Trigeminocardiac Reflex Research Articles

Management of the trigeminocardiac reflex: Facts and own experience

The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hyper-motility during stimulation of any of the sensory branches of the trigeminal nerve. The proposed mechanism for the development of TCR is--the sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. It has been demonstrated that the TCR may occur with mechanical stimulation of all the branches of the trigeminal nerve anywhere along its course (central or peripheral). The reaction subsides with cessation of the stimulus. But, some patients may develop severe bradycardia, asystole, and arterial hypotension which require intervention. The risk factors already known to increase the incidence of TCR include: Hypercapnia; hypoxemia; light general anesthesia; age (more pronounced in children); the nature of the provoking stimulus (stimulus strength and duration); and drugs: Potent narcotic agents (sufentanil and alfentanil); beta-blockers; and calcium channel blockers. Because of the lack of full understanding of the TCR physiology, the current treatment options for patients with TCR include: (i) risk factor identification and modification; (ii) prophylactic measures; and (iii) administration of vagolytic agents or sympathomimetics.

Asystole due to trigemino-cardiac reflex: A rare complication of trans-sphenoidal surgery for pituitary adenoma

The trigemino-cardiac reflex (TCR) is a well-known reflexive response in which bradycardia, hypotension, and gastric hypermotility are induced by stimulation of a peripheral or central portion of the trigeminal nerve. This reflex occurs during craniofacial surgery and other operations on or near the cerebellopontine angle, petrosal sinus, orbit and trigeminal ganglion. TCR is a well-known, although not well documented, phenomenon commonly observed during trans-sphenoidal surgery for resection of pituitary adenomas. We report a case in which asystole occurred during trans-sphenoidal surgery on a pituitary adenoma that was infiltrating the right cavernous sinus. When the anesthesiologist reported asystole, the team stopped manipulation and administered intravenous atropine. Intra-operative MRI showed a small tumour remnant in the right cavernous sinus. The operation was terminated but subsequent radiosurgery was planned for the residual tumor. Although TCR is rare and usually self-limiting, this case led us to change our treatment strategy. Surgeons who perform trans-sphenoidal surgery should be aware of this potential problem. Invasive pituitary adenomas should be removed gently and the risk of triggering TCR should be kept in mind.

The Trigeminocardiac Reflex as Oxygen Conserving Reflex in Humans: Its Ischemic Tolerance Potential

The Trigeminocardiac Reflex as Oxygen Conserving Reflex in Humans: Its Ischemic Tolerance Potential

Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18

Use of the Onyx liquid embolic system has become an option for treating dural arteriovenous fistulas (DAVFs) because of its advantageous nonadhesive and cohesive properties. However, the complication rates associated with the use of this system have not been reported. The authors present their initial experience of the risks related to transarterial embolization using this system. Between February 2005 and February 2007, 31 patients with DAVFs were treated at Beijing Tiantan Hospital. Transarterial embolization using Onyx-18 was performed as a preoperative adjunct or as definitive therapy. The demographic characteristics, angiographic features, clinical presentation, treatment, and outcome of the patients were reviewed. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. In 19 patients (61.3%) there was complete angiographic evidence of elimination of the shunts and resolution of the symptoms. The remaining 12 patients were treated successfully but did not attain complete embolization and had residual shunting. Adverse events occurred in 5 of 31 patients, with 3 DAVFs located at the tentorium, 1 at the inferior petrosal sinus, and 1 at the cavernous sinus. Complications included trigeminocardiac reflex in 2 patients (6.5%), hemifacial hypesthesia in 3 patients (9.7%), hemifacial palsy in 2 patients (6.5%), jaw pain in 1 patient (3.2%), posterior fossa infarction in 1 patient (3.2%), and microcatheter gluing in 1 patient (3.2%). At the last follow-up examination, all patients had returned to an independent clinical status. Although a complete resolution of symptoms can be achieved with transarterial embolization using the Onyx liquid embolic system, the potential for serious complications exists with this procedure, necessitating the participation of a skilled neurointerventionalist.

The Trigeminocardiac Reflex as Oxygen Conserving Reflex in Humans: Its Ischemic Tolerance Potential

The Trigeminocardiac Reflex as Oxygen Conserving Reflex in Humans: Its Ischemic Tolerance Potential

Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy

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.

Cardiovascular Responses During Percutaneous Radiofrequency Thermocoagulation Therapy in Primary Trigeminal Neuralgia: An Explanation of the Trigeminocardiac Reflex?

Cardiovascular Responses During Percutaneous Radiofrequency Thermocoagulation Therapy in Primary Trigeminal Neuralgia: An Explanation of the Trigeminocardiac Reflex?

