Abstract
Background:Considering wide variations regarding the incidence of trigeminocardiac reflex (TCR) during cranial neurosurgical procedures, and paucity of reliable data, we intended to design a prospective study to determine the incidence of TCR in patients undergoing standard general anesthesia for surgery of supra/infra-tentorial cranial and skull base lesions.Methods:A total of 190 consecutive patients candidate for elective surgery of supra-tentorial, infra-tentorial, and skull base lesions were enrolled. All the patients were operated in the neurosurgical operating room of a university-affiliated teaching hospital. All surgeries were performed using sufficient depth of anesthesia achieved by titration of propofol–alfentanil mixture, adjusted according to target Cerebral State Index (CSI) values (40-60). All episodes of bradycardia and hypotension indicating the occurrence of TCR during the surgery (sudden decrease of more than 20% from the previous level) were recorded.Results:Four patients, two female and two male, developed episodes of TCR during surgery (4/190; 2.1%). Three patients showed one episode of TCR just at the end of operation when the skin sutures were applied while CSI values were 70-77 and in the last case, when small tumor samples were taken from just beneath the lateral wall of the cavernous sinus TCR episode was seen while the CSI value was 51.Conclusion:TCR is a rare phenomenon during brain surgeries when patient is anesthetized using standard techniques. Keeping the adequate depth of anesthesia using CSI monitoring method may be an advisable strategy during whole period of a neurosurgical procedure.
Highlights
Considering wide variations regarding the incidence of trigeminocardiac reflex (TCR) during cranial neurosurgical procedures, and paucity of reliable data, we intended to design a prospective study to determine the incidence of TCR in patients undergoing standard general anesthesia for surgery of supra/infra‐tentorial cranial and skull base lesions
Was first suggested by a researcher in 1999 when he encountered a drop in mean arterial pressure (MAP) and heart rate (HR) during a skull base surgery procedure
Surgical Neurology International 2013, 4:116 defined the term of TCR as a drop in MAP and HR of more than 20% compared with the baseline values before the stimulus and coinciding with the manipulation around the trigeminal nerve endings.[9,24]
Summary
A total of 190 consecutive patients candidate for elective surgery of supra‐tentorial, infra‐tentorial, and skull base lesions were enrolled. All episodes of bradycardia and hypotension indicating the occurrence of TCR during the surgery (sudden decrease of more than 20% from the previous level) were recorded. A total of 190 consecutive patients with American Society of Anesthesiologists (ASA) grade I‐III who were candidate for elective supra‐ and infra‐tentorial craniotomy, trans‐sphenoidal hypophysectomy and skull base surgery from September 2011 to November 2012 were enrolled. All episodes of bradycardia and hypotension during the surgery (sudden decrease of more than 20% from the previous level) coinciding with a simultaneous surgical manipulation in the territory of trigeminal nerve endings were regarded as TCR.[24] A uniform protocol was designed for treatment of all episodes of TCR as the following: The surgeon must be requested to withdraw the imposing stimulus and simultaneously a bolus dose of IV atropine (20 μg/kg) must be injected via a central venous line. Depth of anesthesia was measured by a cerebral state index (CSI) monitor (Dan meter; Odense, Denmark) during the surgery.[1,4]
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