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Alexandre AM, Scarcia L, Clarençon F, Camilli A, Bartolo A, Incandela F, Mele DA, Rigante M, Natola M, Valente I, D'Argento F, Galli J, Tshomba Y, Pedicelli A. Preoperative Direct Puncture Embolization Using a Nonadhesive Ethylene Vinyl Alcohol (EVOH) Liquid Embolic Agent for Head and Neck Paragangliomas. Clin Neuroradiol 2024; 34:307-314. [PMID: 38066106 DOI: 10.1007/s00062-023-01364-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/07/2023] [Indexed: 05/29/2024]
Abstract
PURPOSE This retrospective study aimed to assess the safety and technical efficacy of preoperative direct puncture embolization using a nonadhesive ethylene vinyl alcohol (EVOH) copolymer-based liquid embolic agent (LEA) combined with balloon occlusion at the origin of the external carotid artery for head and neck paragangliomas (HNP). METHODS We conducted a review of all consecutive cases of HNPs treated with direct puncture embolization using EVOH-based LEAs between 2017 and 2022 in 2 tertiary high-volume hospitals. RESULTS A total of 25 cases of HNPs in 24 patients underwent direct puncture embolization (12 males, 12 females, mean age 50.9 ± 15.6 years). The average lesion volume was 299.95 mm3. The mean procedure time was 139.11 min, and the mean volume of EVOHs used per case was 19.38 mL. Successful complete devascularization was achieved in all cases, with a homogeneous and deep penetration of the embolic agent into the tumor vessel bed regardless of the LEA type. CONCLUSION Preoperative embolization of HNPs using a direct puncture technique and EVOHs is a safe, efficient, and feasible treatment option with a low risk of complications. This procedure facilitates surgery by transforming tumors into avascular masses that are well-delineated against the surrounding normal tissue.
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Affiliation(s)
- Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy.
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Sorbonne University, APHP, 47, Bd de l'Hôpital, 75013, Paris, France
- Sorbonne University, Paris, France
| | - Arianna Camilli
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
| | - Andrea Bartolo
- Diagnostic and Therapeutic Neuroradiology Unit, IRCCS INM Neuromed, 86077, Isernia, Italy
| | - Francesca Incandela
- UOC Neuroradiologia diagnostica ed interventistica, Arnas Civico Palermo, Italy
| | - Dario Antonio Mele
- Unit of Otorhinolaryngology, Fondazione Policlinico Universitario A.Gemelli IRCCS, 00168, Rome, Italy
| | - Mario Rigante
- Unit of Otorhinolaryngology, Fondazione Policlinico Universitario A.Gemelli IRCCS, 00168, Rome, Italy
| | - Marco Natola
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Francesco D'Argento
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Jacopo Galli
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
- Unit of Otorhinolaryngology, Fondazione Policlinico Universitario A.Gemelli IRCCS, 00168, Rome, Italy
| | - Yamume Tshomba
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
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Kothari DS, Linker LA, Tham T, Maroda AJ, McElfresh JM, Fastenberg JH, Hachem RA, Elijovich L, Michael LM, Rangarajan SV. Preoperative Embolization Techniques in the Treatment of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review. Otolaryngol Head Neck Surg 2023; 169:454-466. [PMID: 36808756 DOI: 10.1002/ohn.303] [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: 10/03/2022] [Revised: 12/20/2022] [Accepted: 01/16/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Preoperative embolization has proven beneficial in the surgical treatment of juvenile nasopharyngeal angiofibromas (JNA). However, the consensus for the best embolization practices remains unclear. This systematic review seeks to characterize the reporting of embolization protocols throughout the literature and to compare differences in surgical outcomes. DATA SOURCES PubMed, Embase, and Scopus. REVIEW METHODS Studies investigating embolization in the treatment of JNA from 2002 to 2021 were selected from defined inclusion criteria. All studies underwent a 2-stage blinded screening, extraction, and appraisal process. Embolization material, time to surgery, and embolization route were compared. Embolization complications, surgical complications, and rate of recurrence were pooled. RESULTS Of 854 studies, 14 retrospective studies with 415 patients met the criteria for inclusion. A total of 354 patients underwent preoperative embolization. A total of 330 patients (93.2%) underwent transarterial embolization (TAE) and 24 patients had a combination of direct puncture embolization and TAE. Polyvinyl alcohol particles were the most used embolization material (n = 264, 80.0%). The most common reported time to surgery was 24 to 48 hours (n = 8, 57.1%). Pooled results showed an embolization complication proportion of 3.16% (95% confidence interval [CI]: 0.96-6.60) (n = 354), a surgical complication proportion of 4.96% (95% CI: 1.90-9.37) (n = 415), and a recurrence proportion of 6.30% (95% CI: 3.01-10.69) (n = 415). CONCLUSION The current data on JNA embolization parameters and their effect on surgical outcomes remains too heterogenous to provide expert recommendations. Future studies should use uniform reporting to allow for more robust comparisons of embolization parameters, which, in turn, may lead to optimized patient outcomes.
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Affiliation(s)
- Dhruv Shreedhar Kothari
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lauren A Linker
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tristan Tham
- Department of Otolaryngology-Head and Neck Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
| | - Andrew J Maroda
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jenessa M McElfresh
- Department of Research and Learning Services, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Judd H Fastenberg
- Department of Otolaryngology-Head and Neck Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
| | - Ralph Abi Hachem
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lattimore Madison Michael
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sanjeet V Rangarajan
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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3
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Sun Z, Bhuiyan P, Lu H, Qian Y, Xiao H. Prognostic factors for trigeminocardiac reflex during cerebrovascular intervention operation. Front Surg 2022; 9:989644. [PMID: 36211295 PMCID: PMC9538902 DOI: 10.3389/fsurg.2022.989644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/09/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Trigeminocardiac reflex (TCR) is a brainstem reflexive response of hemodynamic instability during surgery. Identification of risk factors relevant to TCR during cerebrovascular intervention procedures is helpful to efficiently prevent and treat its occurrence. The purpose of this study was to demonstrate the risk factors for Onyx embolization during cerebrovascular intervention operation so as to optimize perioperative management strategies on TCR. Methods We performed a retrospective study on the patients with Onyx embolization under general anaesthesia over 6-years period from 2013 to 2018. 354 patients were finally eligible for inclusion, and then divided into TCR group (group T) and control group (group N). Patient characteristics, clinical diagnosis, comorbidities, lesion sites, hemodynamics changes, and complications were compared between two groups. Several multivariable regression models were applied to analyze the risk factors associated with TCR. Results TCR occurred in 59 patients (16.7%) among 354 patients. There was no significant difference in patient characteristics between two groups (P > 0.05). During DMSO/Onyx injection, HR and MAP were much lower in group T than group N (P < 0.01). Notably, univariable analysis revealed that the patients with dural arteriovenous fistula (DAVF) and middle meningeal artery being affected were associated with a higher incidence of TCR (P < 0.01). Furthermore, multivariable analysis showed that there was a close link of TCR with DAVF [OR = 4.12; 95% CI (1.83–10.65)] and middle meningeal artery embolization [OR = 3.90; 95% CI (1.58–9.63)]. Further stratified analysis of patients with TCR found that patients with middle meningeal artery embolization were more likely to experience hypotension during TCR episode (P < 0.05). Finally, more incidence of postoperative adverse events was observed when TCR episode (P < 0.05). Conclusion We found that DAVF and middle meningeal artery embolization were independent risk factors for TCR episodes during Onyx endovascular embolization, highly likely leading to intraoperative hemodynamics fluctuations and postoperative adverse events.