Peribulbar block or topical application of local anaesthesia combined for paediatric strabismus surgery

We read with great interest Gupta’s recent study [1] where patients were randomly allocated to either peribulbar block or topical lidocaine combined with general anaesthesia, or general anaesthesia alone, investigating the oculo-cardiac reflex during strabismus surgery. The study is certainly a step in the right direction, as the authors demonstrated a significantly reduced incidence and severity of the oculo-cardiac reflex, part of the trigemino-cardiac reflex. The study also demonstrates the common problem of prophylaxis in the prevention of the intra-operative trigemino-cardiac reflex [2–5]. Gupta et al. found a high incidence of trigemino-cardiac reflex in their control group. This can be explained by the large number of factors that increase its risk [6]. Examples include hypercarbia, hypoxemia, light anaesthesia, young age, pharmacological, potent narcotics (e.g. sufentanil or alfentanil), calcium channel blockers, and the nature of the provoking stimulus. Several pharmacological substances (e.g. gallamine, atropine) have been found already to more or less prevent the occurrence of this reflex during eye surgery [2, 7], but no substance alone has completely suppressed it. A combination of intravenous atropine blocking the myocardial peripheral muscarinic receptor combined with retrobulbar xylocaine hydrochloride blocking conduction at the ciliary ganglion in the afferent limb of the trigemino-cardiac reflex, is effective in controlling it during eye surgery [8]. Gupta’s current results [1] do not justify the routine use of peribulbar block in paediatric anaesthesia to prevent the trigemino-cardiac reflex. The potential usefulness of this technique is much smaller (especially in strabismus surgery), than the potential harmful side effects (e.g. persistent diplopia through direct damage to the inferior rectus muscle).

Trigemino-cardiac reflex may be refractory to conventional management in adults

Dear Sir, We have read with great interest the recent article of Prabhakar et al. [2] that points out some important aspects about how to prevent the trigeminocardiac reflex (TCR), which we have also pinpointed in our recent articles [5, 7, 9]. But the case report of Prabhakar et al. [2] is of great importance because it demonstrates clearly that application of intravenous anticholinergics to block the muscarinic receptors of the heart—either prophylactically or after the elicit of the reflex—cannot be alone a sufficient strategy to prevent further episodes of TCR [3, 4, 8] as it prevent the occurrence of bradycardia; this recommendation is especially and additionally based on (patho)physiological knowledge [3, 4]. One has therefore to assume that the (potential) adverse effects of epinephrine in combination with pretreatment by calcium-channel blockers eliminated by atropine in Prabhakar et al. case report [2] are evoked by a reflex response through the efferent vagus nerve. From our recent investigations, it seems that insufficient microsurgical technique with coagulation may be one of the principal risk factors of subsequent intraoperative occurrence of TCR. It seems that heat—for example by the use of bipolar coagulation—may impose a big risk for the trigger of the TCR [10]. However, it is interesting that Prabhakar et al [2] found that calcium-channel blocker could have been responsible for the occurrence of the TCR in their patient, an observation that we have made also in our initial report [8]. In this context, an interesting case series of Fujita et al. [1] demonstrates that topical anesthesia with lidocaine on the exposed trigeminal nerve may prevent circulatory turbulence based on a sodium channel blockade during skull base surgery, thus, avoiding an excessive increase of general anesthesia. We are far away to understand the TCR [6], but in the last months we have step by step gain further insights in this interesting and important phenomenon of skull base surgery [5]; not at least by the work of Prabhakar et al [2]. These findings may be in line with the suggestion that the TCR is a physiological, but not a pathophysiological entity [3]. Prevention will only be possible, if we better understand the physiology of this reflex.

Trigemino-cardiac reflex may be refractory to conventional management in adults

Trigemino-cardiac reflex may be refractory to conventional management in adults

Transient asystole during endoscopic transsphenoidal surgery: an example of trigeminocardiac reflex

