Sudden arrhythmia followed by bradycardia during sagittal split ramus osteotomy: trigeminocardiac reflex.

Trigeminocardiac reflex (TCR) is a brainstem reflex triggered by the stimulation of any branch of the fifth cranial nerve along its course, presenting as a reduction in heart rate and blood pressure. Oculocardiac reflex is a well-known subtype of TCR. In the case reported here, remarkable arrhythmia followed by bradycardia occurred suddenly in a healthy patient undergoing orthognathic surgery. The heart rhythm recovered when the surgical manipulation ceased, but bradycardia was reproduced when the surgery resumed. This case of TCR is unique in that remarkable arrhythmia first appeared and led to bradycardia; accordingly, intravenous lidocaine and an anticholinergic agent were administered simultaneously instead of anticholinergic agents alone, and were protective. Although TCR rarely occurs during orthognathic surgery, clinicians should be aware of its possibility and able to judge and manage it promptly.

Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa.

The trigeminocardiac reflex (TCR) is defined as a sudden onset of parasympathetic dysrhythmias during stimulation of the trigeminal nerve. We describe a peripheral variation of TCR during manipulation of the nasal mucosa. A 42-year-old patient suffering from severe obstructive sleep apnoea was scheduled for surgical treatment. After inducted anaesthesia, the surgeon infiltrated the nasal mucosa with a local anaesthetic. The patient immediately showed an asystole and was treated with ephedrine and five chest compressions, despite spontaneous sinus rhythm return after ceasing of manipulation. Treatment with atropine established this TCR episode and ensured an event-free surgery.The authors present here, for the first time, a prolonged asystole caused by the TCR, triggered by minimal manipulation of the nasal mucosa. This severe manifestation of peripheral TCR demonstrates its importance in daily clinical business. This case was treated according to a modified treatment algorithm for all subtypes of TCR which is presented here.

Management of a temporomandibular joint synovial cyst in a case complicated by severe trigeminocardiac reflex.

The trigeminocardiac reflex is a rare occurrence in patients undergoing maxillofacial surgery, with a reported incidence of 1-2%. Clinical signs and symptoms include bradycardia, nausea, with further stimulation potentially leading to cardiac dysrhythmias, ectopic beats, atrioventricular blocks and asystole. Most maxillofacial procedures, including temporomandibular joint procedures, are considered low risk. We report the first case of a tender temporomandibular joint synovial cyst whose management was complicated by severe trigeminocardiac reflex resulting in asystole. We suggest that in such cases communication between surgeons and the anaesthesia team is of paramount importance and informing the anaesthetist intraoperatively prior to the manipulation of the capsule or temporomandibular joint meniscus is recommended in the prevention or successful treatment of this condition.

[Trigemino-cardiac reflex in skull base surgery].

OBJECTIVE: To explore the mechanism, clinical features, and prognosis of Trigemino-cardiac reflex (TCR) during skull base operations. METHODS: A retrospective analysis was performed on 291 patients with skull base disease from Jan. 2009 to Oct. 2015 in Peking University First Hospital. By reviewing the patients' operative data and anaesthetic electrical record, and we picked out all the patients who suffered from TCR during the operation and analyzed their surgical procedures, clinical features, influence factors, and prognosis. TCR was defined as a drop in mean arterial blood pressure (MABP) and the heart rate (HR) of more than 20% to the baseline values before the stimulus and coinciding with the manipulation of the trigeminal nerve. RESULTS: In all the 291 patients receiving skull base surgery, 9 patients suffering TCR for 19 times during the operation were found. These 9 cases included three acoustice schwannomas, one trigeminal schwannoma, one petroclival meningioma, one epidermoid cyst in cerebellopontine angle, one cavernous sinus cavernous hemangioma, one pituitary adenoma, and one trigeminal neuralgia. The trigger of TCR was related to manipulation, retraction, and stimulation of the trunk or branches of trigeminal nerve. The baseline heart rate was 62-119/min [mean (79.4±14.6) /min] and dropped about 29.0%-66.4% (mean 44.3%) to 22-60 /min [mean (44.2±9.6) /min] after TCR. The baseline mean arterial blood pressure was 75-103 mmHg [mean (87.5±7.8) mmHg] and dropped about 23.4%-47.2% (mean 37.3%) to 45-67 mmHg [mean (54.9±6.3) mmHg] after TCR. During the 19 times of TCR, heart rate and blood pressure could return to baseline in a short time while stopping manipulation (8 times), using atropine (8 times, dose 0.5-1.0 mg, mean 0.69 mg), using ephedrine hydrochloride (one time, 15 mg), using epinephrine (one time, 1 mg), and using dopamine (one time, 2 mg). TCR also could be triggered again by a second stimulation. There was no relative cardiologic complication or neurological deficit in the postoperative 24 hours. CONCLUSION: TCR is a short neural reflex with a drop in blood pressure and heart rate coinciding with the manipulation of the trigeminal nerve in skull base surgery. Correct recognition, intensive observation, and essential management of TCR will lead to a good prognosis.

