Evidences in Neurological Surgery and a Cutting Edge Classification of the Trigeminocardiac Reflex: A Systematic Review

Exploring the trigeminocardiac reflex: an integrated view from mechanism to clinic

PURPOSE

This review aims to summarize the complex nature of the trigeminocardiac reflex into a brief overview, focusing on its mechanism, anatomy, classification, manifestations, and treatment approaches.

METHOD

By examining the latest clinical studies and anatomical insights, we outline the neural pathways of trigeminocardiac reflex, identify subtypes on the basis of stimulation points, and describe the physiological responses it elicits.

RESULTS

Trigeminocardiac reflex is a brainstem reflex characterized by symptoms, such as bradycardia, hypotension, hypertension, apnea, and gastric hypermotility. It has been reported in surgical procedures involving stimulation of sensory branches of the trigeminal nerve. Trigeminocardiac reflex management typically involves prophylactic measures to prevent intraoperative cardiovascular complications.

CONCLUSION

A comprehensive understanding of trigeminocardiac reflex mechanisms and subtypes is essential to anticipate and mitigate its effects during procedures that may trigger this reflex. This knowledge ensures patient well-being and optimizes surgical outcomes, highlighting the importance of continued research in this area.

The protective role of lidocaine in surgeries involving trigeminal nerve manipulation: a meta-analysis of trigeminocardiac reflex prevention

The trigeminocardiac reflex (TCR) is activated when the trigeminal nerve is manipulated through mechanical pressure, traction, or irritation. This leads to a rapid increase in parasympathetic activity, resulting in a decrease in heart rate (HR) and blood pressure, which can potentially lead to bradycardia, and cardiac arrest, with a prevalence of 14.5% during neurointerventional procedures (8). The aim of this study was to assess the effect of lidocaine injection on preventing TCR during cranial surgeries. We conducted a comprehensive search of PubMed, Web of Science, and Cochrane CENTRAL electronic databases for clinical trials comparing the use of lidocaine versus placebo, or no intervention for TCR prevention during cranial surgeries up until 20 May 2024. Meta-analyses were performed using fixed-effects models, and heterogeneity was assessed using I-squared and Chi-square tests. A total of five studies involving 421 patients were included in this meta-analysis. The incidence of TCR was significantly lower in the lidocaine group compared to the control group, with a risk ratio of 0.05 (95% CI 0.01 to 0.37, P = 0.003). Additionally, the lidocaine group had a relatively small change in HR, with a mean difference of -10.56 (95% CI -13.30 to -7.83 beat per minute, P = 0.00001). No statistically significant difference in mean arterial pressure was observed between the two groups (MD -5.15, 95% CI [-10.38 to 0.08 mmHg], P = 0.09). Our results suggest that lidocaine may be effective in preventing TCR and stabilizing HR. The use of lidocaine could be considered a prophylactic measure during cranial surgeries. Further studies are needed to investigate the optimal dose and timing of lidocaine administration.

Risk factors associated with trigeminocardiac reflex in patients with trigeminal neuralgia during percutaneous balloon compression: A retrospective cohort study

BACKGROUND

The trigeminocardiac reflex (TCR) is a brainstem reflex commonly elicited during percutaneous balloon compression (PBC) for the treatment of trigeminal neuralgia (TN), which is characterized by drastic hemodynamic disturbances, such as bradycardia, arrhythmias and even cardiac arrest. In order to prevent catastrophic consequences, it is vital to screen the risk factors of TCR during perioperative period. The primary purpose of this study was to identify potential risk factors associated with TCR in patients with TN undergoing PBC, and to summarize the enlightenment of clinical anesthesia management.

METHODS

The clinical data of 165 patients diagnosed with TN undergoing PBC from January 2021 to December 2021 were retrospectively analyzed. TCR was defined as a sudden decrease in heart rate of 20% or more compared with baseline, and / or cardiac arrest, coinciding with the stimulus of any branch of the trigeminal nerve. And a clear cause-effect relationship between heart rate reduction and PBC-related intervention was required. All demographic characteristics as well as surgical and anesthetic data were compared between TCR group and TCR-free group. Univariate and multivariate logistic regression analysis were used to further analyze TCR-related risk factors.