Dear Sir We have read with great interest the case report of AbouZeid et al. [1] demonstrating a trigeminocardiac reflex (TCR) after transsphenoidal surgery in the wall of the cavernous sinus. It underlines our previous findings that a central reflex-triggering is only possible during transsphenoidal surgery by manipulation in the cavernous sinus [2–4]. However, there is strong evidence for our hypothesis that the TCR triggered by peripheral stimulation (via spinal nucleus of trigeminal nerve to the Kolliker-Fuse nucleus) is different from the TCR triggered by central stimulation (via nucleus of solitary tract to the lateral parabrachial nucleus) [2, 5]. The peripheral TCR plays a key role in the diving response of mammals which is induced by face immersion. The diving reflex, elicited in mammals by contact of the fact with cold water, consists of breath holding, intense peripheral vasoconstriction, bradycardia, decreased ventilation and increased mean arterial pressure, with the purpose to prevent drowing and to provide an oxygen reservoir in the lungs, heart and brain [6]. The diving reflex is physiologically programmed to maintain life under conditions of danger but, if pathological, is frequently considered in the pathogenesis of sudden infant death syndrome (SIDS) [7–9]. The main risk factor for intraoperative TCR may be a hyperactive diving reflex underlying our data that demonstrate that TCR is a refractory to conventional management in adults [5]. This hypothesis may be underlined by the finding of Prabhakar et al. [10] who described the occurrence of a TCR in the inital and also in the re-operation of a tumor in the cerebellopontine angle. It is most likely that even minimal alterations or stimulations along neuronal pathways of the reflex arches interfere with the triggering and/or the reflex response and thus could transform a (para)physiological action into a lethal event. Cardiac or cardiorespiratory arrest could happen whenever lesions are located in the central or peripheral neuronal centers and in the most delicate and complex brainstem neuronal circuitry [7, 8]. In conclusion, the partly different reflex arches for peripheral -and central induced-TCR may also explain why the peripheral-induced TCR is seen so seldom in transsphenoidal surgery compared with the centralinduced TCR one [11]. Further studies on triggering factors and related mechanisms are needed to gain a better understanding of the complex interactions involved in the TCR in case of sudden death after diving or other trigeminal stimulation. Precise examinations of the brainstem on serial sections [7–9] are crucial to the identification of the morphological substrates responsible for these reflexes. B. Schaller (&) N. Sandu Departments of Neurosurgery, University of Paris, Paris, France e-mail: skull_base_surgery@yahoo.de

Trigemino-cardiac reflex in humans initiated by peripheral stimulation during neurosurgical skull-base operations. Its first description

The trigemino-cardiac reflex (TCR) is a well-recognised phenomenon (first described in skull base surgery by the authors in 1999) that consists of bradycardia, arterial hypotension, apnoea, and gastric hypermobility. TCR occurs during skull base surgery at or around structures that are innervated by any sensory branch of the trigeminal nerve. Thus far, it has not been shown that peripheral stimulation of a trigeminal nerve can also cause this reflex. The TCR was defined as clinical hypotension with a drop in mean arterial blood pressure (MABP) and in heart rate (HR) of more than 20% compared to the baseline level and coinciding with the surgical manipulation at or around any branches of the trigeminal nerve. The anaesthesiological and the operative techniques that were used were standardised. We describe here a 29-year-old woman with an endocrinological and imaging-proved micro-prolactinoma in which a TCR with a decrease in "arterial blood pressure" (130/70 mmHg up to a 100/40 mmHg) and an accompanying decrease of the HR (70 beats/min to 50 beats/min) was seen during preparation of the nasal mucosa for a transsphenoidal approach under general anaesthesia, lasting a few seconds until normalisation. After immediate application of atropine, the surgical procedure and the post-operative course was uneventful. We present the first report of peripheral stimulation of a sensory branch of the trigeminal nerve that leads to a TCR under general anaesthesia according to our strict criteria as defined in 1999. The present finding is therefore a key research development and gives substantial evidence that TCR is coincident enhancement of sympathetic and parasympathetic outflows to the heart, suggesting that genetic differences may affect the susceptibility for TCR.

Trigemino-cardiac reflex—The trigeminal depressor responses during skull base surgery

Objective To observe and analyze the occurrence and management of the trigemino-cardiac reflex (TCR) defined as the phenomenon of abrupt drops in heart rate (HR) and blood pressure during skull base surgery. Method One hundred patients underwent skull base surgery for various lesions were recruited and great attention was paid to heart rate and blood pressure throughout the surgical procedure to screen intraoperative TCR. Result Twelve patients had TCR intro-operatively, all patients showed abrupt drops in HR of 38% from a mean of 78 beats/min to a mean of 49 beats/min, mean arterial blood pressure (MABP) decreased 33% from a mean of 93 mmHg to a mean of 60 mmHg, respectively. TCR was resolved spontaneously in eight patients, but had to be offset by intraoperative administration of relatively higher dose atropine in another four patients. Conclusion (1) Manipulation at or near the trigeminal nerve during the skull base surgery may cause TCR, even if premedication with anticholinergic drug is used; (2) cessation of irritation from surgical manipulation to disrupt the reflex is the most important step to offset TCR; (3) continuous, especially repeated TCR in some rare cases occasionally necessitates the administration of high dose atropine.

