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La Corte E, Gelmi CAE, Bertolini G, Ruggiero F, Younus I, Sturiale C, Mazzatenta D, Conti A, Aspide R. Giuseppe Dagnini (1866-1928): Discoverer of the Trigemino-Cardiac Reflex and Practical Implications in Neurosurgery and Other Medical Specialties. World Neurosurg 2024; 186:116-121. [PMID: 38521222 DOI: 10.1016/j.wneu.2024.03.086] [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: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 03/25/2024]
Abstract
The authors present the life and art of Giuseppe Dagnini, a renowned Italian physician who was born in Bologna in 1866. He was the chief of the Maggiore Hospital in Bologna and authored valuable scientific works on the trigemino-cardiac reflex which is still applied in modern clinical practice. Dr. Dagnini firstly described the reflex in 1908 postulating that stimulation of one of the 3 branches of the trigeminal nerve triggers the afferent pathway in lowering heart rate. The authors also provide a modern outlook on the clinical implications of the TCR in neurosurgery, neuroanesthesia, and other medical specialties.
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Affiliation(s)
- Emanuele La Corte
- Neurosurgery and Neurotraumatology Unit, Department of Neurosciences, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | | | - Giacomo Bertolini
- Neurosurgery Unit, Head and Neck Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Federica Ruggiero
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy; Maxillofacial Surgery Operative Unit, Bellaria-Maggiore Hospital, Azienda Unità Sanitaria Locale di Bologna, Italy
| | - Iyan Younus
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carmelo Sturiale
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy; Programma Neurochirurgia Ipofisi - Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy; Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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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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Sloekers JC, Herrler A, Hoogland G, Rijkers K, Beckervordersandforth J, van Kuijk SM, Schijns OE. Nerve fiber density differences in the temporal dura mater: an explanation for headache after temporal lobectomy?, An anatomical study. J Chem Neuroanat 2022; 121:102082. [DOI: 10.1016/j.jchemneu.2022.102082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 10/19/2022]
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Cucu AI, Turliuc MD, Costea CF, Dascălu CG, Dumitrescu GF, Sava A, Turliuc Ş, Scripcariu DV, Poeată I. Tumor recurrence in parasagittal and falcine atypical meningiomas invading the superior sagittal sinus. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY 2021; 61:385-395. [PMID: 33544790 PMCID: PMC7864307 DOI: 10.47162/rjme.61.2.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: Parasagittal and falcine meningiomas are still a challenge in terms of surgical resection. Although maximal safe resection is the main therapeutic approach, numerous postoperative complications can still occur depending on the locations of these tumors. Moreover, previous studies have reported that parasagittal meningiomas have a higher recurrence rate than meningiomas with other locations. Patients, Materials and Methods: We retrospectively reviewed 21 patients with parasagittal and falcine atypical meningiomas [World Health Organization (WHO) grade II], nine of whom had their superior sagittal sinus (SSS) invaded by the tumor. We reviewed the demographic information, operative notes, pathological reports, and clinical and imagistic follow-up reports of each patient over a 5-year time span. Results: All the patients were surgically treated, and the tumor removal was grade II according to Simpson’s grading system in 47.6% and grade III in 19% of the cases. The SSS was invaded in 42.9% of the patients. No immediate mortality or morbidity was revealed by our study. Tumor recurrence/progression documented on postoperative imaging amounted to 14.3% and 19%, 12 and 24 months after surgery, respectively. Furthermore, 36, 48 and 60 months after the surgery, the recurrence rate remained the same, namely in 9.5% of the cases. The recurrence was higher in patients with SSS invasion than in patients with no SSS invasion. The tumor recurrence was slightly more predominant in women, i.e., 6% higher than in the male group. Conclusions: In our group of patients with parasagittal and falcine meningiomas, we report a 47.6% Simpson II resection rate and 19% Simpson III resection rate associated with a very low complication rate and no immediately postoperative morbidity and mortality, compared to more aggressive techniques. The recurrence of parasagittal meningiomas predominated after grade III and IV Simpson resection and dural sinus invasion was a negative predictive factor for recurrence. Therefore, the surgery of parasagittal and falcine meningiomas is beneficial, both for tumor control, but also for improving neurological outcome. Aggressive meningioma resection should be balanced with the increased neurosurgical risk.
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Affiliation(s)
- Andrei Ionuţ Cucu
- Department of Ophthalmology, Department of Psychiatry, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Romania; ,
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Sun Z, Lu H, Hu Y. Prophylactic Intra-Arterial Injection of Lidocaine Prevents Trigeminocardiac Reflex During Endovascular Embolization for Dural Arteriovenous Fistula: A Report of 2 Cases. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930837. [PMID: 34077403 PMCID: PMC8183304 DOI: 10.12659/ajcr.930837] [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] [Indexed: 11/23/2022]
Abstract
Case series Patients: Male, 56-year-old • Male, 57-year-old Final Diagnosis: Trigeminocardiac reflex Symptoms: Bradycardia • severe hemodynamic fluctuation Medication: — Clinical Procedure: — Specialty: Anesthesiology • Neurosurgery
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Affiliation(s)
- Zhaochu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China (mainland)
| | - Hua Lu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China (mainland)
| | - Youli Hu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China (mainland)
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Recinos MA, Hsieh J, Mithaiwala H, Mucci JJ, Recinos PF. A rare appearance of the trigeminocardiac reflex during resection of posterior parasagittal meningioma. Surg Neurol Int 2021; 12:183. [PMID: 34084611 PMCID: PMC8168658 DOI: 10.25259/sni_737_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/25/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Although a well-recognized phenomenon of the tentorium and posterior fossa, the trigeminocardiac reflex (TCR) has been rarely reported during surgery involving the posterior falx cerebri. Case Description: We present the case of a 63-year-old woman who underwent repeat resection of an atypical parasagittal meningioma involving the posterior falx. During resection, TCR was repeatedly elicited during manipulation and coagulation of the falx. Air embolism and cardiac etiologies were initially considered while TCR was not suspected, given the location. Ultimately, TCR was recognized when asystole self-resolved upon cessation of stimulus and due to its reproducibility. Conclusion: Awareness by the anesthesiologist and neurosurgeon of the possibility of TCR during falcine procedures can help with rapid identification to avoid a potentially catastrophic outcome.
