Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy

doi:10.1054/jcms.2001.0264

Journal of Cranio-Maxillofacial Surgery

Volume 30, Issue 2, April 2002, Pages 108-111

https://doi.org/10.1054/jcms.2001.0264 Get rights and content

Abstract

Background: The trigeminocardiac reflex is the sudden-onset of dysrhythmia and hypotension during manipulation of any of the branches of the trigeminal nerve. The trigeminal nerve and cardioinhibitory vagus nerve constitute the afferent and efferent pathways in the reflex arc. The trigeminocardiac reflex has been reported to occur during craniofacial surgery, balloon-compression rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle. Patient & Method: A 2-year-old male patient with haemangioma near the sella turcica underwent rhizotomies of both sides of the dorsal sensory roots, of the trigeminal nerves for palliation of intractable trigeminal pain. Results: In this report, we experienced two unexpected episodes of asystole after transection of the sensory roots of the trigeminal nerves. Conclusion: Sectioning of the intracranial dorsal sensory root of the trigeminal nerve provides clear evidence of the central role of the trigeminal nerve as the afferent pathway of the trigeminocardiac reflex arc.

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Cited by (58)

Asystole induced by trigeminocardiac reflex during zygomatic fracture repositioning: A rare case report
2023, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
Citation Excerpt :
Therefore, bony manipulation from the repositioning of the zygomatic fracture fragment could cause indirect pressure changes to the eyeball; this may serve as the initiation of TCR that eventually leads to asystole. Communication between the operating oral-maxillofacial surgeons and anesthesiologists, especially during sensitive portions, such as elevation of the zygoma or manipulation of the orbit/orbital segments, should be maintained [24]. In the event of bradycardia, immediate cessation of the surgery to avoid further surgical stimulus and preparation for chest compression, using atropine or glycopyrrolate, and local anesthetic blockade of the afferent nerves for an asystolic event are recommended [16,25].
The trigeminocardiac reflex (TCR) in maxillofacial surgical procedures can occasionally lead to sudden bradycardia in response to the manipulation of maxillofacial bony structures. However, asystole induced by TCR during maxillofacial surgery has rarely been reported. Here, we report an extremely rare case of ventricular asystole induced by the TCR in a 56-year-old female patient, which was caused by zygomatic fracture repositioning during the surgical repair of a zygomaticomaxillary complex fracture. Chest compressions that were performed immediately by the oral-maxillofacial surgeons was successful, and an electrocardiogram confirmed the patient’s return to sinus rhythm. The patient’s postoperative clinical course was unremarkable.
Asystole Triggered by the Mouth Opening With a Dental Mouth Gag Under General Anesthesia During Pediatric Oral Surgery: Report of a Rare Case
2021, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Although a dental mouth gag is commonly used during oral surgery, asystole is rarely induced by the gag. The trigeminovagal reflex sometimes manifests during surgical procedures, particularly in eye surgery7 and otolaryngology surgery,8 but this reflex was also triggered by maxillofacial surgery,4,9 cerebellopontine angle surgery,5 microvascular trigeminal decompression,6 facial injury,10 and sleep bruxism.11 It has been reported that the incidence of trigeminovagal reflex in maxillofacial surgical procedures is approximately 1.6%.12
The trigeminovagal reflex manifests as a sudden onset of bradycardia, hypotension, and cardiac arrest in response to the stimulation of the trigeminal nerve. The incidence of trigeminovagal reflex in maxillofacial surgical procedures is approximately 1.6%. We report a case of asystole in a pediatric patient in whom a dental mouth gag triggered the trigeminovagal reflex during oral surgery. The patient was a 5-year-old boy who was scheduled to undergo extraction of maxillary supernumerary teeth. After tracheal intubation, anesthesia was maintained with sevoflurane and remifentanil. At the beginning of the surgery, his mouth was opened with a dental mouth gag, and electrocardigram showed asystole for 20 seconds. Thereafter, his heart rate spontaneously returned to basal value within 60 seconds. Since sufficient mouth opening was required to conduct the surgery, his mouth was opened again with the gag. When the interincisal distance exceeded about 40 mm, his heart rate suddenly decreased, but spontaneously returned to baseline within 60 second. The subsequent anesthetic course was uneventful.
The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?