Trigemino-cardiac reflex may be refractory to conventional management in adults

Dear Sir, We appreciate the interest of Schaller and colleagues in our articles on trigemino-cardiac reflex (TCR) [2, 3]. Trigeminocardiac reflex was found to be refractory to the conventional methods of treatment and use of vasopressor was required as reported [2]. We are in line with works of Schaller and colleagues and believe that the reflex could be more of a physiological entity. It could possibly be considered a ‘protective reflex’ during the skull-base surgery as its occurrence suggests manipulation of the vital structures in the brain. It has been reported that cardiovascular changes like bradycardia and sinus arrest can occur following exposure of brain to high temperature [5]. Therefore, heat produced by bipolar coagulation and triggering TCR could also be considered a possibility, as suggested by Schaller and colleagues. It would, however, be interesting to note the clinical outcome of patients who elicit the reflex during intraoperative period. The recent work of Schaller and colleagues [4] and Gharabaghi and colleagues [1] is appreciable and could help provide an answer although there is still a long way to reach the goal.

Transient asystole during endoscopic transsphenoidal surgery for Acromegaly: an example of trigeminocardiac reflex

Cardiac arrhythmias are rare during transsphenoidal surgery and is often secondary to stimulation of the trigeminal nerve endings that supply the nasal passages and cavernous sinus walls. Authors report a patient with Acromegaly, who developed transient asystole, during the dissection of the adenoma extending into the left cavernous sinus wall. In such cases, the use of prophylactic atropine may help to avoid such a complication.

Trigeminocardiac Reflex in Embolization of Intracranial Dural Arteriovenous Fistula

We have read with great interest the article of Lv et al[1][1] about the immediate reproducible and reflexive response of the trigeminocardiac reflex (TCR) stimulation by Onyx (ev3, Irvine, Calif) injection during embolization of a tentorial dural arteriovenous fistula in a 53-year-old man. We are

Asystole via Trigeminocardiac Reflex during Skin Flap Elevation in a Patient Undergoing Craniotomy for Cerebral Aneurysm Clipping - A case report -

The trigeminocardiac reflex (TCR) consists of the sudden development of severe bradycardia or even asystole with arterial hypotension during manipulation of branches of the trigeminal nerve.TCR can occur during craniofacial surgery, rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle.We report a case of TCR-induced asystole during skin flap elevation in a patient undergoing craniotomy for cerebral aneurysm clipping.

Difference in functional outcome of ipsilateral tinnitus after intraoperative occurence of the trigemino-cardiac reflex in surgery for vestibular schwannomas

Surgical manipulation of the fifth cranial nerve in its intra- or extracranial course may lead to bradycardia or even asystole as well as arterial hypotension, a phenomenon described as the trigemino-cardiac reflex (TCR), first described by the authors previously [11]. The authors report here the impact of this reflex on post-operative ipsilateral tinnitus in patients undergoing vestibular schwannoma surgery. Thirty six patients scheduled for vestibular schwannoma surgery were studied retrospectively for parameters influencing the post-operative ipsilateral tinnitus function. According to the occurrence of intra- operative TCR the patients were divided into a TCR-subgroup and a non-TCR subgroup. There was no difference in tumour size between these subgroups. The TCR occurred in 17% of the patients during vestibular schwannoma surgery and influenced the occurrence of post-operative ipsilateral tinnitus: the overall incidence of post-operative ipsilateral tinnitus was 22%. Sixty (60) percent of the patients in the TCR subgroup and 17% of those in the non-TCR subgroup experienced ipsilateral tinnitus postoperatively. There was no correlation between tinnitus and pre- or post-operative hearing function. Hypotension after intra-operative TCR is not only a negative prognostic factor for hearing preservation but also for ipsilateral tinnitus in patients undergoing vestibular schwannoma surgery. In combination with worse hearing function after intra-operative TCR, the present finding underlines the importance of the TCR during skull base surgery in relation to improved functional outcome.

Trigeminocardiac reflex unresponsive to atropine during microvascular decompression of trigeminal nerve root:A potentially lethal complication of a simple surgery

Microvascular decompression (MVD) of trigeminal nerve root entry zone is a well described technique in the treatment of trigeminal neuralgia. It is considered safe and is reported to have a high level of effectiveness.1 Trigeminocardiac reflex (TCR), a reflex consisting of bradycardia, hypotension, apnoea and gastric hypermotility is reported to occur, during craniofacial surgery,2,3 cerebellopontine angle surgery,4 percutaneous micro decompression of trigeminal ganglion5,6 and MVD for trigeminal neuralgia.7 We describe a case of TCR during MVD in a patient on chronic amitryptyline and carbamazepine therapy presenting as bradycardia followed by cardiac arrest nonresponsive to atropine, adrenaline and dopamine. This was successfully treated with isoprenaline and noradrenaline.

Trigeminocardiac Reflex

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.