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Affiliation(s)
- Zhaochu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Piplu Bhuiyan
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hua Lu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yanning Qian
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Correspondence: Yanning Qian Hang Xiao
| | - Hang Xiao
- Department of Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
- Correspondence: Yanning Qian Hang Xiao
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Ren H, Wang Y, Luo B, Ma L, Ma Y, Yin L, Huang Y. Case Report: Trigeminocardiac Reflex in Endovascular Recanalization of Intracranial Internal Carotid Artery Occlusion. Front Neurol 2022; 13:902620. [PMID: 35911896 PMCID: PMC9328409 DOI: 10.3389/fneur.2022.902620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background The trigeminocardiac reflex (TCR) is a unique brainstem reflex that manifests as sudden negative hemodynamic changes. Although rare, TCR may develop during interventional neuroradiology procedures. Intracranial internal carotid artery occlusion (ICAO) is a cause or risk factor of ischemic stroke. Endovascular recanalization is an effective treatment for intracranial ICAO. The occurrence of TCR during the endovascular treatment of intracranial ICAO has not been reported previously. Methods We identified and reviewed four intracranial ICAO cases who suffered a sudden negative hemodynamic change during endovascular therapy at our hospital between March 2019 and December 2020. Results There were five sudden heart rate and/or blood pressure drops in the four cases; all occurred just after contrast agents were injected. Some angioarchitectural characteristics were common among the four cases. First, the intracranial internal carotid artery distal to the ophthalmic artery was occluded, leaving the ophthalmic artery as the only outflow tract. Second, there were obstructive factors proximal to the end of the guiding catheter, including a vasospasm or dilated balloon. This type of angioarchitecture with a limited outflow tract creates a “blind alley.” The five negative hemodynamic events all recovered: two spontaneously and three after drug administration. Postoperatively, two of the four patients developed ocular symptoms. Conclusions Intracranial ICAOs may produce a distinctive angioarchitecture, such as a blind alley, that predisposes patients to TCR. Surgeons should pay special attention to the possibility of TCR during the endovascular recanalization of intracranial ICAO. Low-pressure contrast injections should be attempted, and anticholinergics should be ready for use.
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Sun Z, Wang R, Dong H, Li Z, Lu H, Hu Y. Prophylactic intra-arterial injection of lidocaine: a novel strategy to prevent endovascular embolization-induced trigeminocardiac reflex. J Neurointerv Surg 2022; 15:473-477. [PMID: 35459713 PMCID: PMC10176414 DOI: 10.1136/neurintsurg-2022-018735] [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: 02/09/2022] [Accepted: 04/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Trigeminocardiac reflex (TCR) is a brainstem reflex that can lead to hemodynamic instability manifested as bradycardia, decrease/increase of mean arterial pressure (MAP) and, in the worst case scenario, asystole during surgery. The effective intraoperative management of recurrent and profound TCR has yet to be established. This randomized paired study was performed to identify the effect of a prophylactic intra-arterial injection of lidocaine to prevent TCR caused by Onyx embolization during cerebrovascular intervention surgery. METHODS A total of 136 patients who received Onyx embolization under general anesthesia were assigned to a control group pretreated with intra-arterial saline injection or a lidocaine group pretreated with an intra-arterial injection of 20 mg lidocaine. Heart rate (HR) and MAP were closely monitored during the embolization procedures and the incidence of TCR, mainly characterized by a decrease in HR of ≥20%, and perioperative adverse events was recorded. RESULTS During dimethyl sulfoxide (DMSO)/Onyx injection, HR was much slower in the control group than in the lidocaine group (p<0.05). TCR occurred in 12 patients (17.6%) in the control group (cardiac arrest in 3 patients) with decreased (7 cases) or increased (5 cases) MAP, whereas no TCR was observed in the lidocaine group. Notably, most TCR episodes occurred in patients with dural arteriovenous fistula and middle meningeal artery being affected. The composite adverse events were significantly higher in the control group than in the lidocaine group (p<0.05). CONCLUSION This prospective study shows that a prophylactic intra-arterial injection of 20 mg lidocaine could be recommended as a novel strategy to effectively and safely prevent TCR during endovascular embolization.