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Affiliation(s)
- Miguel A Recinos
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
| | - Jason Hsieh
- Department of Neurological Surgery Cleveland Clinic, Cleveland, Ohio, United States
| | - Hussain Mithaiwala
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, United States
| | - Joti Juneja Mucci
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, United States
| | - Pablo F Recinos
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States.,Department of Neurological Surgery Cleveland Clinic, Cleveland, Ohio, United States
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Dhokte N, Sankhla CS, Ratan C, Sankhe M. Cardiac Asystole During Deep Brain Stimulation Surgery. Neurol India 2020; 68:696-697. [PMID: 32643693 DOI: 10.4103/0028-3886.289005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ninad Dhokte
- Department of Anaesthesiology, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Charulata S Sankhla
- Department of Neurology, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Chelani Ratan
- Department of Anaesthesiology, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Milind Sankhe
- Department of Neurosurgery, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
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Suzuki T, Waki H, Imai K, Hisajima T. Electroacupuncture of the Ophthalmic Branch of the Trigeminal Nerve: Effects on Prefrontal Cortex Blood Flow. Med Acupunct 2020; 32:143-149. [PMID: 32595821 DOI: 10.1089/acu.2019.1406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: The current authors observed enhanced cerebral blood flow (CBF) in the prefrontal cortex (PFC) in response to 100-Hz electroacupuncture (EA) stimulation of the ophthalmic branch of the trigeminal nerve. However, it is not yet clear if responsiveness to 100-Hz EA depends on stimulus intensity. This study examined the effects of stimulus strength on PFC CBF during 100-Hz EA of the ophthalmic branch of the trigeminal nerve. Materials and Methods: Twelve subjects underwent 3 acupuncture sessions: I, control, no stimulation; II, 0.1 mA EA; and III, 0.2 mA EA). Needles were inserted 1 cm lateral of the head median line; the anterior insertion point was on the front hairline and the posterior insertion point was ∼7 cm behind the hairline. Stimulation frequency was set to 100-Hz. PFC CBF was measured in terms of oxygenated, deoxygenated, and total hemoglobin (OxyHb, DeoxyHb, TotalHb, respectively), using 16-channel (Ch) near-infrared spectroscopy. Results: Stimulation of 0.2 mA was associated with significant elevation of OxyHb levels in the 0.1 mA condition in Chs 6, 10, and 12. Ch 2-6, 10, 12 signals were notably higher than in the control condition. Stimulation of 0.2 mA and 0.1 mA were associated with significant declines in DeoxyHb levels, compared to the control condition in Ch 4. Finally, 0.2 mA stimulation in Chs 12 and 13 was associated with significant elevation of TotalHb levels in the control condition. Conclusions: Using 0.2-mA stimulation, 100-Hz EA of the ophthalmic nerve enhances PFC CBF more strongly than 0.1-mA stimulation.
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Affiliation(s)
- Takuya Suzuki
- Graduate School of Health Sciences, Teikyo Heisei University, Toshima-ku, Tokyo, Japan
| | - Hideaki Waki
- Faculty of Health Care, Teikyo Heisei University, Toshima-ku, Tokyo, Japan.,Research Institute of Oriental Medicine, Toshima-ku, Tokyo, Japan
| | - Kenji Imai
- Faculty of Health Care, Teikyo Heisei University, Toshima-ku, Tokyo, Japan.,Research Institute of Oriental Medicine, Toshima-ku, Tokyo, Japan
| | - Tatsuya Hisajima
- Faculty of Health Care, Teikyo Heisei University, Toshima-ku, Tokyo, Japan.,Research Institute of Oriental Medicine, Toshima-ku, Tokyo, Japan
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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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Aoki RH, Bezerra IMP, de Almeida-Júnior AD, de A. Barbosa RT, Valenti VE, Oliveira FR, Roque AL, Júnior HMFES, Garner DM, Raimundo RD, de Abreu LC. The effects of cataract surgery on autonomic heart rate control: a prospective cross-sectional and analytical study. Clinics (Sao Paulo) 2019; 74:e809. [PMID: 31508720 PMCID: PMC6724456 DOI: 10.6061/clinics/2019/e809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/10/2019] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the effects of cataract surgery on cardiac autonomic modulation. METHODS A cross-sectional and analytical study was conducted at the Hospital Maria Braido in the city of São Caetano do Sul, São Paulo, between 2015 and 2016. We investigated 19 patients of both sexes who were all over 50 years old; all patients had a diagnosis of senile or bilateral cataracts and were recommended to undergo implantation of the intraocular lens. Heart rate variability (HRV) was evaluated before, during and after cataract surgery. RESULTS There were no significant changes in the time and geometric domains of HRV before, during or after surgery. The high-frequency (HF) band in normalized units (nu) on the spectral analysis significantly increased (p=0.02, Cohen's d=0.9, large effect size). However, the low-frequency (LF) band in nu significantly decreased during surgery (p=0.02, Cohen's d=0.9, large effect size). CONCLUSION Throughout the intraocular lens implantation cataract surgery, there was an increase in parasympathetic modulation and a decrease in the sympathetic component of the heart rate (HR). We propose that this result is attributable to the supine position of the patients during surgery and the trigeminal reflex.
