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Asaari SAH, Balasubramaniam D, Ramli N, Ismail F. When brakes fail you: Oculocardiac reflex elicited by a retained foreign body in a penetrating orbital injury. Am J Ophthalmol Case Rep 2024; 34:102029. [PMID: 38464502 PMCID: PMC10921240 DOI: 10.1016/j.ajoc.2024.102029] [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] [Received: 07/11/2023] [Revised: 12/26/2023] [Accepted: 02/20/2024] [Indexed: 03/12/2024] Open
Abstract
Purpose To report a case of oculocardiac reflex following penetrating orbital injury with entrapment of extraocular muscle secondary to a retained orbital foreign body. Observation A 19-year-old man with no known comorbidities presented with a foreign object in his right orbit following a motor vehicle accident. Visual acuity was 20/20 bilaterally with positive relative afferent pupillary defect for the right eye. A motorcycle brake lever was embedded in the right inferotemporal conjunctival fornix, missing his globe. He was bradycardic in the emergency department, with a pulse rate ranging between 45 and 48 beats per minute. An urgent computed tomography scan of the orbit confirmed the penetrating injury with a linear hyperdense foreign body extending from the right inferior orbit into the right maxillary sinus. This foreign body was seen abutting the right lateral rectus and the globe inferiorly. Fractures involving the inferior and medial wall of the right orbit were seen with the inferior rectus, and orbital fat herniated into the maxillary sinus.The patient underwent urgent orbit exploration with foreign body removal and orbital floor repair under general anesthesia. Immediately after removing the foreign body, his pulse rate returned to normal, within 72-80 beats per minute. Six months postoperatively, visual acuity was 20/20 for both eyes. Although he had persistent diplopia on upgaze, he refused any other interventions. Conclusion and importance Prompt detection of the oculocardiac reflex and removal of the inciting stimulus is vital to prevent any life-threatening events.
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Affiliation(s)
- Sabrina Abu Hassan Asaari
- Universiti Malaya Eye Research Centre, Department of Ophthalmology, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Dharshini Balasubramaniam
- Universiti Malaya Eye Research Centre, Department of Ophthalmology, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Norlina Ramli
- Universiti Malaya Eye Research Centre, Department of Ophthalmology, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Fazliana Ismail
- Universiti Malaya Eye Research Centre, Department of Ophthalmology, Universiti Malaya, Kuala Lumpur, Malaysia
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Guo S, Iyengar R, Chudnofsky C, Song B, Zhang-Nunes S. Misdiagnosis of Orbital Foreign Body as Glaucoma Drainage Device. J Emerg Med 2022; 63:e22-e27. [PMID: 35953325 DOI: 10.1016/j.jemermed.2022.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/07/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Sight-threatening complications from retained orbital and intraocular foreign bodies are frequently reported in literature. Delays in diagnosis can result in severe complications, including choroidal neovascularization, infection, and irreversible vision loss. Therefore, it is imperative that emergency physicians consider the possibility of orbital and intraocular foreign bodies when evaluating patients with acute facial trauma. CASE REPORT A 91-year-old woman with a history of laser-treated glaucoma and cataracts presented to an outside emergency department after a ground-level fall. A maxillofacial noncontrast computed tomography scan showed no facial fractures or hemorrhage, but a 41 mm × 4 mm foreign body within the intraconal compartment of the right orbit was identified. The object was presumed to be an implanted glaucoma drainage device, and the patient was discharged without antibiotics. One day after discharge, the patient developed right periorbital swelling and erythema with increasing purulent discharge and skin thickening, ultimately requiring transfer to our facility for management of complex right orbital cellulitis, orbital compartment syndrome, and surgical foreign body removal. Despite globe exploration and surgical intervention, the patient developed a frozen globe with no light perception in the right eye. Why Should an Emergency Physician Be Aware of This? Subtle ophthalmologic emergencies such as sight-threatening foreign bodies can be challenging to diagnose on imaging, particularly with the advent of implantable ocular technology. When an orbital foreign body is discovered in the context of facial trauma, early ophthalmology consultation should be considered.
