The Effect of Depth of Anesthesia on Hemodynamic Changes Induced by Therapeutic Compression of the Trigeminal Ganglion

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.

Comparison of Remimazolam and Propofol for Intravenous Anesthesia on Trigeminocardiac Reflex in Percutaneous Balloon Compression for Trigeminal Neuralgia: A Randomized Controlled Trial

Background

Trigeminal neuralgia usually presents as incapacitating facial pain. Percutaneous balloon compression (PBC) is frequently utilized to manage this ailment. Trigeminocardiac reflex (TCR) commonly presents with sudden severe bradycardia or even asystole, alongside a sudden increase in blood pressure during this surgical procedure. Notably, remimazolam has been reported to maintain higher heart rate (HR) levels during anesthesia than propofol. Thus, this study aims to assess the impact of remimazolam anesthesia versus propofol on TCR occurrence during this procedure.

Methods

This randomized controlled trial involved patients with trigeminal neuralgia scheduled for elective PBC. Patients were randomly assigned to receive either remimazolam or propofol for anesthesia. The primary outcome was the incidence of TCR, a potential complication during the procedure. Secondary outcomes included the occurrence of severe TCR, usage of atropine, HR at the time of foramen ovale puncture (T4), HR at the time of trigeminal ganglion compression (T5), and any adverse events.

Results

A total of 80 patients were included in the study, with 40 patients in each group. The incidence of TCR was significantly lower in the remimazolam group compared to the propofol group (30.0% vs 82.5%; risk difference -52.5%, 95% CI -67.3% to -18.6%; P < 0.001). The remimazolam group also showed a lower incidence of severe TCR (7.5% vs 45.0%) and significantly lower usage of atropine compared to the propofol group (P < 0.001). Furthermore, HR at T4 and T5 were higher in the remimazolam than in the propofol group (P < 0.001). There was no significant difference in the incidence of adverse events between the two groups.

Conclusion

In PBC surgery for trigeminal neuralgia, remimazolam-based intravenous anesthesia showed a higher HR and a lower incidence of TCR than propofol without any increased adverse events.

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

The term “sinonasal tumours” includes a large spectrum of diseases, which are characterized by heterogeneous biological behavior and prognosis, and located in a critical anatomic area. Diagnosis and treatment of sinonasal tumours require the contribution of different disciplines. A narrative review was performed to highlight the role of surgeons in contributing to a multidisciplinary approach to sinonasal tumours. Diagnosis and staging of sinonasal tumours is challenging and requires collaboration between surgeons, radiologists, and pathologists. The identification and management of critical extensions (orbital or intracranial encroachment, vascular abutment or encasement) is fundamental for successful treatment. Most cases of advanced sinonasal tumours can undergo surgical intervention by an adequately trained otorhinolaryngological team. The contribution of neurosurgeons and oculoplastic surgeons is required in selected scenarios. In rare circumstances, multidisciplinary reconstructive strategies can be indicated for complex tissue defects. Furthermore, a multidisciplinary approach is pivotal in the management of perioperative complications. While surgery remains the mainstay of treatment, the role of non-surgical adjuvant or even exclusive treatments is constantly expanding.

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.