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Affiliation(s)
- Zhaochu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ruiliang Wang
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongquan Dong
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hua Lu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Youli Hu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Glue, Onyx, Squid or PHIL? Liquid Embolic Agents for the Embolization of Cerebral Arteriovenous Malformations and Dural Arteriovenous Fistulas. Clin Neuroradiol 2021; 32:25-38. [PMID: 34324005 PMCID: PMC8894162 DOI: 10.1007/s00062-021-01066-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/01/2021] [Indexed: 12/29/2022]
Abstract
Background Endovascular embolization is an effective treatment option for cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs). A variety of liquid embolic agents have been and are currently used for embolization of AVMs and DAVFs. Knowledge of the special properties of the agent which is used is crucial for an effective and safe embolization procedure. Material and Methods This article describes the properties and indications of the liquid embolic agents which are currently available: cyanoacrylates (also called glues), and the copolymers Onyx, Squid and PHIL, as well as their respective subtypes. Results Cyanoacrylates were the predominantly used agents in the 1980s and 1990s. They are currently still used in specific situations, for example for the occlusion of macro-shunts, for the pressure cooker technique or in cases in which microcatheters are used that are not compatible with dimethyl-sulfoxide. The first broadly used copolymer-based embolic agent Onyx benefits from a large amount of available experience and data, which demonstrated its safety and efficacy in the treatment of cerebral vascular malformations, while its drawbacks include temporary loss of visibility during longer injections and artifacts in cross-sectional imaging. The more recently introduced agents Squid and PHIL aim to overcome these shortcomings and to improve the success rate of endovascular embolization. Novelties of these newer agents with potential advantages include extra-low viscosity versions, more stable visibility, and a lower degree of imaging artifacts. Conclusion All the available liquid embolic agents feature specific potential advantages and disadvantages over each other. The choice of the most appropriate embolic agent must be made based on the specific material characteristics of the agent, related to the specific anatomical characteristics of the target pathology.
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7
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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.
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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
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Intra-Arterial Lidocaine Blunts the Trigeminocardiac Reflex during Endovascular Treatment of a Carotid-Cavernous Fistula. Case Rep Anesthesiol 2021; 2021:2342347. [PMID: 33489381 PMCID: PMC7803410 DOI: 10.1155/2021/2342347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 11/17/2022] Open
Abstract
Carotid-cavernous fistulas (CCFs) are vascular shunts that allow blood to flow from the carotid artery or its branches into the cavernous sinus. Endovascular embolization is the treatment modality of choice. The trigeminocardiac reflex (TCR) is a vagally mediated reflex that can lead to hemodynamic instability. It can be activated during embolization procedures due to the proximity of vagal efferent neurovascular structures within the cavernous sinus. This case report describes the intraoperative management of recurrent, profound bradycardia due to TCR during endovascular CCF embolization.
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Alias Q, Boulouis G, Blauwblomme T, Benichi S, Beccaria K, Gariel F, Garzelli L, Meyer P, Kossorotoff M, Boddaert N, Brunelle F, Naggara O. First Line Onyx Embolization in Ruptured Pediatric Arteriovenous Malformations : Safety and Efficacy. Clin Neuroradiol 2019; 31:155-163. [PMID: 31802150 DOI: 10.1007/s00062-019-00861-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/18/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Brain arteriovenous malformations (bAVM) are the main cause of pediatric intracerebral hemorrhage (pICH). Embolization with Onyx (ev3, Irvine, CA, USA) in children with ruptured bAVM has been infrequently reported. The aim of this study was to assess the safety and efficacy profile of Onyx embolization as first line endovascular treatment of ruptured pediatric bAVMs. METHODS Children with non-traumatic pICH due to bAVM rupture at a pediatric quaternary care center were prospectively enrolled in a registry and retrospectively analyzed between 2013 and 2018. Clinical and demographic data, treatment modalities and clinical imaging follow-up were retrieved, and detailed procedural data were retrospectively assessed by two investigators. The safety (procedural morbidity and mortality) and efficacy (obliteration and interval rebleeding) were evaluated. RESULTS In this study 29 children treated for a bAVM by Onyx embolization were included (14 girls, 48%; median age 11.1 years, interquartile range, IQR 8.1-12.7 years) with a total of 72 endovascular sessions (median of 2 sessions per patient IQR 1-3). The AVMs were deeply located in 23 patients (79%). No systemic complications occurred, and no child experienced embolization-related persistent neurological deficits. Non-clinically relevant complications were observed during five procedures, unrelated to Onyx. After a mean follow-up of 31 months from rupture complete obliteration rates were 100%, 89%, 29%, 14% in bAVM Spetzler Martin grades I, II, III and IV-V, respectively. CONCLUSION It was found that Onyx embolization is safe and represents a good option for an initial treatment approach, in a sequential treatment strategy for pediatric ruptured brain AVMs. Younger age may not be an argument to deny Onyx embolization.