RESULTS

Of the 165 patients enrolled in this study, 73 (44.2%) were male and 92 (55.8%) were female, and the average age was 64.22 ± 9.72 years. The incidence of TCR in the patients with TN during PBC was 54.5%. The results of multivariate regression analysis indicated that the risk factor for TCR was heart rate < 60 beats/min immediately before foramen ovale puncture (OR: 4.622; 95%CI: 1.470-14.531; P < 0.05).

CONCLUSION

Heart rate < 60 beats/min immediately before foramen ovale puncture was independently associated with TCR. Therefore, it is necessary for anesthesiologists to raise heart rate appropriately to prevent TCR during PBC.

Trigeminocardiac Reflex: A Review and Key Implications to Dermatologic Surgery

BACKGROUND

The trigeminocardiac reflex is a common but underreported occurrence that can vary from benign to life threatening. This reflex can be elicited by placing direct pressure on the globe of the eye or from traction of the extraocular muscles, stimulating the trigeminal nerve.

OBJECTIVE

To provide a review of potential stimuli for the trigeminocardiac reflex within dermatologic surgery and to discuss management options for the treatment of the trigeminocardiac reflex.

METHODS

PubMed and Cochrane were used to identify articles and case reports that established scenarios in which the trigeminocardiac reflex was provoked and subsequently how the reflex was managed.

RESULTS

Within the field of dermatologic surgery, the trigeminocardiac reflex can be stimulated during biopsies, cryoablations, injections, laser treatments, Mohs micrographic surgery, and oculoplastic interventions, most often occurring in an office setting. The most common presentations include significant bradycardia, hypotension, gastric hypermobility, and lightheadedness. The most definitive treatment is cessation of the inciting stimulus, monitoring, and symptomatic management. Glycopyrrolate and atropine are common treatments for severe, intractable cases of the trigeminocardiac reflex.

CONCLUSION

The trigeminocardiac reflex, while underreported and underrepresented in dermatologic literature and dermatologic surgery settings, should be considered in the setting of bradycardia and hypotension during dermatologic procedures.

Prolonged asystole induced by trigeminocardiac reflex accompanied with abnormal heart rate variability during percutaneous balloon compression: a case report

Trigeminocardiac reflex (TCR) can result in bradycardia and even cardiac arrest, and is reversible with elimination of the stimulus. Here, we report the case of a 68-year-old man who experienced cardiac arrest during percutaneous balloon compression for the treatment of trigeminal neuralgia. In this patient, sinus rhythm did not recover after stimulation removal, causing us to successfully perform cardiopulmonary resuscitation (CPR). The patient regained a sinus rhythm and was pretreated with atropine 0.5 mg, allowing the operation to be started again. The operation was completed successfully and the patient experienced no complications. Subsequent heart rate variability (HRV) analysis showed that parasympathetic activity predominated before anesthesia induction and after tracheal intubation. It further elevated during foramen ovale puncture, leading to prolonged asystole. Fortunately, sympathetic activity predominated after atropine was administered, which manifested as an increase in sympathetic activity and a decrease in parasympathetic activity. This could be beneficial for patients with TCR. This case indicates that TCR-related cardiac arrest might not be reversed with stimulus cessation, and atropine played a key role in preventing TCR. Moreover, HRV analysis might be essential for preoperative screening for high-risk patients. We also reviewed the literature for cases of TCR with prolonged asystole.

Prophylactic intra-arterial injection of lidocaine: a novel strategy to prevent endovascular embolization-induced trigeminocardiac reflex

BACKGROUND

Trigeminocardiac reflex (TCR) is a brainstem reflex that can lead to hemodynamic instability manifested as bradycardia, decrease/increase of mean arterial pressure (MAP) and, in the worst case scenario, asystole during surgery. The effective intraoperative management of recurrent and profound TCR has yet to be established. This randomized paired study was performed to identify the effect of a prophylactic intra-arterial injection of lidocaine to prevent TCR caused by Onyx embolization during cerebrovascular intervention surgery.

