Clinical StudyThe trigeminocardiac reflex in Onyx embolisation of intracranial dural arteriovenous fistula
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.
References (25)
- et al.
The trigeminal depressor response: a novel vasodepressor response originating from the trigeminal system
Brain Res
(1977) - et al.
The falcine trigeminocardiac reflex: case report and review of the literature
Surg Neurol
(2005) - et al.
Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy
J Craniomaxillofac Surg
(2002) - et al.
Asystole due to trigeminocardiac reflex: a rare complication of transsphenoidal surgery for pituitary adenoma
J Clin Neurosci
(2009) - et al.
Bradycardia and the trigeminal nerve
J Craniomaxillofac Surg
(1990) - et al.
Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy
Clin Neurol Neurosurg
(2008) - et al.
The oculocardiac reflex: a graphic and statistical analysis in infants and children
Can Anaesth Soc J
(1983) Trigeminocardiac reflexes
Can J Anaesthesiol
(1991)- et al.
Trigeminocardiac reflex: maxillary and mandibular variants of the oculocardiac reflex
Can Anaesth
(1991) - et al.
Trigeminocardiac reflex during skull base surgery: mechanism and management
Acta Neurochir (Wien)
(2005)