotension while packing his large sella tursica with autologous fat after removing a large nonfunctional pituitary adenoma transsphenoidally to prevent cerebrospinal fluid leakage. The changes in his vital signs were detected and controlled rapidly. The second case was a 52-year-old female who underwent right pterional craniotomy for right clinoidal meningioma. She developed severe bradycardia and hypotension after skin closure completed and just when the subgaleal drain was connected to the aspirating bag and negative pressure maintained in the subgaleal region. Both cases could be managed successfully after on time detection of such life threatening complication and proper management. CONCLUSION WE DO NOT INTEND ONLY TO ADD TWO NEW CASES OF TCR OCCURRING IN THE PERIOPERATIVE PERIOD IN NEUROSURGICAL PRACTICE, BUT WE WISH TO RAISE THE QUESTION: (a) what could be the predisposing factors for development of such issue for better handling of the problem and (b) stress upon careful continuous mapping of the vital signs during surgery and even till very late after operation.
Collapse
|
17
|
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: 1.8] [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.
Collapse
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
| |
Collapse
|
18
|
Yorgancilar E, Gun R, Yildirim M, Bakir S, Akkus Z, Topcu I. Determination of trigeminocardiac reflex during rhinoplasty. Int J Oral Maxillofac Surg 2012; 41:389-93. [PMID: 22240287 DOI: 10.1016/j.ijom.2011.12.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 10/14/2011] [Accepted: 12/09/2011] [Indexed: 11/19/2022]
Abstract
In most rhinoplasty procedures, osteotomies are usually required. The osteotomy areas are innervated by sensory branches of the trigeminal nerve. The trigeminocardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity during stimulation of the trigeminal nerve. When an osteotomy is performed or external pressure is applied over the nasal bone, the infraorbital nerve may send signals via this nerve. The aim of this prospective study is to determine the blood pressure changes and occurrence of TCR during rhinoplasty. one hundred and eight patients were enrolled into the study. Lidocaine and adrenaline combination (LAC) was injected only into the left lateral osteotomy sites. All patients underwent median, right-side, then left-side lateral osteotomies and nasal pyramid infracture. The haemodynamic changes were recorded. A 10% or more decrease in the heart rate from baseline was considered a TCR. TCR was detected in nine patients following lateral osteotomies and nasal pyramid infracture procedures (8.3%). The authors determined that LAC injection prior to osteotomy did not prevent TCR. Manipulation at or near the infraorbital nerve during rhinoplasty may cause TCR, even if local anaesthetic infiltration is used.
Collapse
Affiliation(s)
- E Yorgancilar
- Department of Otorhinolaryngology and Head and Neck Surgery, Dicle University School of Medicine, Diyarbakir, Turkey.
| | | | | | | | | | | |
Collapse
|
19
|
Vasudev S, Reddy KS. Trigemino-cardiac reflex during orbital floor reconstruction: a case report and review. J Maxillofac Oral Surg 2011; 14:32-7. [PMID: 25861181 DOI: 10.1007/s12663-011-0271-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Accepted: 08/02/2011] [Indexed: 11/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sunil Vasudev
- Department of Oral & Maxillofacial Surgery, DAPMRV Dental College & Hospital, JP Nagar 1st Phase, Bangalore, India
| | - K Sudhakara Reddy
- Department of Oral & Maxillofacial Surgery, Sri Rajiv Gandhi College of Dental Sciences, Bangalore, India
| |
Collapse
|
20
|
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.
Collapse
Affiliation(s)
- Joshua M Levine
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
21
|
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: 2.2] [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.
Collapse
Affiliation(s)
- A S Puri
- Neurointerventional Service, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | |
Collapse
|
22
|
A case of delayed oculocardiac reflex induced by an intraorbital foreign body. Ophthalmic Plast Reconstr Surg 2011; 27:e2-4. [PMID: 20859241 DOI: 10.1097/iop.0b013e3181d644f4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 56-year-old male presented with a history of left periorbital pain, nausea, vomiting, dyspnea, sweating, and pallor. His left eye was injured by a bomb explosion approximately 40 years ago. Evisceration was performed. There were no cardiopulmonary and gastroenterological findings except mild bradycardia (54/min). CT evaluation revealed a 4-cm-sized, sharp, metallic, intraorbital foreign body in the left orbit. After the removal of the foreign body, the symptoms completely resolved with a normal heart rate (69/min). The authors present a case of delayed oculocardiac reflex induced by an old intraorbital foreign body.
Collapse
|
23
|
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.