Trigeminal Cardiac Reflex Caused by Onyx Embolization of Intracranial Dural Arteriovenous Fistula.

Trigeminocardiac reflex (TCR) is a reflexive response of bradycardia, hypotension and gastric hypermotility which is observed upon mechanical stimulation in the distribution of the trigeminal nerve. Previous articles have described TCR during intracranial operations, ophthalmic surgery, microcompression of the trigeminal ganglion and radiofrequency lesioning of the trigeminal ganglion. TCR may occur during transarterial embolization of dural arteriovenous fistula (DAVF) with Onyx, leading to a significant decrease in heart rate under a standard anesthetic protocol. TCR may also occur due to chemical stimulus of dimethyl sulfoxide (DMSO) in transvenous Onyx embolization of dural cavernous sinus fistula. Slow rate of injection may give DMSO enough time to dissipate in the blood stream which is important for the prevention of toxicity. This report confirms that the reflex was blunted by the anticholinergic effects of atropine and there was no harm to patients if stopped immediately.

The Importance of the Trigeminal Cardiac Reflex in Rhinoplasty Surgery.

BACKGROUND: Trigeminocardiac reflex (TCR) consists of bradycardia or asystole along with hypotension and apnea coinciding with stimulation of the trigeminal nerve. During rhinoplasty procedures, we noticed that local anesthetic solution (LAS) application to the columellar area results in bradycardia. We planned to conduct a randomized prospective study on 47 patients undergoing rhinoplasty to demonstrate the characteristics of TCR arising from the columella. METHOD: Local anesthetic solution containing 2% prilocaine with 1:80,000 adrenaline was applied under standard general anesthesia protocol. In group 1 (study group, n = 24), 2 mL of LAS was applied to the columella. In group 2 (control group, n = 23), 2 mL of LAS was applied to the nasal dorsum. In group 3 (control group, n = 20), after LAS was applied to nasal dorsum in group 2, we waited for 10 minutes. Then, 2 mL of LAS was applied to the columella. Here, recordings were taken for the columella.Heart rate (HR) and blood pressure (BP) were recorded just before needle insertion (baseline level), at the time of needle insertion (NIT) to the columella or dorsum, and after the 1st, 5th, 10th, 30th, and 60th seconds. RESULTS: Transient bradycardia (≥20% drop in HR) was observed in 33% of the patients in group 1.Decrease in HR compared to the baseline level in group 1 was significantly greater than that of groups 2 and 3 at all times (P ≤ 0.05).Systolic BP in NIT and in 60th second in group 1, only in NIT in group 2 was significantly lower than that of baseline levels (P ≤ 0.05). CONCLUSIONS: We concluded that stimulation of a sensory branch of the trigeminal nerve in the columellar area leads to TCR under general anesthesia by eliciting clinical hypotension with a drop in systolic BP and in HR of more than 20% compared to the baseline level.Knowing the existence of a certain TCR area will be helpful to the surgeon and anesthesiologist to exercise extra vigilance and to make continuous and meticulous monitoring of the electrocardiogram, HR, and BP during which the TCR may be precipitated such as local anesthetic infiltration to the columellar area in rhinoseptoplasty operations.