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Affiliation(s)
- Quentin Alias
- Pediatric Radiology, Necker Children Hospital, Paris, France
| | - Grégoire Boulouis
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Kevin Beccaria
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Florent Gariel
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.,Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France.,Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | | | - Philippe Meyer
- Pediatric Neuro ICU, Necker Children Hospital, APHP, Paris, France
| | - Manoelle Kossorotoff
- Department of Pediatric Neurology, French Centre for Pediatric Stroke, APHP University Necker Children Hospital, Paris, France
| | | | | | - Olivier Naggara
- Pediatric Radiology, Necker Children Hospital, Paris, France. .,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.
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10
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Li L, Lin C, Peña M, Challa C. Trigeminocardiac reflex in pediatric adenotonsillectomy: A report of two cases with literature review. Laryngoscope 2019; 130:803-805. [DOI: 10.1002/lary.28016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Lilun Li
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Connie Lin
- Division of Anesthesiology, Pain and Perioperative MedicineChildren's National Health System Washington DC U.S.A
- Department of AnesthesiologyGeorge Washington University Washington DC U.S.A
| | - Maria Peña
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Chaitanya Challa
- Division of Anesthesiology, Pain and Perioperative MedicineChildren's National Health System Washington DC U.S.A
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Meuwly C, Chowdhury T, Gelpi R, Erne P, Rosemann T, Schaller B. The clinical surrogate definition of the trigeminocardiac reflex: Development of an optimized model according to a PRISMA-compliant systematic review. Medicine (Baltimore) 2017; 96:e9033. [PMID: 29245296 PMCID: PMC5728911 DOI: 10.1097/md.0000000000009033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmias including hemodynamic irregularities, apnea, and gastric hypermotility during stimulation of sensory branches of the trigeminal nerve. Since the first description of the TCR 1999, there is an ongoing discussion about a more flexible than the existing clinical definition. Aim of this work was to create a clinical surrogate definition through a systematic review of the literature. METHODS In this meta-analysis study, literature about TCR occurrences was, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, systematically identified through various search engines including PubMed (Medline), Embase (Ovid SP), and ISI Web of Sciences databases from January 2005 to August 2015. TCR was defined as a drop of heart rate (HR) below 60 bpm or 20% to the baseline. We extracted detailed data about hemodynamic changes and searched for connections between arterial blood pressure (BP) and HR changes during such episodes. RESULTS Overall 45 studies harboring 57 patients were included in the study but only 32 patients showed sufficient data for final analyze. HR showed a nonlinear behavior with a "tipping point" phenomena that differs in variance from the central/peripheral (20-30% drop) to ganglion (40-49% drop). BP showed a linear behavior with a "central limit" phenomena not differing in variance in the whole subgroup (30-39% drop). An analyzation of the correlation between BP and HR showed a trend to a linear correlation. CONCLUSIONS We can show for the first time that HR is the dominant variable in the TCR and present a new surrogate definition model. This model and the role of BP must be better investigated in further studies.
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Affiliation(s)
- Cyrill Meuwly
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba, Winnipeg, Canada
| | - Ricardo Gelpi
- Department of Pathology, Institute of Cardiovascular Physiopathology, University of Buenos Aires, Buenos Aires, Argentina
| | - Paul Erne
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Thomas Rosemann
- Department of Primary Care, University of Zurich, Zurich, Switzerland
| | - Bernhard Schaller
- Department of Primary Care, University of Zurich, Zurich, Switzerland
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Trigeminocardiac reflex during endoscopic juvenile nasopharyngeal angiofibroma surgery: an appraisal. Eur Arch Otorhinolaryngol 2017; 274:2779-2784. [PMID: 28324181 DOI: 10.1007/s00405-017-4521-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 02/23/2017] [Indexed: 10/19/2022]
Abstract
Juvenile nasopharyngeal angiofibroma is a locally aggressive benign tumour which has propensity to erode the skull base. The tumour spreads along the pathways of least resistance and is in close proximity to the extracranial part of trigeminal nerve. Advancements in expanded approaches for endoscopic excision of tumours in infratemporal fossa and pterygopalatine fossa increase the vulnerability for the trigeminocardiac reflex. The manipulation of nerve and its branches during tumour dissection can lead to sensory stimulation and thus inciting the reflex. The aim of our study is to report the occurrence of trigeminocardiac reflex in endoscopic excision of juvenile nasopharyngeal angiofibroma. To describe the occurence of trigeminocardiac reflex during endoscopic endonasal excision of juvenile nasopharyngeal angiofibroma. We studied the occurrence of TCR in 15 patients (out of 242 primary cases and 52 revision cases) operated for endoscopic endonasal excision of JNA. The drop in mean arterial blood pressure and heart rate were observed and measured. To the best of our knowledge of English literature, this is the first case series reporting TCR as complication in endoscopic excision of JNA. occurence of this reflex has been mentioned in various occular, maxillofacial surgeries but its occurence during endoscopic excision of JNA has never been reported before. Manifestation of trigeminocardiac reflex during surgery can alter the course of the surgery and is a potential threat to life. It is essential for the anesthetist and surgeons to be familiar with the presentations, preventive measures and management protocols.
