Posterior meningeal artery DMSO injection resulting in reproducible asystole prior to Onyx therapy of a dural arteriovenous fistula: a previously undescribed variant of the trigeminocardiac reflex or a new phenomenon?

Efficacy of transcutaneous cardiac pacing for transient asystole caused by trigeminocardiac reflex: illustrative case

BACKGROUND

Trigeminocardiac reflex (TCR) is a brainstem reflex caused by stimulation of the trigeminal nerve, which results in bradycardia, hypotension, and asystole. TCR can occur during any neurosurgical procedure. Initially, it is managed via the immediate removal of the stimulus from the trigeminal nerve. If asystole persists after intravenous atropine or glycopyrrolate, chest compression or transcutaneous cardiac pacing may be considered. The authors present the first case of TCR that was successfully managed with transcutaneous cardiac pacing.

OBSERVATIONS

A 51-year-old man presented with aneurysmal subarachnoid hemorrhage. Although he had no history of cardiac disease and there were no abnormal findings on electrocardiography, transient asystole due to TCR occurred during craniotomy. The patient’s heart rate spontaneously recovered after the immediate discontinuation of the procedure. The authors completed aneurysm clipping with transcutaneous cardiac pacing because intravenous atropine was not effective in preventing TCR. There were no complications associated with intraoperative asystole or transcutaneous cardiac pacing, and the patient was discharged without neurological deficits.

LESSONS

TCR can be appropriately managed with the immediate discontinuation of intraoperative procedures. Furthermore, transcutaneous cardiac pacing may be considered for persistent TCR with poor response to intravenous atropine or glycopyrrolate.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

Clinical importance of the posterior meningeal artery: a review of the literature

The posterior meningeal artery, which arises from the vertebral artery, is a critical artery in neurological lesions. However, a comprehensive review of the importance of the posterior meningeal artery is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the posterior meningeal artery to increase our understanding of its role in vascular lesions. The posterior meningeal artery provides the main blood supply to the paramedial and medial portions of the dura covering the cerebellar convexity. The posterior meningeal artery is often involved in dural arteriovenous fistulas occurring near the posterior fossa, and the posterior meningeal artery can be the path for transarterial embolisation or a path through which to monitor the degree of dural arteriovenous fistula embolisation. In posterior circulation ischaemia and moyamoya disease, the posterior meningeal artery can form transdural anastomoses with pial arteries at the surface of the brain, and these can help prevent ischemia. The posterior meningeal artery can also develop aneurysms, most of which are traumatic pseudoaneurysms; patients should therefore be treated in a timely manner or followed up carefully in cases of rebleeding. In addition, during a craniotomy, the posterior meningeal artery should be protected intraoperatively to avoid damaging any transdural anastomosis that may be present. In addition, when the posterior meningeal artery is the main feeding artery of an intracranial tumour, that artery is a satisfactory path for preoperative embolisation. Briefly, the posterior meningeal artery is a very important artery in neurosurgery.