Prenatal nicotine exposure enhances the trigeminocardiac reflex via serotonin receptor facilitation in brainstem pathways.

In this study we used a rat model for prenatal nicotine exposure to test whether clinically relevant concentrations of brain nicotine and cotinine are passed from dams exposed to nicotine to her pups, whether this changes the trigeminocardiac reflex (TCR), and whether serotonergic function in the TCR brainstem circuitry is altered. Pregnant Sprague-Dawley dams were exposed to 6 mg·kg(-1)·day(-1) of nicotine via osmotic minipumps for the duration of pregnancy. Following birth dams and pups were killed, blood was collected, and brain nicotine and cotinine levels were measured. A separate group of prenatal nicotine-exposed pups was used for electrophysiological recordings. A horizontal brainstem slice was obtained by carefully preserving the trigeminal nerve with fluorescent identification of cardiac vagal neurons (CVNs) in the nucleus ambiguus. Stimulation of the trigeminal nerve evoked excitatory postsynaptic current in CVNs. Our data demonstrate that prenatal nicotine exposure significantly exaggerates both the TCR-evoked changes in heart rate in conscious unrestrained pups, and the excitatory neurotransmission to CVNs upon trigeminal afferent nerve stimulation within this brainstem reflex circuit. Application of the 5-HT1A receptor antagonist WAY 100635 (100 µM) and 5-HT2A/C receptor antagonist ketanserin (10 µM)significantly decreased neurotransmission, indicating an increased facilitation of 5-HT function in prenatal nicotine-exposed animals. Prenatal nicotine exposure enhances activation of 5-HT receptors and exaggerates the trigeminocardiac reflex.

Determination of trigeminocardiac reflex during rhinoplasty.

In most rhinoplasty procedures, osteotomies are usually required. The osteotomy areas are innervated by sensory branches of the trigeminal nerve. The trigeminocardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity during stimulation of the trigeminal nerve. When an osteotomy is performed or external pressure is applied over the nasal bone, the infraorbital nerve may send signals via this nerve. The aim of this prospective study is to determine the blood pressure changes and occurrence of TCR during rhinoplasty. one hundred and eight patients were enrolled into the study. Lidocaine and adrenaline combination (LAC) was injected only into the left lateral osteotomy sites. All patients underwent median, right-side, then left-side lateral osteotomies and nasal pyramid infracture. The haemodynamic changes were recorded. A 10% or more decrease in the heart rate from baseline was considered a TCR. TCR was detected in nine patients following lateral osteotomies and nasal pyramid infracture procedures (8.3%). The authors determined that LAC injection prior to osteotomy did not prevent TCR. Manipulation at or near the infraorbital nerve during rhinoplasty may cause TCR, even if local anaesthetic infiltration is used.

Trigeminocardiac reflex during the percutaneous injection of ethylene vinyl alcohol copolymer (Onyx) into a juvenile nasopharyngeal angiofibroma: a report of two cases.

The trigeminocardiac reflex (TCR) is a rare but well-described phenomenon encountered during invasive procedures involving the face, orbit, and cranial base. The reflex is characterized by the abrupt onset of hypotension, bradycardia, asystole, and dysrhythmias. With temporary cessation of the surgical procedure, vital signs typically stabilize without the need for further investigation, though anticholinergic drugs are often used to prevent prolonged hypotension and bradycardia. Two separate cases of the TCR were encountered during the percutaneous embolization of a juvenile nasopharyngeal angiofibroma with dimethylsulfoxide (DMSO) before the injection of ethylene vinyl alcohol copolymer (Onyx, ev3, Irvine, California, USA). In both cases, the injection of DMSO precipitated approximately 30 s of bradycardia/asystole, which then resolved after halting the procedure and administering anticholinergic drugs. There were no additional occurrences afterward and the patients underwent tumor excision with good recovery.