METHODS

A total of 136 patients who received Onyx embolization under general anesthesia were assigned to a control group pretreated with intra-arterial saline injection or a lidocaine group pretreated with an intra-arterial injection of 20 mg lidocaine. Heart rate (HR) and MAP were closely monitored during the embolization procedures and the incidence of TCR, mainly characterized by a decrease in HR of ≥20%, and perioperative adverse events was recorded.

RESULTS

During dimethyl sulfoxide (DMSO)/Onyx injection, HR was much slower in the control group than in the lidocaine group (p<0.05). TCR occurred in 12 patients (17.6%) in the control group (cardiac arrest in 3 patients) with decreased (7 cases) or increased (5 cases) MAP, whereas no TCR was observed in the lidocaine group. Notably, most TCR episodes occurred in patients with dural arteriovenous fistula and middle meningeal artery being affected. The composite adverse events were significantly higher in the control group than in the lidocaine group (p<0.05).

CONCLUSION

This prospective study shows that a prophylactic intra-arterial injection of 20 mg lidocaine could be recommended as a novel strategy to effectively and safely prevent TCR during endovascular embolization.

Combined Presigmoid-Subtemporal Approach in a Semi-Sitting Position for Petroclival Meningiomas: A Technical Report

The removal of petroclival meningiomas (PMs) is considered a neurosurgical challenge due to the critical mobilization of key neurovascular structures. Limited knowledge about the benefits of operating on patients with PMs using the combined presigmoid-subtemporal approach (CPSA) in a semi-sitting position has precluded its generalizability. We report on ten patients with PMs operated in a semi-sitting position using CPSA. We remark that before the surgical approach was accomplished in our group of patients, the CPSA via semi-sitting position was conducted and standardized in six adult cadaveric heads. The neuroanatomic dissections made in cadavers allowed us to confidently use CPSA in our set of patients. There were no comorbidities, perioperative complications, or deaths associated with the surgical procedure. CPSA via a semi-sitting position can be considered a safe approach to remove PMs.

Unusual Manifestations of the Trigeminocardiac Reflex During Awake Craniotomy: A Case Report and Review of the Literature

The trigeminocardiac reflex (TCR) is triggered by stimulation of a branch of the trigeminal nerve and results in vagally mediated bradycardia, hypotension, apnea, and gastrointestinal hypermotility. In the operating theatre, patients susceptible to TCR are typically under general anesthesia; thus, cardiac abnormalities are the most common manifestation. Our case highlights the less common intraoperative manifestations of gastric hypermotility and apnea in a patient undergoing awake craniotomy for tumor resection. Prompt recognition, removal of stimuli, and airway management prevented catastrophic complications while facilitating completion of the procedure.

Prophylactic Intra-Arterial Injection of Lidocaine Prevents Trigeminocardiac Reflex During Endovascular Embolization for Dural Arteriovenous Fistula: A Report of 2 Cases

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

The trigeminal system: The meningovascular complex- A review

Supratentorial sensory perception, including pain, is subserved by the trigeminal nerve, in particular, by the branches of its ophthalmic division, which provide an extensive innervation of the dura mater and of the major brain blood vessels. In addition, contrary to previous assumptions, studies on awake patients during surgery have demonstrated that the mechanical stimulation of the pia mater and small cerebral vessels can also produce pain. The trigeminovascular system, located at the interface between the nervous and vascular systems, is therefore perfectly positioned to detect sensory inputs and influence blood flow regulation. Despite the fact that it remains only partially understood, the trigeminovascular system is most probably involved in several pathologies, including very frequent ones such as migraine, or other severe conditions, such as subarachnoid haemorrhage. The incomplete knowledge about the exact roles of the trigeminal system in headache, blood flow regulation, blood barrier permeability and trigemino-cardiac reflex warrants for an increased investigation of the anatomy and physiology of the trigeminal system. This translational review aims at presenting comprehensive information about the dural and brain afferents of the trigeminovascular system, in order to improve the understanding of trigeminal cranial sensory perception and to spark a new field of exploration for headache and other brain diseases.