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Affiliation(s)
- Sarah Guo
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rahul Iyengar
- Roski Eye Institute, University of Southern California, Los Angeles, California
| | - Carl Chudnofsky
- Department of Emergency Medicine, University of Southern California, Los Angeles, California
| | - Brian Song
- Roski Eye Institute, University of Southern California, Los Angeles, California
| | - Sandy Zhang-Nunes
- Roski Eye Institute, University of Southern California, Los Angeles, California.
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Chowdhury T, Sternberg Z, Golanov E, Gelpi R, Rosemann T, Schaller BJ. Photic sneeze reflex: another variant of the trigeminocardiac reflex? FUTURE NEUROLOGY 2019. [DOI: 10.2217/fnl-2019-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The photic sneeze reflex (PSR) is a condition of uncontrollable sneezing episodes in response to bright light. This reflex often manifests as a mild phenomenon but may cause devastating consequences in some situations (aeroplane pilots, car drivers, etc.). Its exact mechanism is poorly understood. Interestingly, the roles of the fifth and tenth cranial nerves, brainstem nuclei and inciting patterns closely mimic a well-known brainstem reflex, known as the trigeminocardiac reflex (TCR). In this critical review, we hypothesize that the PSR can be a variant of the TCR. This concept will lead to a better understanding of the PSR and sharpens the TCR characteristics and open the doors for new research possibilities.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anaesthesiology & Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Zohara Sternberg
- Department of Neurology, Buffalo University of New York, NY, USA
| | - Eugene Golanov
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA & Weill Cornell Medicine, NY, USA
| | - Riccardo Gelpi
- Department of Cardiovascular Pathophysiology, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Thomas Rosemann
- Department of Primary Care, University of Zurich, Zurich, Switzerland
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Chowdhury T, Schaller B. Chronic Trigemino-Cardiac Reflex: An Underestimated Truth. Front Neurol 2017; 8:22. [PMID: 28194134 PMCID: PMC5278256 DOI: 10.3389/fneur.2017.00022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/13/2017] [Indexed: 12/02/2022] Open
Abstract
The trigemino-cardiac reflex (TCR) is a brainstem reflex that manifests as adverse cardiorespiratory events upon the stimulation of sensory branches of the fifth cranial nerve. This reflex is mainly investigated in different neurosurgical procedures and intervention. This reflex is commonly considered as an acute and mild physiological response. On the other hand, more devastating and chronic nature of this reflex is largely underreported and unknown. Therefore, this article aims to provide the comprehensive understanding of the chronic form of TCR, its manifestations, and management by literature search. Also, this paper would certainly impart a better diagnosis and understanding of TCR phenomenon by knowing the relatively less common form of a chronic TCR. This will help thousands and thousands of patients who are still in the phase of diagnosis and are suffering from vague symptoms related to this reflex.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba , Winnipeg, MB , Canada
| | - Bernhard Schaller
- Department of Research, University of Southampton , Southampton , UK
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Merali FI, Grant MP, Mahoney NR. Orbital Floor Fracture with Atypical Extraocular Muscle Entrapment Pattern and Intraoperative Asystole in an Adult. Craniomaxillofac Trauma Reconstr 2015; 8:370-4. [PMID: 26576246 DOI: 10.1055/s-0035-1556052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/31/2015] [Indexed: 10/23/2022] Open
Abstract
Extraocular muscle entrapment in a nondisplaced orbital fracture, although a well-known entity in pediatric trauma, is atypical in adults. It can present with a triad of bradycardia, nausea, and in rare cases, syncope, and result in severe fibrosis of damaged and incarcerated muscle. We present a case of muscle entrapment in a partially nondisplaced two-wall orbital fracture with accompanying preoperative bradycardia and intraoperative asystole in an adult.
