Clinical Study
The trigeminocardiac reflex in Onyx embolisation of intracranial dural arteriovenous fistula

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Abstract

We investigated the incidence of the trigeminocardiac reflex (TCR) during ethylene vinyl alcohol copolymer (Onyx Liquid Embolic System, ev3 Neurovascular, Irvine, CA, USA) embolisation of intracranial dural arteriovenous fistulas (DAVFs) and evaluated the post-procedural recovery of these patients. Between June 2006 and July 2009, 21 patients (11 females, 10 males) with a mean age of 61 years (range: 25–85 years) underwent 28 Onyx embolisations of intracranial DAVFs at our institution. The case histories of these patients were reviewed retrospectively. A TCR occurred in three (10.7%) of the embolisations, with bradycardia lower than 60 beats/minute and a drop in mean arterial blood pressure of 20% or more. The reflex was blunted promptly with intravenous atropine, and follow-up of these patients showed no complications that might have been directly related to it. The TCR may occur during Onyx embolisation of intracranial DAVFs. Recognition of this phenomenon allows for early detection and appropriate intraoperative management.

Introduction

The trigeminocardiac reflex (TCR), first described by Kumada et al., is a well-known reflexive phenomenon of bradycardia, hypotension, apnoea and gastric hypermotility upon mechanical stimulation in the distribution of the trigeminal nerve.1 It has been reported to occur during ophthalmic, craniomaxillofacial and skull base surgery, as well as operations involving manipulations of the trigeminal ganglion and falx cerebri.[2], [3], [4], [5], [6], [7], [8], [9]

With an increasing number of intracranial dural arteriovenous fistulas (DAVFs) being treated endovascularly, TCR has also been reported in several instances of tentorial DAVFs that were embolised with ethylene vinyl alcohol copolymer (Onyx Liquid Embolic System, ev3 Neurovascular, Irvine, CA, USA).[10], [11]

Over the last few years, almost all of the patients who presented to our institution with intracranial DAVFs have been treated with Onyx embolisation as the definitive therapy. We present the occurrence of TCR in our patients and analyse its possible underlying mechanisms.

Section snippets

Materials and methods

We define the occurrence of TCR as abrupt bradycardia of less than 60 beats/minute and hypotension with a drop in mean arterial blood pressure of 20% or more, during transarterial or transvenous injection of Onyx or its solvent, dimethyl-sulfoxide (DMSO).

Results

Intraoperative TCR was encountered during three (10.7%) of the 28 embolisations. All three of these patients were female; the mean age was 76 years (range: 70–85 years; Table 1). One of the patients (patient 3) had hypertension, for which she took regular perindopril, an angiotensin-converting enzyme inhibitor. The other two patients had no significant medical history. None of these patients were taking a beta-blocker or calcium channel antagonist pre-operatively.

Patient 1 had a Cognard type IV

Discussion

Any irritation of the trigeminal nerve, or of the structures innervated by this nerve, may trigger the TCR. Neuronal signals are transmitted through the trigeminal nerve back to its sensory nucleus, constituting the afferent pathway of the reflex arc.13 The sensory nucleus of the trigeminal nerve is connected, via short internuncial fibres in the reticular formation, to the motor nucleus of the vagus nerve, from which cardioinhibitory fibres arise as the efferent pathway terminating in the

Conclusion

It is well documented that TCR occurs during various ophthalmologic, craniomaxillofacial and neurosurgical procedures. Accumulated evidence has shown that this reflex may occur during Onyx embolisation of intracranial DAVFs, possibly through mechanical compression or chemical irritation of the trigeminal nerve or its branches. Recognition and understanding of this phenomenon would allow for early detection and appropriate management during the endovascular procedure.

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