- Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
1Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
DOI:10.4103/2152-7806.118340Copyright: © 2013 Etezadi F This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Etezadi F, Orandi AA, Orandi AH, Najafi A, Amirjamshidi A, Pourfakhr P, Khajavi MR, Abbassioun K. Trigeminocardiac reflex in neurosurgical practice: An observational prospective study. Surg Neurol Int 18-Sep-2013;4:116
How to cite this URL: Etezadi F, Orandi AA, Orandi AH, Najafi A, Amirjamshidi A, Pourfakhr P, Khajavi MR, Abbassioun K. Trigeminocardiac reflex in neurosurgical practice: An observational prospective study. Surg Neurol Int 18-Sep-2013;4:116. Available from: http://sni.wpengine.com/surgicalint_articles/trigeminocardiac-reflex-in-neurosurgical-practice-an-observational-prospective-study/
Background:Considering wide variations regarding the incidence of trigeminocardiac reflex (TCR) during cranial neurosurgical procedures, and paucity of reliable data, we intended to design a prospective study to determine the incidence of TCR in patients undergoing standard general anesthesia for surgery of supra/infra-tentorial cranial and skull base lesions.
Methods:A total of 190 consecutive patients candidate for elective surgery of supra-tentorial, infra-tentorial, and skull base lesions were enrolled. All the patients were operated in the neurosurgical operating room of a university-affiliated teaching hospital. All surgeries were performed using sufficient depth of anesthesia achieved by titration of propofol–alfentanil mixture, adjusted according to target Cerebral State Index (CSI) values (40-60). All episodes of bradycardia and hypotension indicating the occurrence of TCR during the surgery (sudden decrease of more than 20% from the previous level) were recorded.
Results:Four patients, two female and two male, developed episodes of TCR during surgery (4/190; 2.1%). Three patients showed one episode of TCR just at the end of operation when the skin sutures were applied while CSI values were 70-77 and in the last case, when small tumor samples were taken from just beneath the lateral wall of the cavernous sinus TCR episode was seen while the CSI value was 51.
Conclusion:TCR is a rare phenomenon during brain surgeries when patient is anesthetized using standard techniques. Keeping the adequate depth of anesthesia using CSI monitoring method may be an advisable strategy during whole period of a neurosurgical procedure.
The precise definition of trigeminocardiac reflex (TCR) was first suggested by a researcher in 1999 when he encountered a drop in mean arterial pressure (MAP) and heart rate (HR) during a skull base surgery procedure. He defined the term of TCR as a drop in MAP and HR of more than 20% compared with the baseline values before the stimulus and coinciding with the manipulation around the trigeminal nerve endings.[
The incidence of TCR in cranial surgeries has been reported in the range of 1.6-18%. It is noteworthy to mention that irrespective of two prospective studies in the literature, all of investigations regarding TCR had been performed either as a retrospective study or as case reports.[
We designed a prospective observational study to detect the incidence of TCR during cranial and skull base neurosurgical procedures, which was approved by the ethics committee of the university. Because this study was observational and noninvasive, only obtaining verbal consent from the patients was sufficed. A total of 190 consecutive patients with American Society of Anesthesiologists (ASA) grade I-III who were candidate for elective supra- and infra-tentorial craniotomy, trans-sphenoidal hypophysectomy and skull base surgery from September 2011 to November 2012 were enrolled. Patients who had any conductive heart blocking disease or any history of known autonomic system dysfunction, and those who underwent emergency craniotomy were excluded from the study. All episodes of bradycardia and hypotension during the surgery (sudden decrease of more than 20% from the previous level) coinciding with a simultaneous surgical manipulation in the territory of trigeminal nerve endings were regarded as TCR.[
Standard monitoring continued in the recovery ward and all patients were transferred to the intensive care unit for the rest of their reanimation process.
The primary outcome was determining the incidence of TCR during neurosurgical procedures and the secondary outcomes were determining the probable risk factors. Data were analyzed by SPSS version 19.1 software (Chicago, Il, USA). The incidence rate of TCR was obtained from the prospective study of Filis et al.[
n = required sample size
t = confidence level at 95%
p = estimated incidence rate
m = margin of error at 5% (standard value of 0.05)
We classified the pathologies to three main groups: (1) supra-tentorial gliomas or meningiomas, (2) infra-tentorial gliomas or meningiomas (in the skull base region and cerebellopontine angle), and (3) pituitary adenomas. Then, we calculated the Odds Ratio (OR) and Relative Risk (RR) for each group versus to the other one in the development of TCR.
Data was collected from 190 patients who fulfilled the including criteria and underwent the neurosurgery. Demographics data of patients are shown in
This is the first observational prospective study designed for determining the incidence of TCR in neurosurgical patients who were controlled in terms of depth of anesthesia. The incidence of TCR in the current study was 2.1%. The result of this study is in concordance with the study of Precious and Skulsky.[
Even though, some investigators propose that the TCR is phylogenetically, just like ‘diving reflex’ in birds and amphibians and may have a protective role in human being, Occasional reports of death due to TCR, create a major concern regarding this life threatening phenomenon in mind.[
According to this study, it is found that the incidence of so-called TCR during cranial and skull base surgery can be very low while performing a standard neuro-anesthesia practice. The number of TCR events in our study was not sufficient enough to perform an advanced statistical analysis; we would like to suggest that all patients who undergo craniofacial surgeries are better to be anesthetized deeply. This strategy may lessen the incidence of TCR to the least and reduce its danger. This suggestion may contradict with the current growing concept of the craniotomy in patients who are not deeply anesthetized electively.
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