Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report

The clinical surrogate definition of the trigeminocardiac reflex: Development of an optimized model according to a PRISMA-compliant systematic review

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.

Trigeminocardiac reflex caused by selective angiography of the middle meningeal artery

We describe an interesting case of trigeminocardiac reflex (TCR) caused by selective angiography of the middle meningeal artery (MMA). A 28-year-old woman presented with a symptomatic meningioma. Preoperative tumour embolisation was performed. In the procedure, when selective MMA angiography was done with Omnipaque 300 mg I/mL for 3 mL by manual injection, the patient complained of flashing lights in her eye followed by vomiting and bradycardia down to 40 bpm without increased intracranial pressure signs. On selective MMA angiography, the choroidal crescent and arteries of the periorbital region were opacified by anastomosis from the MMA via the meningo-ophthalmic artery. We diagnosed that her symptoms were caused by selective MMA angiography leading to high pressure stimulation towards the ophthalmic nerve innervation around the orbit as a TCR. We suggest that the operator should be prepared to manage TCR during treatment with expected selective MMA angiography, and gentle low pressure contrast injection should be attempted.

Trigeminocardiac reflex caused by selective angiography of the middle meningeal artery

We describe an interesting case of trigeminocardiac reflex (TCR) caused by selective angiography of the middle meningeal artery (MMA). A 28-year-old woman presented with a symptomatic meningioma. Preoperative tumour embolisation was performed. In the procedure, when selective MMA angiography was done with Omnipaque 300 mg I/mL for 3 mL by manual injection, the patient complained of flashing lights in her eye followed by vomiting and bradycardia down to 40 bpm without increased intracranial pressure signs. On selective MMA angiography, the choroidal crescent and arteries of the periorbital region were opacified by anastomosis from the MMA via the meningo-ophthalmic artery. We diagnosed that her symptoms were caused by selective MMA angiography leading to high pressure stimulation towards the ophthalmic nerve innervation around the orbit as a TCR. We suggest that the operator should be prepared to manage TCR during treatment with expected selective MMA angiography, and gentle low pressure contrast injection should be attempted.

Functional Outcome Changes in Surgery for Pituitary Adenomas After Intraoperative Occurrence of the Trigeminocardiac Reflex: First Description in a Retrospective Observational Study

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.