Collapse
Affiliation(s)
- Laura B Hemmer
- Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | | | | |
Collapse
|
24
|
Ong C, Ong M, Le K, Power M, Wang L, Lam D, Parkinson R, Wenderoth J. The trigeminocardiac reflex in Onyx embolisation of intracranial dural arteriovenous fistula. J Clin Neurosci 2010; 17:1267-70. [DOI: 10.1016/j.jocn.2010.01.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
|
25
|
Tibano AT, de Siqueira SRDT, da Nóbrega JCM, Teixeira MJ. Cardiovascular response during trigeminal ganglion compression for trigeminal neuralgia according to the use of local anesthetics. Acta Neurochir (Wien) 2010; 152:1347-51. [PMID: 20473771 DOI: 10.1007/s00701-010-0664-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 04/13/2010] [Indexed: 12/31/2022]
Abstract
OBJECTIVES There are controversies about the use of local anesthetics during balloon compression for trigeminal neuralgia (TN) as a protective factor for cardiovascular events. The objective of this study was to investigate cardiovascular parameters (blood pressure and heart rate [HR]) of patients that underwent trigeminal balloon compression with local anesthetics compared to a control group (placebo). METHODS This is a randomized controlled study; 55 patients were randomized into two groups: study (deep sedation and trigeminal block with 0.8-mL lidocaine 2%) and control group (deep sedation and trigeminal injection of 0.8-mL saline). Blood pressure and HR were measured in five distinct moments: preoperative, during puncture for local anesthesia/placebo, during puncture with the catheter, during balloon compression, and final evaluation. Statistical analysis was performed with Pearson's chi (2) and McNemar tests and the analysis of variance for repetitive measures. RESULTS The means of systolic and diastolic blood pressures (SBP and DBP, respectively) were higher in the control group when compared to the study group at the evaluation during puncture with the catheter (p < 0.001) and balloon compression (p < 0.001 and p = 0.018 for DBP and SBP, respectively). There was an increase in the HR in the control group during the procedure (p = 0.017). CONCLUSION The use of local anesthetics during the trigeminal balloon compression for TN can have a preventive role for the risk of cardiovascular events.
Collapse
Affiliation(s)
- Adriana Tanaka Tibano
- Neurology Department, Hospital das Clinicas, Medical School, University of São Paulo, São Paulo, SP, Brazil
| | | | | | | |
Collapse
|
26
|
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: 31] [Impact Index Per Article: 2.2] [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.
Collapse
Affiliation(s)
- Behnam Bohluli
- Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Azad University of Tehran, Tehran, Iran
| | | | | | | | | | | |
Collapse
|
27
|
Lübbers HT, Zweifel D, Grätz KW, Kruse A. Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg 2010; 68:1317-21. [PMID: 20347202 DOI: 10.1016/j.joms.2009.12.039] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 11/19/2009] [Accepted: 12/30/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Trigeminocardiac reflex (TCR) in craniomaxillofacial surgery can lead to severely life-threatening situations. At least mild forms are probably much more common than the existing surgical literature suggests. Therefore, the aim of this presentation of cases and literature review was to evaluate the predisposing factors leading to a classification of risk factors for potential TCR and to give information concerning preventive measures and management procedures. PATIENTS AND METHODS All surgery reports from the Department of Cranio-Maxillofacial and Oral Surgery in the University Hospital in Zurich between 2003 and 2008 were searched for severe intraoperative cardiovascular complications, and a literature review was performed for publications concerning asystole or bradycardia during maxillofacial surgical procedures. RESULTS Three incidents were revealed in which severe bradycardia--in 2 cases followed by asystole--had occurred. All incidents were successfully managed. CONCLUSION All craniomaxillofacial surgeons involved in orbital surgery in general and in the treatment of midface fractures, eyelid surgery, and orthognathic procedures in particular should be aware of the possibility of the TCR and should be familiar with its prevention and therapy.
Collapse
Affiliation(s)
- Heinz-Theo Lübbers
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital, Zürich, Switzerland.
| | | | | | | |
Collapse
|
28
|
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: 2.9] [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.
Collapse
Affiliation(s)
- X Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China.
| | | | | | | |
Collapse
|
29
|
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.
