Trigeminocardiac Reflex Induced by Maxillary Nerve Stimulation during Sphenopalatine Ganglion Implantation: A Case Series

Abstract

Background: The trigeminocardiac reflex (TCR) is a brainstem reflex following stimulation of the trigeminal nerve, resulting in bradycardia, asystole and hypotension. It has been described in maxillofacial and craniofacial surgeries. This case series highlights TCR events occurring during sphenopalatine ganglion (SPJ) neurostimulator implantation as part of the Pathway CH-2 clinical trial “Sphenopalatine ganglion Stimulation for Treatment of Chronic Cluster Headache”. Methods: This is a case series discussing sphenopalatine ganglion neurostimulator implantation in the pterygopalatine fossa as treatment for intractable cluster headaches. Eight cases are discussed with three demonstrating TCR events. All cases received remifentanil and desflurane for anesthetic maintenance. Results: Each patient with a TCR event experienced severe bradycardia. In two cases, TCR resolved with removal of the introducer, while the third case’s TCR event resolved with both anticholinergic treatment and surgical stimulation cessation. Conclusion: Each TCR event occurred before stimulation of the fixed introducer device, suggesting the cause for the TCR events was mechanical in origin. Due to heightened concern for further TCR events, all subsequent cases had pre-anesthesia external pacing pads placed. Resolution can occur with cessation of surgical manipulation and/or anticholinergic treatment. Management of TCR events requires communication between surgical teams and anesthesia providers, especially during sphenopalatine ganglion implantation when maxillary nerve stimulation is possible.

Efficacy of transcutaneous cardiac pacing for transient asystole caused by trigeminocardiac reflex: illustrative case

“… 20 The authors of a previous report used transcutaneous cardiac pacing as a prophylactic for TCR occurring during sphenopalatine ganglion implantation. 7 However, to the best of our knowledge, there is no report about TCR occurring during neurosurgery that was successfully managed with intraoperative transcutaneous cardiac pacing. Hence, further studies must be conducted to validate our results.…”

“… 14 If asystole or atropine-resistant bradycardia is persistent, chest compression and transcutaneous cardiac pacing can be considered. 7 Furthermore, alternative treatment modalities such as endovascular treatment instead of craniotomy should be considered. The outcome of endovascular coiling for ruptured cerebral aneurysms is not inferior to that of neurosurgical clipping.…”

“… 3 Moreover, if asystole persists, chest compression and transcutaneous cardiac pacing may be considered. 7 Herein, we present the first case of TCR occurring during emergency surgery for a ruptured cerebral aneurysm that was successfully managed with transcutaneous cardiac pacing.…”

Intraoperative Pulseless Electrical Activity Cardiac Arrest during Intracranial Aneurysm Clipping: Case Report

“…This neurogenic brainstem reflex is elicited by the stimulation of trigeminal afferents, leading to increased vagal tone with consequent bradycardia, hypotension, and gastric hypermotility [14,15]. Several case reports attribute periods of bradycardia and hypotension during neurosurgery to this phenomenon [12,[16][17][18][19][20][21][22]. The finding that the ophthalmic division of the trigeminal nerve supplies the supratentorial cerebral vasculature and dura of the rhesus macaque [23] has been proposed as a mechanism by which the TCR could be elicited during aneurysmal clipping [21].…”

“…The finding that the ophthalmic division of the trigeminal nerve supplies the supratentorial cerebral vasculature and dura of the rhesus macaque [23] has been proposed as a mechanism by which the TCR could be elicited during aneurysmal clipping [21]. Additionally, there are at least 2 case series' which have suggested an association between Remifentanil and elicitation of the TCR [19,22]. .…”