Prophylactic Intra-Arterial Injection of Lidocaine Prevents Trigeminocardiac Reflex During Endovascular Embolization for Dural Arteriovenous Fistula: A Report of 2 Cases

Abstract

Case series Patients: Male, 56-year-old • Male, 57-year-old Final Diagnosis: Trigeminocardiac reflex Symptoms: Bradycardia • severe hemodynamic fluctuation Medication: — Clinical Procedure: — Specialty: Anesthesiology • Neurosurgery Objective: Unusual clinical course Background: Trigeminocardiac reflex (TCR) is a unique brain stem reflex that manifests as the sudden onset of hemodynamic perturbation in heart rate and blood pressure as a result of stimulation of any branches of the trigeminal nerve. Onyx™ embolization in cerebrovascular interventional surgery can trigger TCR, leading to severe hemo-dynamic fluctuations and even cardiac arrest. Appropriate prophylactic approaches to prevent Onyx™ embolization-induced TCR are still lacking. Case Reports: We report the cases of 2 patients with recurrent and profound bradycardia due to TCR during endovascular Onyx™ embolization for a dural arteriovenous fistula. Prophylactic intra-arterial injection of lidocaine (10–20 mg) effectively and safely blocked the recurrence and potential occurrence of TCR. These 2 patients had reduced heart rate with either hypotension or hypertension during their TCR episodes, suggesting that stimulating a distinct cerebral artery (occipital artery versus vertebral artery branch) can initiate TCR by provoking the vagus nerve via the common neuronal pathway while simultaneously inhibiting or exciting the sympathetic pathway. Conclusions: Intra-arterial injection of lidocaine during endovascular procedures can be recommended as an effective prophylactic approach for use in the treatment of the cerebrovascular disorder where there is high risk of embolization-induced TCR.

Prophylactic intra-arterial injection of lidocaine: a novel strategy to prevent endovascular embolization-induced trigeminocardiac reflex

“…In the present randomized controlled trial we found that a 20 mg lidocaine injection in the cerebral artery could effectively inhibit the incidence of TCR without central nervous side effects, showing that the prophylactic intra-arterial application of low-dose lidocaine is safe and effective in blocking endovascular embolization-induced TCR. Our result confirms the findings of two recent published case reports13 14 in which 5–20 mg lidocaine prevented TCR during endovascular treatment in a patient with CCF and two patients with DAVF.…”

“…Peripheral stimulation of the trigeminal nerve co-activates the vagal and sympathetic nerves resulting in both hypertension (peripheral vasoconstriction) and bradycardia 9. By contrast, central stimulation causes hypotension and bradycardia by generating profound activation of the cardiac vagal branch and distinct inhibition of the inferior cardiac sympathetic nerve 10 14. In the present study we found that seven patients with TCR had a decrease in blood pressure which, in six patients, was >20%.…”

“…However, there has been no systematic research on the use of lidocaine for TCR caused by mechanical stimulation of the trigeminal nerve during Onyx embolization. Two recent case reports by Coleman et al 13 and our group14 showed that a prophylactic intra-arterial injection of lidocaine was able to blunt TCR during endovascular treatment of CCF and DAVF.…”

Asystole during Onyx embolization of 64-year-old patient with dural arteriovenous fistula

“…During some procedures when administration of atropine and glycopyrrolate did not improve the bradycardia, the use of intra-arterial lidocaine successfully stopped the recurrence of trigeminal-cardiac reflex (TCR) and allowed the procedure to be completed successfully. 8,9…”

“…During some procedures when administration of atropine and glycopyrrolate did not improve the bradycardia, the use of intra-arterial lidocaine successfully stopped the recurrence of trigeminalcardiac reflex (TCR) and allowed the procedure to be completed successfully. 8,9 Onyx is a liquid embolizing agent that has been used frequently in treating arteriovenous malformations and has shown great efficacy; once in contact with fluid (blood) it begins to polymerize and causes vasoocclusion of the nearby structures. It is dissolved in DMSO and mixed with tantalum powder, which is useful for fluoroscopic visualization.…”