Collapse
|
30
|
Bohluli B, Ashtiani AK, Khayampoor A, Sadr-Eshkevari P. Trigeminocardiac reflex: A MaxFax literature review. ACTA ACUST UNITED AC 2009; 108:184-8. [DOI: 10.1016/j.tripleo.2009.03.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Revised: 03/10/2009] [Accepted: 03/20/2009] [Indexed: 11/25/2022]
Affiliation(s)
- Behnam Bohluli
- Oral and Maxillofacial Surgery, School of Dental Medicine, Azad University of Tehran, Tehran, Iran
| | | | | | | |
Collapse
|
31
|
Selk Ghaffari M, Marjani M, Masoudifard M. Oculocardiac reflex induced by zygomatic arch fracture in a crossbreed dog. J Vet Cardiol 2009; 11:67-9. [PMID: 19451043 DOI: 10.1016/j.jvc.2009.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2008] [Revised: 02/01/2009] [Accepted: 02/16/2009] [Indexed: 11/17/2022]
Abstract
A 3-year-old crossbreed male dog was presented with a history of blunt facial trauma. Skull radiographs showed right zygomatic arch fracture. An electrocardiogram revealed bradycardia, first-degree atrioventricular block and QT prolongation. Standard biochemical profile including electrolytes was normal. Atropine response test (0.04 mg/kg intravenously) restored normal sinus rhythm at a rate of 140 bpm with normal QT and PR intervals. This observation is consistent with oculocardiac reflex secondary to zygomatic arch fracture.
Collapse
Affiliation(s)
- Masoud Selk Ghaffari
- Department of Clinical Studies, School of Veterinary Medicine, Islamic Azad University, Karaj Branch, Karaj, Iran.
| | | | | |
Collapse
|
32
|
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: 1.3] [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.
Collapse
|
33
|
Agrawal A, Timothy J, Cincu R, Agarwal T, Waghmare LB. Bradycardia in neurosurgery. Clin Neurol Neurosurg 2008; 110:321-7. [DOI: 10.1016/j.clineuro.2008.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2007] [Revised: 01/25/2008] [Accepted: 01/26/2008] [Indexed: 02/06/2023]
|
34
|
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
| |
Collapse
|
35
|
Prabhakar H, Rath GP, Arora R. Sudden cardiac standstill during skin flap elevation in a patient undergoing craniotomy. J Neurosurg Anesthesiol 2007; 19:203-4. [PMID: 17592354 DOI: 10.1097/ana.0b013e31804e45e8] [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: 11/25/2022]
|
36
|
Webb MD, Unkel JH. Anesthetic Management of the Trigeminocardiac Reflex During Mesiodens Removal—A Case Report. Anesth Prog 2007; 54:7-8. [PMID: 17352528 PMCID: PMC1821135 DOI: 10.2344/0003-3006(2007)54[7:amottr]2.0.co;2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Accepted: 09/12/2006] [Indexed: 11/11/2022] Open
Abstract
We describe a case in which reflection of a palatal flap for removal of a mesiodens is presented as the triggering factor for bradycardia caused by stimulation of the trigeminocardiac reflex. The management of the case, as well as the reflex arc, is discussed.
Collapse
Affiliation(s)
- Michael D Webb
- Virginia Commonwealth University School of Dentistry, Department of Pediatric Dentistry, Richmond, VA 23298, USA.
| | | |
Collapse
|
37
|
Yilmaz T, Erol FS, Yakar H, Köhle U, Akbulut M, Faik Ozveren M. Delayed trigeminocardiac reflex induced by an intraorbital foreign body. Case report. Ophthalmologica 2006; 220:65-8. [PMID: 16374051 DOI: 10.1159/000089277] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2004] [Accepted: 04/15/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To emphasize the importance of the mechanism and surgical approach to trigeminocardiac reflex (TCR) developing 48 h after orbital trauma due to a foreign body. CASE REPORT After gunshot injury of a 17-year-old male patient, computerized tomography evaluation revealed a right globe perforation and an intraorbital metallic foreign body in the right orbita adjacent to the lateral wall. The ocular perforation was repaired, but the foreign body was not removed. Constant bradycardia (45/min) developed 48 h after the operation. Since there were no cardiological findings, a temporary cardiac pacemaker was inserted and on the 6th postoperative day, the foreign body was removed through orbitolateral approach. After the removal of the foreign body, bradycardia completely recovered. CONCLUSION In the presence of an intraorbital foreign body accompanied by globe perforation, TCR may develop 48 h after the trauma and insertion of a temporary pacemaker may be required to control the cardiac rhythm. In this paper, the delayed TCR complication presented an indication for the removal of the intraorbital foreign body.