Neuroanesthesiology Update

This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.

A Case of Skull Base Chondrosarcoma with Intraoperative Trigemino-Cardiac Reflex

A 75-year-old female patient presented with a suspected recurrence of a clival chordoma. The tumor was resected using the infratemporal fossa type B and anterior petrosal approach with the help of a neurosurgeon. During cauterization of the trigeminal nerve, the patient developed cardiac arrest for approximately 10 seconds because of the trigemino-cardiac reflex (TCR). After several sternal compressions, there was return of spontaneous circulation. The operation was resumed after the circulatory dynamics stabilized. Subsequently, the surgery was completed with partial resection of the tumor without the recurrence of cardiac arrest. The pathological diagnosis was chondrosarcoma, and postoperative treatment with radiotherapy was started. Stimulation of the sensory branches of the trigeminal nerve induces TCR. There are reports of TCR developing in approximately 10% of skull base surgery cases in the absence of atropine administration. We report a rare case of TCR during the surgical procedure for the treatment of a skull base chondrosarcoma.

Territorial and Extraterritorial Trigeminocardiac Reflex: A Review for the Neurosurgeon and a Type IV Reflex Vignette

The trigeminocardiac reflex (TCR) is a complex and, sometimes, fatal event triggered by overstimulation of the trigeminal nerve (TN) and its territorial and spinal cord branches. We reviewed and compiled for the neurosurgeon key aspects of the TCR that include a novel and straightforward classification, as well as morphophysiology, pathophysiology, neuromonitoring and neuromodulation features. Further, we present intraoperative data from a patient who developed extraterritorial, or type IV, TCR while undergoing a cervical surgery. TCR complexity, severity and unwanted outcomes indicate that this event should not be underestimated or overlooked in the surgical room. Timely TCR recognition in surgical settings is valuable for applying effective intraoperative management to prevent catastrophic outcomes.

Isolated Bradycardia During Aneurysmal Clipping: Rebleed or Trigeminocardiac Reflex?

The most common cause of nontraumatic subarachnoid hemorrhage is the rupture of intracranial aneurysm. After initial bleed, the risk of rebleeding is highest in the early postictal period and this rebleed is strongly associated with poor neurological outcome. The major goal of anesthesia in these surgeries is to prevent the rebleed. If rebleeding occurs prior to the craniotomy, it results in the acute rise of intracranial pressure and usually presents as bradycardia and hypertension (Cushing’s reflex). Here we reported a case where rebleeding presented unusually as isolated bradycardia without associated hypertension and was mistaken as trigeminocardiac reflex. The surgeon was informed about the event and they planned to proceed. After craniotomy, despite all the efforts the brain was persistently tight and surgery could not be completed. Postoperative scan showed rebleeding and the patient died after a few days in ICU.

We highlighted in this case report the fact that isolated transient bradycardia may also be the presentation of rebleed with closed cranial vault. It is not always necessary to see all the features of Cushing’s traid in every patient. If bradycardia occurs before the craniotomy, the surgeon should be notified, the severity of bleed should be assessed, and further management should be planned according to the severity of bleed.

ioCT-guided percutaneous radiofrequency ablation for trigeminal neuralgia: how I do it

BACKGROUND

Percutaneous trigeminal nerve rhizotomy is usually performed by free-handed puncture of the foramen ovale under radiographic control with the patient kept semiconscious. The procedure has thus been reported to be highly uncomfortable for both the patient and surgeon. To our knowledge, this is the first description of a technique that includes precise navigated, CT-guided puncture of the foramen with the patient in general anesthesia and confirmation of needle placement by intraoperative CT.

METHOD

Radiofrequency ablation of the trigeminal nerve was guided by intraoperative CT navigation with neuromonitoring of trigeminal nerve function. The patient was kept under general anesthesia during the procedure.

CONCLUSION

CT-guided percutaneous trigeminal nerve rhizotomy is a safe and efficient treatment strategy for the management of trigeminal neuralgia without the need of the patient being in a semiconscious state.