Unstable bradycardia induced by posterior nasal packing: a rare activation of the Trigeminocardiacreflex.

A woman in her 40s presented to the emergency department with epistaxis. Anterior nasal packing was unsuccessful in achieving haemostasis. After the exchange of devices and insertion of a posterior nasal pack, the patient developed a junctional rhythm and progressively unstable bradycardia. The rhythm and bradycardia immediately improved following the removal of the posterior nasal pack. This case describes a rare occurrence of Trigeminocardiac reflex (TCR), following an insertion of a posterior nasal pack. Only one other such case has been reported and published. This case highlights the importance of raising awareness of this rare reflex and the need for prompt removal of the triggering cause in such scenarios. TCR can induce a junctional rhythm, which progresses to unstable bradycardia and may lead to asystole in susceptible individuals. The removal of the stimulus resolves the reflex and can result in prompt resolution of the bradycardia and hypotension induced via the TCR.

A case report: A patient rescued by VA-ECMO after cardiac arrest triggered by trigeminocardiac reflex after nasal surgery.

RATIONALE: Cardiac arrest (CA) caused by trigeminocardiac reflex (TCR) after endoscopic nasal surgery is rare. Hence, when a patient suffers from TCR induced CA in the recovery room, most doctors may not be able to find the cause in a short time, and standard cardiopulmonary resuscitation and resuscitation measures may not be effective. Providing circulatory assistance through venous-arterial extracorporeal membrane oxygenation (VA-ECMO) can help healthcare providers gain time to identify the etiology and initiate symptom-specific treatment. PATIENT CONCERNS: We report a rare case of CA after endoscopic nasal surgery treated with VA-ECMO. DIAGNOSES: We excluded myocardial infarction, pulmonary embolism, allergies, hypoxia, and electrolyte abnormalities based on the relevant examination results. Following a multidisciplinary consultation, clinical manifestation and a review of previous literature, we reasoned that the CA was due to TCR. INTERVENTIONS: VA-ECMO was established to resuscitate the patient successfully during effective cardiopulmonary resuscitation. OUTCOMES: ECMO was successfully evacuated a period of 190 minutes of therapy. The patient was discharged home on day 8. LESSONS: TCR is notable during endoscopic nasal surgery. Our case indicates that CA in operating room is worth prolonged CCPR. The ideal time for ECPR implementation should not be limited within 20 minutes after CCPR.

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.

The Influence of Trigeminocardiac Reflex on Postoperative Cardiac Adverse Events in Patients Undergoing Cerebellopontine Angle Tumor Resections: A Case-Control Study.

OBJECTIVE: To assess the potential impact of the trigeminocardiac reflex (TCR) on postoperative adverse cardiac events and to identify predictors of the TCR in cerebellopontine angle surgery. METHODS: Patients undergoing elective cerebellopontine angle surgery from October 1, 2015, to September 30, 2020, were recruited consecutively for this retrospective case-control study. The TCR was evaluated by reviewing electronic anesthesia records and defined as a drop in heart rate was >20%. Controls were identified from the same retrospective cohort and matched by age, sex, and similar (±5 days) surgery date in the ratio of 1:2. RESULTS: Of 2446 patients, 68 (2.78%) experienced TCR episodes. A total of 97 TCR episodes occurred among the 68 patients. In 2 TCR episodes, severe cardiac complications developed after surgery-myocardial injury in one case and cardiac arrest in the other case. The prevalence of adverse cardiovascular events was higher in the TCR group (60.3% vs. 36.0%, P = 0.001) than in the control group. The independent risk factor for the TCR in the multivariate condition logistic regression was tumor compression of the brainstem (odds ratio = 2.36, 95% confidence interval 1.40-3.95; P = 0.001). CONCLUSIONS: Intraoperative TCR episodes seemed to be associated with postoperative adverse cardiac events in patients undergoing cerebellopontine angle surgery. Moreover, tumor compression of the brainstem might be a risk factor for TCR episodes.

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.

Atypical trigeminocardiac reflex during intranasal dexmedetomidine sedation of a 6-month-old premature baby.

The trigeminocardiac reflex (TCR) is an established brainstem reflex leading to parasympathetic dysrhythmias-including haemodynamic irregularities, apnoea and gastric hypermotility-during stimulation of any sensory branches of the trigeminal nerve. Most of the clinical knowledge about TCR was gathered from general anaesthesia observations, not from procedural sedation.We present a case of a 6-month-old premature baby experiencing the reflex twice under dexmedetomidine-propofol-sedation while undergoing ophthalmic and ear examination. This was interpreted as cross-over sensitisation between the facial and trigeminal cranial nerve (N V and N VII).The present case demonstrates that different TCR subtypes can occur during the same anaesthetic procedure. Triggering TCR seems to be based on several factors and not just on a single stimulus as often presumed. Therefore, for premature babies, there is a risk for TCR under procedural sedation, and we recommend using glycopyrrolate as preventive treatment.

A Step Further-The Role of Trigeminocardiac Reflex in Therapeutic Implications: Hypothesis, Evidence, and Experimental Models.