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Affiliation(s)
- Ricardo H Aoki
- Laboratorio de Delineamento de Estudos e Escrita Cientifica, Centro Universitario Saude ABC, Santo Andre, SP, BR
| | - Italla Maria Pinheiro Bezerra
- Laboratorio de Delineamento de Estudos e Escrita Cientifica, Centro Universitario Saude ABC, Santo Andre, SP, BR
- Programa de Mestrado em Politicas Publicas e Desenvolvimento Local da Escola Superior de Ciencias da Santa Casa de Misericordia, Vitoria, ES, BR
- Programa de Mestrado em Ciencias da Saude da Amazonia da Universidade Federal do Acre, Bolsista CAPES Brasil, Rio Branco, AC, BR
| | | | - Renata Thaís de A. Barbosa
- Laboratorio de Delineamento de Estudos e Escrita Cientifica, Centro Universitario Saude ABC, Santo Andre, SP, BR
| | - Vitor E Valenti
- Centro de Estudos do Sistema Nervoso Autonomo, Faculdade de Filosofia e Ciencias, Universidade Estadual Paulista, Marilia, SP, BR
| | - Fernando R Oliveira
- Programa de Pos-Graduacao em Epidemiologia, Faculdade de Saude Publica, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Adriano L Roque
- Programa de Pos-Graduacao em Cardiologia, Universidade Federal de Sao Paulo, Escola Paulista de Medicina, Sao Paulo, SP, BR
| | | | - David M Garner
- Cardiorespiratory Research Group, Department of Biological and Medical Sciences, School of Health and Life Sciences, Oxford Brookes University, Headington Campus, Gipsy Lane, Oxford OX3 0BP, United Kingdom
| | - Rodrigo D Raimundo
- Laboratorio de Delineamento de Estudos e Escrita Cientifica, Centro Universitario Saude ABC, Santo Andre, SP, BR
| | - Luiz Carlos de Abreu
- Laboratorio de Delineamento de Estudos e Escrita Cientifica, Centro Universitario Saude ABC, Santo Andre, SP, BR
- Programa de Mestrado em Politicas Publicas e Desenvolvimento Local da Escola Superior de Ciencias da Santa Casa de Misericordia, Vitoria, ES, BR
- Programa de Mestrado em Ciencias da Saude da Amazonia da Universidade Federal do Acre, Bolsista CAPES Brasil, Rio Branco, AC, BR
- Graduate Entry Medical School, University of Limerick, Limerick, V94 T9PX, Ireland
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Eichberg DG, Casabella AM, Menaker SA, Shah AH, Komotar RJ. Parasagittal and parafalcine meningiomas: integral strategy for optimizing safety and retrospective review of a single surgeon series. Br J Neurosurg 2019; 34:559-564. [PMID: 31284785 DOI: 10.1080/02688697.2019.1635988] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Parafalcine and parasagittal meningiomas present unique challenges for resection. Although maximal safe resection is the primary goal of surgical management for these lesions, venous infarction and eloquent cortical structure damage occur in up to 14% of cases. Therefore, optimal preoperative planning and intraoperative technique is critical.Methods: We retrospectively reviewed a single surgeon's case series with resection of 58 parafalcine and parasagittal meningiomas. Operative strategy included not crossing the superior sagittal sinus (SSS) during craniotomy, not resecting the falx, use of motor evoked potentials (MEPs) to avoid damage to eloquent brain, and selective use of preoperative embolization.Results: Fifty-eight patients, 45 with parasagittal meningiomas and 13 with parafalcine meningiomas were evaluated. Median age 58.34 years and mean follow-up was 7.7 months. Gross total resection (GTR) was achieved in 51.7% of patients and near-gross total resection rate was 48.3%. Postoperative day one discharge rate was 62.1%. Complication rate was 8.6%, with new postoperative neurologic deficit rate of 5.2%. Tumor recurrence/growth documented on postoperative imaging rate was 3.4%.Conclusions: In our series of parasagittal and parafalcine meningioma resection, we report a 51.7% GTR rate associated with a low complication rate. Techniques to minimize perioperative morbidity include not crossing the SSS on craniotomy, avoiding falx resection, using MEPs, and selective preoperative embolization to optimize the chance of a maximal safe resection. We utilize a strategy of conservative initial tumor resection focused on maximizing the chances of a favorable neurologic outcome, followed as necessary by adjuvant therapies such as radiosurgery and salvage therapies such as laser interstitial thermal therapy, although longer follow-up comparable to that of series with more radical approaches is required to determine if long term outcomes are comparable.
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Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amanda M Casabella
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Simon A Menaker
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Shakil H, Wang AP, Horth DA, Nair SS, Reddy KK. Trigeminocardiac Reflex: Case Report and Literature Review of Intraoperative Asystole in Response to Manipulation of the Temporalis Muscle. World Neurosurg 2019; 122:424-427. [DOI: 10.1016/j.wneu.2018.10.186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/23/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022]
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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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Sokolov AY, Murzina AA, Osipchuk AV, Lyubashina OA, Amelin AV. Cholinergic mechanisms of headaches. NEUROCHEM J+ 2017. [DOI: 10.1134/s1819712417020131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Crockett MT, Robinson AE, Aneja H, Phillips TJ. Posterior meningeal artery DMSO injection resulting in reproducible asystole prior to Onyx therapy of a dural arteriovenous fistula: a previously undescribed variant of the trigeminocardiac reflex or a new phenomenon? BMJ Case Rep 2017; 2017:bcr-2017-221033. [PMID: 28739568 DOI: 10.1136/bcr-2017-221033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of reproducible asystole during endovascular treatment of a posterior fossa dural arteriovenous fistula. Catheterisation of the posterior meningeal artery, a branch of the vertebral artery in this patient, followed by dimethyl sulfoxide injection prior to Onyx administration resulted in two episodes of asystole.To the best of our knowledge, this is the first reported case of asystole occurring during endovascular intervention in the posterior meningeal artery. This may represent a previously undescribed variant of the trigemino-cardiac reflex (TGCR) caused by chemical stimulation of small areas of trigeminally innervated posterior fossa dura. Alternatively, this may represent a newly identified phenomenon with chemical stimulation of regions of posterior fossa dura innervated by branches of the vagus nerve leading to increased parasympathetic activity and resultant asystole.In either case, it is important to recognise the potential for such episodes in this vascular territory to allow case planning and management.