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Khatibi K, Choudhri O, Connolly ID, McTaggart RA, Do HM. Asystole During Onyx Embolization of a Pediatric Arteriovenous Malformation: A Severe Case of the Trigeminocardiac Reflex. World Neurosurg 2017; 98:884.e1-884.e5. [DOI: 10.1016/j.wneu.2016.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
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Zhou WZ, Yang GH, Jung SC, Lee DH. Trigeminocardiac Reflex During the Endovascular Treatment of Intracranial Vascular Disease: A Report of Two Cases. Clin Neuroradiol 2015; 26:359-63. [PMID: 26669593 DOI: 10.1007/s00062-015-0491-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 12/08/2015] [Indexed: 11/25/2022]
Affiliation(s)
- W-Z Zhou
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, 138-736, Seoul, Republic of Korea
- Radiology Department, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China
| | - G H Yang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, 138-736, Seoul, Republic of Korea
| | - S C Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, 138-736, Seoul, Republic of Korea
| | - D H Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, 138-736, Seoul, Republic of Korea.
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Lin N, Smith ER, Scott RM, Orbach DB. Safety of neuroangiography and embolization in children: complication analysis of 697 consecutive procedures in 394 patients. J Neurosurg Pediatr 2015; 16:432-8. [PMID: 26114994 DOI: 10.3171/2015.2.peds14431] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The safe treatment of children using catheter-based angiography and embolization poses unique challenges because of the technical factors regarding the size and fragility of access and target vessels, as well as unique pediatric cerebrovascular pathologies. The complication rates for neurointerventional procedures in children have not been established. METHODS The records of a consecutive cohort of pediatric patients who underwent neuroangiography and/or embolization between 2007 and 2013 were reviewed retrospectively to identify both intraprocedural and postprocedural complications. Demographic and clinical risk factors were analyzed with a multivariate logistic regression model. RESULTS The 697 consecutive procedures consisted of 429 diagnostic angiograms and 268 embolizations (mean age of patients 11.1 years; range 4 days to 18 years; 217 females). There were 130 intracranial, 122 extracranial, and 16 spinal embolizations. Pathologies included 28 intracranial arteriovenous malformations (AVMs), 12 spinal AVMs, 19 aneurysms, 29 vein of Galen malformations, 29 dural arteriovenous fistulas, 96 extracranial AVMs, 39 tumors, 3 strokes, and 13 others. Overall, 2 intraprocedural and 1 postprocedural complication (0.7%) occurred in the diagnostic group, all of which were nonneurological events. In the embolization group, 7 intraprocedural and 11 postprocedural complications (6.7%) were observed. Of these complications, 15 were nonneurological events (5.6%), 1 was a short-term neurological event (0.4%), and 2 were long-term neurological events (0.7%). CONCLUSIONS Neither the technical challenges posed by children's access and target vessels nor the unique neuro-vascular pathologies seen in children need result in an elevated morbidity rate related to neuroangiography and embolization. At a dedicated high-volume center, the complication rates may be lower than those for comparable procedures performed in adults.
