BackgroundWe present a case of a patient with multinodular goiter disease who suffered asystole during head hyperextension for surgical positioning on the operational table.Case PresentationManipulation of carotid sinus may trigger bradycardia or even asystole even in patients without prior history of carotid sinus hypersensitivity. The time proximity between patient positioning and asystole, the late responsiveness to atropine, the immediate increase of heart rate after head elevation and the lack of any other trigger factor or prior history support the hypothesis of carotid sinus syndrome.ConclusionsHead hyperextension during surgical positioning is not only responsible for jeopardizing blood flow to spinal cord and brainstem but may trigger reflexes, as well, even in patients without prior neck pathology.