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Affiliation(s)
- Matthew Thomas Crockett
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anthony Ernest Robinson
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Harmeet Aneja
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Timothy John Phillips
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Lee SH, Shin KJ, Koh KS, Song WC. Visualization of the tentorial innervation of human dura mater. J Anat 2017; 231:683-689. [PMID: 28695607 DOI: 10.1111/joa.12659] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 01/24/2023] Open
Abstract
Posterior projections of the ophthalmic division of the trigeminal nerve (the ophthalmic nerve) are distributed in the tentorium cerebelli as recurrent meningeal branches. We investigated the morphological tentorial distribution of the ophthalmic nerve. Fifty-two sides of the tentorium cerebelli and adjacent dura mater obtained from 29 human specimens were stained using Sihler's method to examine the nerve fibres in the dural sheets. The innervation patterns of the tentorium cerebelli were classified into the following four types according to their distributions: Type 1, where nerve fibres projected to both the straight and transverse sinuses; Type 2, where nerve fibres projected only to the transverse sinus and lateral convexity; Type 3, where nerve fibres projected medially only to the straight sinus and the posterior part of the falx cerebri; and Type 4, where the nerve fibres terminated within the tentorium cerebelli. Images of the tentorium cerebelli were superimposed to identify areas of dense innervation. The incidence rates of Types 1-4 were 71.2% (n = 37), 21.2% (n = 11), 3.8% (n = 2) and 3.8% (n = 2), respectively. More branches of nerve fibres traversed towards the transverse sinus posterolaterally than towards the straight sinus medially. The space between the anterior half of the straight sinus and the medial tentorial notch can be considered a safe surgical area where innervation is scarce. The posterior part of the falx cerebri was innervated by the ophthalmic nerve that traversed to the straight sinus. The parietal branches of the middle meningeal artery in the lateral convexity that were projected orthogonally by the ophthalmic nerve traversed the transverse sinus, implicating their vulnerability and possible sensitivity under physiological or neurosurgical conditions. This study has revealed the macroscopic tentorial innervation of the dura mater in humans, which could be useful information for both neurosurgeons and neurologists.
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Affiliation(s)
- Shin-Hyo Lee
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Kang-Jae Shin
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Ki-Seok Koh
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Wu-Chul Song
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
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Das KK, Gosal JS, Sharma P, Mehrotra A, Bhaisora K, Sardhara J, Srivastava A, Jaiswal AK, Kumar R, Behari S. Falcine Meningiomas: Analysis of the Impact of Radiologic Tumor Extensions and Proposal of a Modified Preoperative Radiologic Classification Scheme. World Neurosurg 2017; 104:248-258. [PMID: 28478253 DOI: 10.1016/j.wneu.2017.04.159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although extensively studied, few papers have specifically addressed the surgical implications of horizontal and vertical tumor extensions in falcine meningioma (FM). The available classification systems do not address these tumor extensions and thus do not characterize FM in their entirety. OBJECTIVE To determine the influence of radiologic tumor extensions on the clinicoradiologic and surgical aspects of FM, propose a new preoperative radiologic scheme for these tumors, and report our surgical outcomes. METHODS Thirty-five patients with FM (mean age, 50.03 years; male/female ratio, 16:19) were classified into unilateral conventional (type I; n = 17), unilateral high (type II; n = 9) and bilateral FM (type III; n = 9) based on the coronal magnetic resonance imaging findings. We excluded the primary parasagittal meningiomas from our analysis. RESULTS Type II and III tumors were more common in males (unlike the overall cohort), presented more often with seizures, and were associated with less favorable postoperative outcomes. Preoperative motor weakness was almost exclusively seen with the unilateral tumors (type I/II). Preexisting weakness (P = 0.02) was a strong predictor of the likelihood of postoperative motor power worsening, the major surgical complication in our series (n = 9; 25.7%). New-onset postoperative weakness (n = 2) recovered completely, whereas worsening of the preexisting weakness showed only a partial improvement (n = 6). CONCLUSIONS The proposed classification scheme characterizes FMs comprehensively. Bilaterality and parasagittal extensions in FMs affect their clinical presentation, increase surgical difficulty, and influence the surgical outcome adversely. Preexisting motor weakness portends a poor postoperative motor outcome.
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Affiliation(s)
- Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Pradeep Sharma
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kamlesh Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Awadhesh Kumar Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Raj Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Haldar R, Gyanesh P, Srivastava A, Bettaswamy GP. Trigeminocardiac reflex preceding development of postoperative superior orbital fissure syndrome. Asian J Neurosurg 2017; 12:116-119. [PMID: 28413552 PMCID: PMC5379783 DOI: 10.4103/1793-5482.148795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The superior orbital fissure syndrome (SOFS) is a rare condition presenting as painful unilateral opthalmoplegia, ptosis, pupillary dilatation and anesthesia of the upper eyelid and forehead. It has been described after facial trauma. Other etiologies include infections, tumors or spontaneous hemorrhages in the retro-orbital space. Occurrence of SOFS after surgery in the skull base has not been described before. We recently encountered a case where a young female developed SOFS following surgery for cerebrospinal fluid (CSF) rhinorrhea. The occurrence of SOFS was preceded by episodes of trigemino-cardiac reflex (TCR) during the surgery. This is the first case report associating TCR with SOFS. We managed the case report with megadose methylprednisolone and the patient showed improvement in the deficit over time.