The trigeminocardiac reflex (TCR) is a well-recognized brainstem reflex that represents a unique interaction between the brain and the heart through the Vth and Xth cranial nerves and brainstem nuclei. The TCR has mainly been reported as an intraoperative phenomenon causing cardiovascular changes during skull-base surgeries. However, it is now appreciated that the TCR is implicated during non-neurosurgical procedures and in nonsurgical conditions, and its complex reflex pathways have been explored as potential therapeutic options in various neurological and cardiovascular diseases. This narrative review presents an in-depth overview of hypothetical and experimental models of the TCR phenomenon in relation to the Vth and Xth cranial nerves. In addition, primitive interactions between these 2 cranial nerves and their significance are highlighted. Finally, therapeutic models of the complex interactions of the TCR and areas for further research will be considered.

The Effect of Atropine on Trigeminocardiac Reflex-induced Hemodynamic Changes During Therapeutic Compression of the Trigeminal Ganglion.

BACKGROUND: Percutaneous compression of the trigeminal ganglion (PCTG) can induce significant hemodynamic perturbations secondary to the trigeminocardiac reflex (TCR). The aim of this study was to investigate the effect of atropine pretreatment on hemodynamic responses during PCTG for trigeminal neuralgia. MATERIALS AND METHODS: A total of 120 patients who received PCTG were randomly assigned to control and atropine groups that were pretreated with saline (n=60) and atropine 0.004 mg/kg intravenously (n=60), respectively. Heart rate (HR) and mean arterial pressure (MAP) were measured at 9 timepoints from before induction of anesthesia until the end of the PCTG procedure; the incidence of TCR was also observed. RESULTS: HR was higher in the atropine compared with control group from the time of skin puncture with the PCTG needle until after the procedure was completed (P<0.05). MAP was also higher in the atropine compared with control group, but only at entry of the needle into the foramen ovale until 1 minute after trigeminal ganglion compression (P<0.05). HR was reduced in both groups during entry of the needle into the foramen ovale and during ganglion compression, but less so in the atropine compared with the control group (P<0.05). MAP increased during PCTG compared with baseline in both groups, but with a larger increase in the atropine group (P<0.05). Two and 52 cases in the control group, and 6 and 1 cases in the atropine group, exhibited a TCR during entry of the needle into the foramen ovale and at ganglion compression, respectively (P<0.05). CONCLUSION: Pretreatment with atropine was effective in most patients at minimizing abrupt reduction in HR during PCTG.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review.

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

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.

BACKGROUND Trigeminocardiac reflex (TCR) is a unique brain stem reflex that manifests as the sudden onset of hemodynamic perturbation in heart rate and blood pressure as a result of stimulation of any branches of the trigeminal nerve. Onyx™ embolization in cerebrovascular interventional surgery can trigger TCR, leading to severe hemodynamic fluctuations and even cardiac arrest. Appropriate prophylactic approaches to prevent Onyx™ embolization-induced TCR are still lacking. CASE REPORT We report the cases of 2 patients with recurrent and profound bradycardia due to TCR during endovascular Onyx™ embolization for a dural arteriovenous fistula. Prophylactic intra-arterial injection of lidocaine (10-20 mg) effectively and safely blocked the recurrence and potential occurrence of TCR. These 2 patients had reduced heart rate with either hypotension or hypertension during their TCR episodes, suggesting that stimulating a distinct cerebral artery (occipital artery versus vertebral artery branch) can initiate TCR by provoking the vagus nerve via the common neuronal pathway while simultaneously inhibiting or exciting the sympathetic pathway. CONCLUSIONS Intra-arterial injection of lidocaine during endovascular procedures can be recommended as an effective prophylactic approach for use in the treatment of the cerebrovascular disorder where there is high risk of embolization-induced TCR.

Trigeminal Nerve Repair: Is the Trigeminocardiac Reflex a Concern?

PURPOSE: Our hypothesis is that direct manipulation of the third and second divisions of the trigeminal nerve during microneurosurgery does not affect the incidence of trigeminocardiac reflex (TCR). The purpose of this paper was to analyze the incidence of TCR events during microneurosurgery involving the second and third divisions of the trigeminal nerve. MATERIALS AND METHODS: This was a retrospective cohort study of 94 patients who underwent nerve repair of the second and third divisions of the trigeminal nerve, between July 2014 and February 2021 by a single surgeon (J. Z.). The independent variables were the trigeminal nerve branch injured, the laterality of the trigeminal nerve injury, the Sunderland classification, the ASA classification, the intraoperative narcotic(s) used, and the depth of anesthesia. The dependent variables included the occurrence of intraoperative hypercapnia, hypoxia, and TCR event. Since the data was retrospective and categorical in nature, χ2 analysis was performed initially. RESULTS: None of the patients in this retrospective cohort demonstrated intraoperative hypercapnia, hypoxia or TCR events. Initial χ2 calculation was performed for the dependent variables with the trigeminal nerve groups (IAN, LN, and ION). The χ2 calculation [χ2 (1, n = 101)] was 0.2235. The P-value was .6364. Since there was no statistical significance found, there was no further analysis of surgical and anesthesia independent variables in the data collection. CONCLUSIONS: The zero incidence of TCR in a large number of patients provides strong evidence supporting the rejection of the hypothesis that TCR can occur during the surgical repair of peripheral trigeminal nerves.

The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?

The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant. Out of 260 patients' files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type. There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated. 1Introduction.