Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy

• Published in: Clinical neurology and neurosurgery Vol. 110; no. 10; pp. 1064 - 1067
• Main Authors: Prabhu, Vikram C, Bamber, Norman I, Shea, John F, Jellish, W. Scott
• Format: Journal Article
• Language: English
• Published: Amsterdam Elsevier B.V 01.12.2008; Elsevier Science; Elsevier Limited
• Subjects: Aged; Awake-craniotomy; Biological and medical sciences; Bradycardia - etiology; Bradycardia - physiopathology; Bradycardia - therapy; Craniotomy - adverse effects; Craniotomy - methods; Humans; Intraoperative Complications - etiology; Intraoperative Complications - physiopathology; Intraoperative Complications - therapy; Male; Medical sciences; Neurology; Neurosurgery; Parasympathetic responses; Reflex - physiology; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Topical anesthetic; Trigeminal nerve; Trigeminal Nerve - physiology; Trigeminocardiac reflex; Vagal nerve; Vagus Nerve - physiology; Parasympathetic responses; Trigeminocardiac reflex; Trigeminal nerve; Awake-craniotomy; Vagal nerve; Topical anesthetic; Local administration; Nervous system diseases; Clinical management; Anesthetic; Surgery; Craniotomy
• ISSN: 0303-8467; 1872-6968
• DOI: 10.1016/j.clineuro.2008.07.005

Abstract The trigeminocardiac reflex occurs from manipulation or stimulation of peripheral branches or the central component of the trigeminal nerve and consists of bradycardia, hypotension, apnea, and increased gastric motility. The efferent limb of the response is mediated by the vagus nerve. This 65-year-old Caucasian male suffered an episode of bradycardia progressing to transient asystole during the course of an awake-craniotomy procedure for tumor resection. The cardiac rhythm changes resolved with administration of intravenous atropine, removal of the precipitating stimulus, and application of topical anesthetic on the dura of the middle cranial fossa. The trigeminocardiac response may complicate the course of a craniotomy and may place an awake, unintubated patient at increased risk for morbidity. The reflex may be prevented by anesthetizing the dura innervated by the trigeminal nerve via injection or topical application of local anesthetic. If encountered, removal of the stimulus, airway protection, and administration of vagolytic medications are measures that need to be considered.