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Affiliation(s)
- Rudrashish Haldar
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prakhar Gyanesh
- Department of Neuroanesthesia, Global Hospital, Chennai, Tamil Nadu, India
| | - Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Guru Prasad Bettaswamy
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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An Unusual Case of Asystole Occurring during Deep Brain Stimulation Surgery. Case Rep Neurol Med 2016; 2016:8930296. [PMID: 27217962 PMCID: PMC4863081 DOI: 10.1155/2016/8930296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Symptomatic bradycardia and hypotension in neurosurgery can produce severe consequences if not managed appropriately. The literature is scarce regarding its occurrence during deep brain stimulation (DBS) surgery. Case Presentation. A 67-year-old female presented for left DBS lead placement for essential tremors. During lead implantation, heart rate and blood pressure dropped rapidly; the patient became unresponsive and asystolic. Chest compressions were initiated and epinephrine was given. Within 30 seconds, the patient became hemodynamically stable and conscious. A head CT demonstrated no acute findings. After deliberation, a decision was made to complete the procedure. Assuming the etiology of the episode was the Bezold-Jarisch reflex (BJR), appropriate accommodations were made. The procedure was completed uneventfully. Conclusion. The episode was consistent with a manifestation of the BJR. The patient had a history of neurocardiogenic syncope and a relatively low-volume state, factors prone to the BJR. Overall, lead implantation can still occur safely if preventive measures are employed.
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Chowdhury T, Nöthen C, Filis A, Sandu N, Buchfelder M, Schaller B. Functional Outcome Changes in Surgery for Pituitary Adenomas After Intraoperative Occurrence of the Trigeminocardiac Reflex: First Description in a Retrospective Observational Study. Medicine (Baltimore) 2015; 94:e1463. [PMID: 26376385 PMCID: PMC4635799 DOI: 10.1097/md.0000000000001463] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Trigeminocardiac reflex (TCR) represents now a nearly ubiquitary phenomenon in skull base surgery. Functional relevance of the intrainterventional TCR occurrence is hitherto only proven for vestibular schwannoma. In a retrospective observational study, 19 out of 338 (8%) enrolled adult patients demonstrated a TCR during transsphenoidal/transcranial surgery for pituitary adenomas. The 2 subgroups (TCR vs non-TCR) had similar patient's characteristics, risk factors, and histology. Preoperatively, there was a similar distribution of normal pituitary function in the TCR and non-TCR subgroups. In this TCR subgroup, there was a significant decrease of that normal pituitary function after operation (37%) compared to the non-TCR group (60%) (P < 0.03). The TCR subgroup therefore demonstrated a 3.15 times (95%CI 1.15-8.68) higher risk for non-normalizing of postoperative pituitary function compared with the non-TCR subgroup (P < 0.03). It is presented, for the first time, an impact of TCR on the functional hormonal outcome after pituitary surgery and strongly underline again the importance of the TCR in clinical daily practice. As a consequence, TCR should be considered as a negative prognostic factor of hormonal normalization after surgery for pituitary adenomas that should be included into routine practice.
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Affiliation(s)
- T Chowdhury
- From the Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (CT); Department of Neurosurgery, University of Erlangen-Nuremberg, Germany (NC, FA, BM), and Department of Research, University of Southampton, Southampton, UK (SN, SB)
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Meuwly C, Chowdhury T, Sandu N, Reck M, Erne P, Schaller B. Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review. Medicine (Baltimore) 2015; 94:e807. [PMID: 25950688 PMCID: PMC4602521 DOI: 10.1097/md.0000000000000807] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmia including hypotension, apnea, and gastric hypermotility during stimulation of any branches of the trigeminal nerve. Previous publications imply a relation between TCR and depth of anesthesia. To gain more detailed insights into this hypothesis, we performed a systematic literature review.Literature about occurrence of TCR was systematically identified through searching in Cochrane Central Register of Controlled Trials (CENTRAL), PubMed (MEDLINE), EMBASE (Ovid SP), and the Institute for Scientific Information (ISI Web of Sciences) databases until June 2013, as well as reference lists of articles for risk calculation. In this study, TCR was defined as drop in mean arterial blood pressure and heart rate, both >20% to baseline. We calculated intraoperative cerebral state index (CSI) of each TCR-case using a newly developed method. These data were further divided into 3 subgroups: CSI <40 (deep anesthesia), CSI 40-60 (regular anesthesia), and CSI >60 (slight anesthesia).Including 45 studies with 910 patients, 140 (15%) presented with TCR, and 770 (85%) without TCR during operation. TCR occurrence showed a 1.2-fold higher pooled risk slighter anesthesia (CSI <40: 13%, at CSI 40-60: 21%, and at CSI >60: 27%) compared with deeper anesthesia. In addition, we could discover a 1.3-fold higher pooled risk of higher MABP drop with a strong negative correlation (r = -0.935; r = 0.89) and a 4.5-fold higher pooled risk of asystole during TCR under slight anesthesia compared with deeper anesthesia.Our work is the first systematic review about TCR and demonstrates clear evidence for TCR occurrence and a more severe course of the TCR in slight anesthesia underlying the importance of skills in anesthesia management during skull base surgery. Furthermore, we have introduced a new standard method to calculate the depth of anesthesia.
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Affiliation(s)
- Cyrill Meuwly
- From the University Hospital, 4031 Basel, Switzerland (CM, MR); Cardiology Luzerner Kantonsspital, 6000 Luzern, Switzerland (PE); Present address: Cardiology, St Anna Clinic, St Anna Strasse 32, 6006 Luzern, Switzerland (PE); Departments of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (TC); and Department of Research, University of Southampton, Southampton, UK (NS, BS)
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A reminder about the trigeminocardiac reflex in surgeries at the posterior third of the falx cerebri. INTERDISCIPLINARY NEUROSURGERY 2014. [DOI: 10.1016/j.inat.2014.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Amirjamshidi A, Abbasioun K, Etezadi F, Ghasemi SB. Trigeminocardiac reflex in neurosurgical practice: Report of two new cases. Surg Neurol Int 2013; 4:126. [PMID: 24233130 PMCID: PMC3815044 DOI: 10.4103/2152-7806.119053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/13/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Systemic hypotension, cardiac dysrhythmia especially bradycardia, apnea, and gastric hypermotility occurring presumably after stimulation of any of the sensory branches of trigeminal nerve are coined as trigeminocardiac reflex (TCR). Neither enough is known about the predisposing factors in relation with the intraoperative occurrence of this life threatening reflex, nor about the exact pathophysiology of its brain stem pathway. ENCOUNTERING TWO CASES OF BRADYCARDIA AND HYPOTENSION DURING SURGERY ENCOURAGED THE AUTHORS TO: (1) report these two cases and review similar reports in the relevant literature, (2) discuss the suggested mechanisms for such an event, and (3) report the result of a prospective cohort of precisely checked cases in a sister article, to remind the younger neurosurgical community of a possible and bothering even mortal, but avoidable complication in their everyday practice. CASE DESCRIPTION The first case was a 71-year-old male who developed bradycardia and hypotension while packing his large sella tursica with autologous fat after removing a large nonfunctional pituitary adenoma transsphenoidally to prevent cerebrospinal fluid leakage. The changes in his vital signs were detected and controlled rapidly. The second case was a 52-year-old female who underwent right pterional craniotomy for right clinoidal meningioma. She developed severe bradycardia and hypotension after skin closure completed and just when the subgaleal drain was connected to the aspirating bag and negative pressure maintained in the subgaleal region. Both cases could be managed successfully after on time detection of such life threatening complication and proper management. CONCLUSION WE DO NOT INTEND ONLY TO ADD TWO NEW CASES OF TCR OCCURRING IN THE PERIOPERATIVE PERIOD IN NEUROSURGICAL PRACTICE, BUT WE WISH TO RAISE THE QUESTION: (a) what could be the predisposing factors for development of such issue for better handling of the problem and (b) stress upon careful continuous mapping of the vital signs during surgery and even till very late after operation.
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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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Benatar-Haserfaty J, Tardáguila Sancho P. [Anesthesia for craniotomy in the conscious patient]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:264-74. [PMID: 23337779 DOI: 10.1016/j.redar.2012.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 11/14/2012] [Indexed: 11/27/2022]
Abstract
Craniotomy in the conscious patient (CPC) enables the neurological changes to be assessed during the mapping in epilepsy surgery, the location of the electrodes during deep brain stimulation surgery, and tumor resection in eloquent areas of the brain. CPC is a useful technique for radical surgery in order to minimize the damage to the functional areas of the brain. The anesthesiologist must ensure, adequate patient comfort, analgesia and ensure optimal collaboration. The appropriate selection of potential candidates for CPC should be made jointly with all professionals involved in the case. Knowledge of the different phases of CPC, coordination and communication among specialists, the right management of the pharmacology, and anesthetic techniques specific to CPC, along with the ability of psycho-emotional communication with the patient, determine the success of the procedure to be performed in the culture of patient safety. The aim of this review was to describe the anesthetic management, comprehensive considerations, and intraoperative neurophysiological tests for CPC.
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Affiliation(s)
- J Benatar-Haserfaty
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España.
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Kemp WJ, Tubbs RS, Cohen-Gadol AA. The Innervation of the Cranial Dura Mater: Neurosurgical Case Correlates and a Review of the Literature. World Neurosurg 2012; 78:505-10. [DOI: 10.1016/j.wneu.2011.10.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 10/25/2011] [Indexed: 11/24/2022]
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Adeeb N, Mortazavi MM, Tubbs RS, Cohen-Gadol AA. The cranial dura mater: a review of its history, embryology, and anatomy. Childs Nerv Syst 2012; 28:827-37. [PMID: 22526439 DOI: 10.1007/s00381-012-1744-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 03/23/2012] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The dura mater is important to the clinician as a barrier to the internal environment of the brain, and surgically, its anatomy should be well known to the neurosurgeon and clinician who interpret imaging. METHODS The medical literature was reviewed in regard to the morphology and embryology of specifically, the intracranial dura mater. A historic review of this meningeal layer is also provided. CONCLUSIONS Knowledge of the cranial dura mater has a rich history. The embryology is complex, and the surgical anatomy of this layer and its specializations are important to the neurosurgeon.
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Prabhakar H, Pal Singh G, Bindra A, Ali Z. Dysrhythmias resulting from surgical manipulations of pituitary tumour and hydrogen peroxide irrigation of surgical wound. Indian J Anaesth 2011; 54:352-3. [PMID: 20882185 PMCID: PMC2943712 DOI: 10.4103/0019-5049.68397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi - 110 029, India
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Sandu N, Sadr-Eshkevari P, Schaller BJ. Usefulness of case reports to improve medical knowledge regarding trigemino-cardiac reflex in skull base surgery. J Med Case Rep 2011; 5:149. [PMID: 21496216 PMCID: PMC3089793 DOI: 10.1186/1752-1947-5-149] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 04/15/2011] [Indexed: 11/23/2022] Open
Abstract
We describe the discovery of the trigemino-cardiac reflex by Schaller in 1999 and the continued improvement of the knowledge about the trigemino-cardiac reflex involved in neurosurgery, especially in skull base surgery, during the past several years. The achieved medical progress could be gained only by the practical experience described by different case reports and later case series that have been published in several principal scientific journals. Additionally, we explain the scientific as well as clinical importance of the communication of the case reports on TCR. Special reference has been given to the validity of the case reports for new phenomena in clinical medicine.
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Affiliation(s)
- Nora Sandu
- Department of Neurosurgery, University of Paris, Paris, France.
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Spiriev T, Sandu N, Arasho B, Kondoff S, Tzekov C, Schaller B. A new predisposing factor for trigemino-cardiac reflex during subdural empyema drainage: a case report. J Med Case Rep 2010; 4:391. [PMID: 21118536 PMCID: PMC3002900 DOI: 10.1186/1752-1947-4-391] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 11/30/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The trigemino-cardiac reflex is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hypermotility during stimulation of any of the sensory branches of the trigeminal nerve. Clinically, trigemino-cardiac reflex has been reported to occur during neurosurgical skull-base surgery. Apart from the few clinical reports, the physiological function of this brainstem reflex has not yet been fully explored. Little is known regarding any predisposing factors related to the intraoperative occurrence of this reflex. CASE PRESENTATION We report the case of a 70-year-old Caucasian man who demonstrated a clearly expressed form of trigemino-cardiac reflex with severe bradycardia requiring intervention that was recorded during surgical removal of a large subdural empyema. CONCLUSION To the best of our knowledge, this is the first report of an intracranial infection leading to perioperative trigemino-cardiac reflex. We therefore add a new predisposing factor for trigemino-cardiac reflex to the existing literature. Possible mechanisms are discussed in the light of the relevant literature.
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Affiliation(s)
- Toma Spiriev
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria.
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Pires de Aguiar PH, Aires R, Maldaun MVC, Tahara A, de Souza Filho AM, Zicarelli CA, Ramina R. Is sagittal sinus resection in falcine meningiomas a factor of bad surgical outcome? Surg Neurol Int 2010; 1:64. [PMID: 21125007 PMCID: PMC2980903 DOI: 10.4103/2152-7806.71983] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 09/14/2010] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Meningiomas arising purely from the falx below the longitudinal sinus represents a surgical challenge for the neurosurgeon. The authors discuss the new aspects of surgical details that may avoid complications and determine the prognosis. MATERIALS AND METHODS We retrospectively evaluated our surgical experience from June 2004 to January 2010. Seventy patients harboring falcine meningiomas were included and submitted for surgical resection. All historical records, office charts and images were reviewed in order to sample the most important data regarding epidemiology, clinical pictures, radiological findings and surgical results, as well as the main complications. The patients were divided into three main groups: anterior third 32 patients (Group A), middle third 15 patients (Group B), 23 patients in the posterior third of falx (Group C). RESULTS In Group A, total macroscopic resection was achieved in 31 out of 32 cases (96.87%). Twenty five patients had Rankin 0, five patients had Rankin 1-2, two patients had Rankin 6. In Group B (15 patients), 10 patients had gross resection and Rankin 0, four patients had Rankin 1-2 and one patient had Rankin 6. In Group C (23 patients), 20 patients were absolutely able, Rankin score 0, after six months postoperative period (83.3% had excellent results) and no mortality. Four cases had Rankin score 1 - 2 (16.6%). Ten cases (43.47%) had Simpson I resection and ten cases (43.47%) had Simpson II. CONCLUSION Despite larger lesion volumes, Group A meningiomas had a better outcome due to the position they were in, the tumor and surrounding structures. The preoperative preparation and surgical planning can preserve sagittal sinus; but in some cases, this is not possible. Sagittal sinus resection, as proven by this paper, is still a factor of bad surgical outcome. In the middle and posterior third, resection of sagittal sinus is a factor of a bad outcome, due to cerebral infartion.
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Affiliation(s)
- Paulo Henrique Pires de Aguiar
- Department of Neurology - São Paulo Medical School, University of Sao Paulo, São Paulo; Division of Neurosurgery of Santa Paula Hospital, São Paulo; Division of Neurosurgery of Brigadeiro, Unic Brazilian Health System- (SUS-UBHS), São Paulo; Division of Neurosurgery of São Camilo Hospital, São Paulo; Department of Surgery, Catholic Pontific University, Curitiba, Brazil
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Ong C, Ong M, Le K, Power M, Wang L, Lam D, Parkinson R, Wenderoth J. The trigeminocardiac reflex in Onyx embolisation of intracranial dural arteriovenous fistula. J Clin Neurosci 2010; 17:1267-70. [DOI: 10.1016/j.jocn.2010.01.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
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Nöthen C, Sandu N, Prabhakar H, Filis A, Arasho BD, Buchfelder M, Schaller BJ. Trigemino-cardiac reflex and antecedent transient ischemic attacks. Expert Rev Cardiovasc Ther 2010; 8:509-12. [PMID: 20397825 DOI: 10.1586/erc.10.19] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The trigemino-cardiac reflex (TCR) is a brainstem reflex that has gained enormous interest in recent years and was initially described by Schaller and coworkers as a centrally inducible reflex during skull-base surgery. In the meantime, parts of its functional consequences have been described. Here, we present a study that gives special reference to preventive factors of the TCR and investigates the hypothesis linking preceding transient ischemic attacks (TIAs) to the occurrence of TCR. METHODS We retrospectively reviewed 338 consecutive patients with the histological diagnosis of a pituitary adenoma, who were operated on from 2000 to 2006 in the Neurosurgery department of the University of Gottingen in Germany. Depending on the occurrence of intraoperative TCR, patients were divided into TCR and non-TCR groups. In 19 of these patients (6%), we found the intraoperative occurrence of the TCR. The patient characteristics between the two subgroups were comparable. RESULTS There was a statistically significant difference between the subgroups of precedent TIA (TCR: 11% vs non-TCR: 4%) versus nonprecedent TIA (TCR: 89% vs non-TCR: 96%) regarding the intraoperative occurrence of the TCR (chi(2): p < 0.01). CONCLUSION A precedent TIA less than 6 weeks before operation represents a significant risk factor for subsequent intraoperative occurrence of the TCR. Our data may indicate, for the first time, the existence of an oxygen-conserving reflex not only in animals but also in humans. Its neuroprotective effect in the context of the TCR is discussed.