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Affiliation(s)
- Farhan I Merali
- Johns Hopkins University, Wilmer Ophthalmological Institute, Baltimore, Maryland
| | - Michael P Grant
- Johns Hopkins University, Wilmer Ophthalmological Institute, Baltimore, Maryland
| | - Nicholas R Mahoney
- Johns Hopkins University, Wilmer Ophthalmological Institute, Baltimore, Maryland
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Use of polyetheretherketone (PEEK) in orbital floor fracture reconstruction – A case for concern. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2015. [DOI: 10.1016/j.ajoms.2014.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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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Pokhraj P S, Jigar J P, Mehta C, Narottam A P. Intraocular metallic foreign body: role of computed tomography. J Clin Diagn Res 2014; 8:RD01-3. [PMID: 25654008 DOI: 10.7860/jcdr/2014/9949.5271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 09/04/2014] [Indexed: 11/24/2022]
Abstract
Orbital foreign bodies remain a serious diagnostic problem, despite development of diagnostic imaging techniques. Non-metallic orbital foreign body will not be detected in routine x-ray. Here we are presenting a case of 32-year-old male presented with acute pain in left eye immediately after he had been pounding a metal object with a metal chisel. Following this event patient develop blurring of vision in left eye with tearing. Patient's vision in left eye was found to be hand motion with conjunctiva mildly injected, left corneal central 1 mm Seidel-negative full-thickness laceration and dense traumatic cataract was seen on ocular examination. Dilated fundus examination of left eye was not possible due to traumatic cataract. Vitreous hemorrhage, vitreous detachment and a echogenic foreign body present in posterior segment in B-Scan sonography. Well-defied hyperdense foreign body producing streak artifacts with vitreous hemorrhage was seen in the posterior chamber of left eyeball in CT orbit. The patient was diagnosed with a corneal laceration, traumatic cataract, vitreous hemorrhage and a metallic intraocular foreign body. He was brought to the operating room urgently for corneal laceration repair, pars plana vitrectomy, lensectomy, and removal of the metallic intraocular foreign body done.
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Affiliation(s)
- Suthar Pokhraj P
- Resident, Department of Radiology, S.S.G. Hospital, Medical College , Vadodara, Gujrat, India
| | - Patel Jigar J
- MBBS Student, Medical Institute & Research Center, Suamandeep Vidhyapeeth University , Waghodia, Vadodara, Gujrat, India
| | - Chetan Mehta
- Associate Professor, Department of Radiology, S.S.G. Hospital, Medical College , Vadodara, Gujrat, India
| | - Patel Narottam A
- Professor, Department of Radiology, S.S.G. Hospital, Medical College , Vadodara, Gujrat, India
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Correction of Severe Enophthalmos by Simultaneous Fat Grafting and Anatomic Orbital Reconstruction. J Craniofac Surg 2014; 25:1829-32. [DOI: 10.1097/scs.0000000000001057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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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.
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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
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Markowski J, Dziubdziela W, Gierek T, Witkowska M, Mrukwa-Kominek E, Niedzielska I, Paluch J. Intraorbital foreign bodies – 5 own cases and review of literature. Otolaryngol Pol 2012; 66:295-300. [DOI: 10.1016/j.otpol.2012.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 10/28/2022]
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A unique case of asystole secondary to facial injury. Case Rep Med 2012; 2012:382605. [PMID: 22454645 PMCID: PMC3297481 DOI: 10.1155/2012/382605] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 11/18/2011] [Accepted: 11/23/2011] [Indexed: 11/17/2022] Open
Abstract
Bradycardia has been reported during intraoperative settings of craniofacial, cerebropontine angle and trigeminal ganglion surgeries (Schaller et al. (2009, 1999); Parbhakar et al. (2009); Koerbel et al. (2005); Roberts et al. (1999)). It is also commonly seen in children undergoing orbital and maxillary fractures repair. This mechanism has been described as the trigeminocardiac reflex (TCR) (Schaller et al. (2009, 2004); Kim et al. (2000); Lang et al. (1991); Van Brocklin et al. (1982)). We report an unusual case of posttraumatic bradycardia and recurrent asystole in a previously healthy adult patient from possible TCR in the absence of any surgical intervention to the head and orbital area.
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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.
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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.
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Affiliation(s)
- Heinz-Theo Lübbers
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital, Zürich, Switzerland.
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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.
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Affiliation(s)
- X Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China.
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Park JH, Chang SD, Lee SY. A Case of Traumatic Optic Nerve Injury due to Gunshot. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.1.177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ji Hyun Park
- Department of Ophthalmology, College of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
| | - Sung Dong Chang
- Department of Ophthalmology, College of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
| | - Se Youp Lee
- Department of Ophthalmology, College of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
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