Collapse
Affiliation(s)
- Turgut Yilmaz
- Department of Ophthalmology, Firat University, School of Medicine, Elazig, Turkey.
| | | | | | | | | | | |
Collapse
|
38
|
Gharabaghi A, Koerbel A, Samii A, Kaminsky J, von Goesseln H, Tatagiba M, Samii M. The impact of hypotension due to the trigeminocardiac reflex on auditory function in vestibular schwannoma surgery. J Neurosurg 2006; 104:369-75. [PMID: 16572648 DOI: 10.3171/jns.2006.104.3.369] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical manipulation of the fifth cranial nerve during its intra- or extracranial course may lead to bradycardia or even asystole as well as arterial hypotension, a phenomenon described as the trigeminocardiac reflex (TCR). The authors studied the impact of this reflex on postoperative auditory function in patients undergoing vestibular schwannoma (VS) surgery.
Methods
One hundred patients scheduled for VS surgery were studied prospectively for parameters influencing the postoperative auditory function. The evaluation included sex, age, pre- and postoperative auditory function, preoperative mean arterial blood pressure, preoperative medical diseases or medication (for example, antiarrhythmia drugs), tumor size and localization, and the intraoperative occurrence of the TCR.
The TCR, which occurred in 11% of the patients, influenced the postoperative hearing function in the patients with Hannover Class T3 and T4 VSs.
With an overall hearing preservation of 47%, 11.1% of the patients in the TCR group and 51.4% of those in the non-TCR group experienced preserved hearing function postoperatively. In cases involving larger tumors (Hannover Class T3 and T4), an intraoperative TCR was associated with a significantly worse postoperative hearing function during VS surgery (p = 0.005).
Conclusions
The hypotension following TCR is a negative prognostic factor for hearing preservation in patients undergoing VS surgery. Patients’ knowledge of this can be increased pre- and postoperatively. Further study of this phenomenon will advance the understanding of the underlying mechanisms and may help to improve hearing preservation by controlling the occurrence of the TCR.
Collapse
Affiliation(s)
- Alireza Gharabaghi
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany.
| | | | | | | | | | | | | |
Collapse
|
39
|
Bauer DF, Youkilis A, Schenck C, Turner CR, Thompson BG. The falcine trigeminocardiac reflex: case report and review of the literature. ACTA ACUST UNITED AC 2005; 63:143-8. [PMID: 15680656 DOI: 10.1016/j.surneu.2004.03.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2003] [Accepted: 03/25/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Trigeminocardiac reflex (TCR), the reproducible hypotension and bradycardia upon stimulation of the trigeminal nerve, has been reported during craniofacial surgery and during surgery within the cerebellopontine angle, petrosal sinus, orbit, and trigeminal ganglion. Whereas the falx cerebri is known to be innervated by the nervus tentorii, a recurrent branch of V1, there have been no reports to date of this response upon mechanical stimulation of the falx. CASE DESCRIPTION We report a case of immediate, reproducible, and reflexive response of asystole upon stimulation of the falx cerebri during operative resection of a parafalcine meningioma in a 53-year-old woman. Upon recognition of the reproducible relationship between falcine stimulation and increased vagal tone, the patient was given glycopyrrolate in an effort to block cholinergic hyperactivity. After glycopyrrolate was given, no further dysrhythmias occurred. CONCLUSION In this patient, mechanical stimulation of the falx likely resulted in the hyperactivity of the trigeminal ganglion, thereby triggering TCR. The dorsal region of the spinal trigeminal tract includes neurons from hypoglossal and vagus nerves, and projections have been seen between the vagus and trigeminal nuclei. The vagus provides parasympathetic innervation to the heart, vascular smooth muscle, and abdominal viscera. Vagal stimulation via these connections after trigeminal nerve activation likely accounts for the reflexive response of asystole seen in this patient. This is confirmed by the observation that the reflex was inhibited by the anticholinergic effects of glycopyrrolate. Awareness of TCR allows for early detection and appropriate treatment.
Collapse
Affiliation(s)
- David F Bauer
- University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | | | | | | | | |
Collapse
|
40
|
Rath GP, Chaturvedi A, Chouhan RS, Prabhakar H. Transient cardiac asystole in transsphenoidal pituitary surgery: a case report. J Neurosurg Anesthesiol 2004; 16:299-301. [PMID: 15557836 DOI: 10.1097/00008506-200410000-00009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Unlike other cardiac arrhythmia, asystole during neurosurgical procedures is not reported in the literature. We describe such a case during transsphenoidal pituitary surgery in a patient who was not having any history of associated cardiac problems. Its possible cause in relation to the perioperative sequence of events has been discussed.
Collapse
Affiliation(s)
- Girija P Rath
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | |
Collapse
|