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Affiliation(s)
- Christoph Nöthen
- Neurosurgical Department, University Hospitals Erlangen, Germany
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Lv X, Jiang C, Li Y, Wu Z. Embolization of intracranial dural arteriovenous fistulas with Onyx-18. Eur J Radiol 2010; 73:664-71. [PMID: 19144481 DOI: 10.1016/j.ejrad.2008.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 11/15/2008] [Accepted: 12/01/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The use of Onyx in the treatment of AVMs has been reported in the literature, but experience in the treatment of DAVF is lacking. We report the clinical outcome obtained in the treatment of dural arteriovenous fistulas (DAVFs) using a new liquid embolic agent, Onyx-18. METHODS The present series included 21 patients; 9 had DAVFs draining directly into the cortical veins, 6 had DAVFs draining directly into the dural sinus, 4 had DAVFs draining through the ophthalmic veins and 2 had DAVFs involving the dural sinus with leptomeningeal retrograde venous drainage Clinical data were extracted from hospital files and all patients were followed. RESULTS In 14 patients (70%) there was complete angiographic elimination of the shunts and resolution of the symptoms. The remaining 7(30%) patients was not cured with residual shunts. Adverse events occurred in 6(30%) of 21 patients with 1 DAVF located at the transverse sigmoid sinus, 2 at tentorium, and 3 at the cavernous sinus. Cranial deficits occurred in 3(15%) patients, brain infarction in 1(5%) patient and microcatheter gluing in 1(3.2%) patient. At final follow up, 20 patients were asymptomatic with 1 showed clinical improvement. CONCLUSION Definitive cure may be attained effectively with Onyx in dural arteriovenous fistulas and adjunctive to surgery and radiotherapy. Location of the DAVFs affected the outcome of transarterial embolization.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Chongwen, Beijing 100050, PR China
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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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Orbital trauma, bradycardia, and vomiting: trapdoor fracture and the oculocardiac reflex: a case report. Pediatr Emerg Care 2010; 26:143-5. [PMID: 20145507 DOI: 10.1097/pec.0b013e3181ce30d8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The presentation of vomiting and bradycardia after closed head trauma should invariably prompt concern for significant intracranial injury, yet other less common causes for the clinical picture do exist. This case reports one such scenario in which fracture to the patient's inferior orbital wall resulted in the rare though potentially life-threatening oculocardiac reflex, a vagally mediated phenomenon with possible respiratory, cardiovascular, and gastric motility effects.
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USAMI K, KAMADA K, KUNII N, TSUJIHARA H, YAMADA Y, SAITO N. Transient Asystole During Surgery for Posterior Fossa Meningioma Caused by Activation of the Trigeminocardiac Reflex -Three Case Reports-. Neurol Med Chir (Tokyo) 2010; 50:339-42. [PMID: 20448432 DOI: 10.2176/nmc.50.339] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kenichi USAMI
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Kyousuke KAMADA
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Naoto KUNII
- Department of Neurosurgery, The University of Tokyo Hospital
| | | | | | - Nobuhito SAITO
- Department of Neurosurgery, The University of Tokyo Hospital
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Abstract
The trigemino-cardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity, sympathetic hypotension, apnea, or gastric hypermotility during central or peripheral stimulation of any of the sensory branches of the trigeminal nerve. Clinically, the TCR has been reported to occur during craniofacial surgery, manipulation of the trigeminal nerve/ganglion and during surgery for lesion in the cerebellopontine angle, cavernous sinus, and the pituitary fossa. Apart from the few clinical reports, the physiologic function of this brainstem reflex has not yet been fully explored. The manifestation of the TCR can vary from bradycardia and hypotension to asystole. From the experimental findings, the TCR represents an expression of a central reflex leading to rapid cerebrovascular vasodilatation generated from excitation of oxygen-sensitive neurons in the rostral ventro-lateral medulla oblongata. By this physiologic response, the systemic and cerebral circulations may be adjusted in a way that augments cerebral perfusion. This review summarizes the current state of knowledge about TCR.
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Lv X, Jiang C, Li Y, Wu Z. Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18. J Neurosurg 2008; 109:1083-90. [PMID: 19035723 DOI: 10.3171/jns.2008.109.12.1083] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy. Clin Neurol Neurosurg 2008; 110:1064-7. [PMID: 18845385 DOI: 10.1016/j.clineuro.2008.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 05/30/2008] [Accepted: 07/13/2008] [Indexed: 02/07/2023]
Abstract
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.
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Schaller B, Filis A, Buchfelder M. Trigeminocardiac reflex in embolization of intracranial dural arteriovenous fistula. AJNR Am J Neuroradiol 2008; 29:E55. [PMID: 18372414 DOI: 10.3174/ajnr.a1072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lv X, Li Y, Lv M, Liu A, Zhang J, Wu Z. Trigeminocardiac reflex in embolization of intracranial dural arteriovenous fistula. AJNR Am J Neuroradiol 2007; 28:1769-70. [PMID: 17885228 PMCID: PMC8134204 DOI: 10.3174/ajnr.a0675] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report a case of immediate reproducible and reflexive response of asystole upon stimulation of Onyx injection during embolization of a tentorial dural arteriovenous fistula in a 53-year-old man. Upon recognition of the reflexive relationship between Onyx injection and increased vagal tone, the patient was given anticholinergic in an effort to block cholinergic hyperactivity. After atropine was given, no further dysrhythmias occurred.
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Affiliation(s)
- X Lv
- Beijing Neurosurgical Institute and Neurointerventional Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Prabhakar H, Rath GP, Arora R. Sudden cardiac standstill during skin flap elevation in a patient undergoing craniotomy. J Neurosurg Anesthesiol 2007; 19:203-4. [PMID: 17592354 DOI: 10.1097/ana.0b013e31804e45e8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schaller BJ, Buchfelder M. Trigemino-cardiac reflex in skull base surgery: from a better understanding to a better outcome? Acta Neurochir (Wien) 2006; 148:1029-31; discussion 1031. [PMID: 16944048 DOI: 10.1007/s00701-006-0889-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 04/25/2006] [Indexed: 10/24/2022]
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