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Affiliation(s)
- Ning Lin
- Department of Neurosurgery, Weill Cornell Medical Center, New York, New York; and.,Department of Neurosurgery and
| | | | | | - Darren B Orbach
- Division of Interventional and Neurointerventional Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Reyre A, Michel J, Santini L, Dessi P, Vidal V, Bartoli JM, Moulin G, Varoquaux A. Epistaxis: The role of arterial embolization. Diagn Interv Imaging 2015; 96:757-73. [DOI: 10.1016/j.diii.2015.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
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Chowdhury T, Sandu N, Meuwly C, Cappellani RB, Schaller B. Trigeminocardiac reflex: differential behavior and risk factors in the course of the trigeminal nerve. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.13.62] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT; The trigeminocardiac reflex (TCR) is a brainstem reflex describing the acute hemodynamic perturbations in neurosurgical patients. The roles of different anatomic locations of this reflex arc on end responses have been found to be variable. In this article, we have highlighted the role and importance of different TCR pathway (peripheral vs central) mechanisms, their manifestations and the various risk factors associated with these. In addition, new insights into various other non-neurosurgical conditions, in special relation to neurointerventional procedures, are also presented in this article. This study is a narrative review based on a PubMed/Google search (from 1 January 1970 to 31 March 2013) on this topic. The common manifestations, such as hypotension and bradycardia, are vagal-dominated responses; however, unusual manifestations, such as hypertension and tachycardia, signify the involvement of the sympathetic nervous system. In addition, there is a complex interaction of the various sensory receptors at the Gasserian ganglion, and this is responsible for the different presentations. There are many surgical as well as nonsurgical risk factors associated with TCR. Interestingly, TCR may affect functional outcome and has been found to be involved in some normal physiological mechanisms, including bruxism. TCR is a complex neurophysiological reflex and there are variable presentations depending upon the peripheral or central stimulation surrounding the Gasserian ganglion. We suggest, for the first time, that if the TCR is initiated at the Gasserian ganglion, it reacts in a different manner from the better-known central or peripheral TCR.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesia & Perioperative Medicine, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Nora Sandu
- Research University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
| | - Cyrill Meuwly
- University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Ronald B Cappellani
- Department of Anesthesia & Perioperative Medicine, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Bernhard Schaller
- Research University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
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Chowdhury T, Sandu N, Sadr-Eshkevari P, Meuwly C, Schaller B. Trigeminocardiac reflex: current trends. Expert Rev Cardiovasc Ther 2013; 12:9-11. [PMID: 24308808 DOI: 10.1586/14779072.2014.862498] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the first introduction of the trigeminocardiac reflex (TCR) in 1999, substantial new knowledge about this brainstem reflex has been created. First, by different clinical case reports and case studies, and second, from basic research that gives inputs from bench to bedside. In the present work, the authors therefore introduce the molecular/anatomical knowledge of the TCR and show its different connections to clinical aspects. Special reference is given to prevention and treatment of the TCR; but always with a link to knowledge of the basis sciences. In such a context different topics of future interest are introduced.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba, Winnipeg, Canada
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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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Spiriev T, Tzekov C, Laleva L, Kostadinova C, Kondoff S, Sandu N, Schaller B. Central trigeminocardiac reflex in pediatric neurosurgery: a case report and review of the literature. J Med Case Rep 2012; 6:372. [PMID: 23110862 PMCID: PMC3514120 DOI: 10.1186/1752-1947-6-372] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/20/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction Trigeminocardiac reflex is a well-known phenomenon in neurosurgery, craniofacial surgery, ophthalmology and interventional neuroradiology. Even though the trigeminocardiac reflex has become an important factor in skull base surgery and neurosurgery, the central form of trigeminocardiac reflex has only been described in adult subpopulations until now. Case presentation We present a clear form of repetitive trigeminocardiac reflex expressed during revision surgery of a giant (110×61mm) right temporoparietal meningioma in an 18-month-old male Caucasian patient. After cessation of the surgical stimulus, his heart rate and mean arterial blood pressure returned to normal physiological levels. The further follow-up was uneventful. Conclusion Our case demonstrates that the central trigeminocardiac reflex also exists in pediatric patients, especially if manipulating trigeminal innervated structures or around the nerve itself. Whether the incidence and the behavior of the trigeminocardiac reflex is similar in pediatric neurosurgery compared with adult patients has to be shown in further studies.
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Affiliation(s)
- Toma Spiriev
- Department of Neurosurgery, Tokuda Hospital Sofia, 51b Nikola Vaptsarov Boulevard, Sofia, 1407, Bulgaria.
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Transient Cardiac Asystole During Embolization of a Caroticocavernous Fistula. J Neurosurg Anesthesiol 2012; 24:238-9. [DOI: 10.1097/ana.0b013e3182597d57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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