2021, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
The same is also reported about the manipulation of the fractured segments, which leads to mechanical stretch painful stimuli with a high strength (Kosaka et al., 2001; Lübbers et al., 2010)). Also, the nature of the stimuli is the largest potential risk factor that evokes the TVR, where the sustained and abrupt traction is able to elicit the TVR more than gentle and smooth traction as reported by Cha et al. (2002). The ophthalmic nerve is also indirectly stimulated during the release of the entrapped inferior rectus muscle through the manipulation of the ciliary ganglion via long and short ciliary nerves.
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
The Trigeminocardiac Reflex During the Anterior Transpetrosal Approach
2017, World Neurosurgery
The anterior transpetrosal approach (ATPA), during which the trigeminal nerve (TN) is manipulated, has a risk of eliciting the trigeminocardiac reflex (TCR). The aim of this study was to assess the risk of TCR during ATPA.
Surgical records of 92 patients who had surgical treatment via ATPA at the Keio University Hospital between December 2005 and June 2015 were retrospectively analyzed. Patients were divided into 2 groups on the basis of the occurrence of TCR during surgery, and clinical and tumor characteristics were compared. Tumor characteristics were evaluated based on preoperative images and intraoperative findings and included the side of the lesion, size of the lesion, tumor size in Meckel cave, pathology of the disease, cavernous sinus invasion, extension into Meckel cave, and adhesion of lesion to TN.
TCR was observed in 14 of 92 patients (15.2%). TCR occurrence was significantly related to Meckel cave tumor size (P = 0.0264) and adhesion of the lesion to TN (P = 0.0002).
This study suggests that TCR is related to Meckel cave tumor size and tumor adhesion to TN in ATPA. To our knowledge, this is the first report describing TCR during ATPA.
The Trigeminal Nerve: Anatomical Pathways. Trigeminocardiac Reflex Trigger Points
2015, Trigeminocardiac Reflex
The trigeminocardiac reflex (TCR) is gaining increasing importance and interest in various fields of surgery, including skull base, neurovascular, ophthalmological, maxillofacial, and dental procedures. It has been shown that this reflex not only represents an important intraoperative phenomenon, but also may have influence on the postoperative functional outcome (preservation of hearing and elimination or reduction of tinnitus in some of the patients operated on for vestibular schwannoma). The recent past has seen substantial advances in the understanding of the anatomical pathways related to different subtypes (i.e., central versus peripheral) of the TCR. In addition, in-depth knowledge of particular patterns of the trigeminal nerve innervations has an important role in elucidating the occurrence of the TCR and in defining particular trigger points as well. In this chapter, we summarize the current anatomical knowledge of this unique reflex, with special emphasis on the definition of TCR trigger points.
History of the Trigeminocardiac Reflex: An Odyssey
2015, Trigeminocardiac Reflex
Rome ne s’est pas faite en un jour,¹ and neither was our current understanding of the trigeminocardiac reflex. This understanding is based on a series of meticulous observations and experiments over the past two centuries, but predominantly in the last two decades. The journey extends from the initial explanation of the respiration reflexes in the mid-nineteenth century to the clinical and physiological definitions of the phenomenon in the twenty-first century. The history of the trigeminocardiac reflex sheds light on the importance of this phenomenon for everyone involved in the treatment of patients by means of neurosurgery, craniomaxillofacial surgery, facial plastic surgery, and ophthalmology. This chapter presents an in-depth treatment of the history of the trigeminocardiac reflex.

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^f1: Hrayr K. Shahinian M.D. Skull Base Institute, Cedars-Sinai Medical Center, 8635 West Third Street, Suite 490W, Los Angeles, CA 90048, USA Tel: 1 310 423 8091 Fax: 1 310 423 8791 E-mail: [email protected]

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Regular ArticleTrigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy

Abstract

Br J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol

J CranioMaxillofac Surg

J Oral Macillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Plast Surg

Balloon compression rhizolysis in the surgical management of trigeminal neuralgia

Neurosurgery

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Can J Anaesth

The oculocardiac reflex: a graphic and statistical analysis in infants and children

Can Anaesth Soc J

Regular Article
Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy