Trigeminocardiac Reflex: Case Report and Literature Review of Intraoperative Asystole in Response to Manipulation of the Temporalis Muscle

Shakil, Husain; Wang, Alick; Horth, Dillon; Nair, Saeda; Reddy, Kesava

doi:10.1016/j.wneu.2018.10.186

Cited by 9 publications

(6 citation statements)

References 21 publications

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“…Traction applied especially on the rectus medialis has been associated with the occurrence of OCR [ 17 ]. Multiple studies have reported an increased incidence of OCR with medial rectus traction compared to other ocular muscles [ 18 , 19 ]. Similarly, in our study, the right and left rectus medialis were the most common muscles in which OCR occurred by 77%.…”

Section: Discussionmentioning

confidence: 99%

Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial

Kartufan¹,

Kızılcık

Ziylan

et al. 2022

Journal of Ophthalmology

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Objective. In this single-blind, observational prospective clinical trial, we aimed to determine and compare the effects of premedication with hydroxyzine plus midazolam and midazolam alone on the incidence of oculocardiac reflex (OCR). Methods. Forty-five patients were divided into three groups. Group M received 0.5 mg/kg midazolam alone, Group H received 0.5 mg/kg hydroxyzine plus 0.5 mg/kg midazolam, and Group HM received 1 mg/kg hydroxyzine plus 0.5 mg/kg midazolam. The Ramsay Sedation Scale (RSS), the heart rates (HR1: after induction of anesthesia; HR2: before retraction of orbital muscle; and HR3: right after retraction of orbital muscle), the muscles with OCR, and the incidence of OCR (20% decrease of the HR right after the traction) were recorded and compared between the three groups. Results. The mean HR1, HR2, and HR3 values were significantly increased ( p = 0.002 , p < 0.001 , p < 0.001 ) and the incidence of OCR ( p = 0.004 ) was significantly decreased in Group H and in Group HM (for all, p < 0.01 ) compared to Group M. The most common orbital muscle in which OCR occurred was the rectus medialis. Conclusion. Premedication with a combination of 0.5 or 1 mg hydroxyzine with 0.5 mg midazolam significantly reduced the incidence of OCR compared to premedication with midazolam alone. This study was registered on https://clinicaltrials.gov/ with number NCT03806270.

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Section: Discussionmentioning

confidence: 99%

Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial

Kartufan¹,

Kızılcık

Ziylan

et al. 2022

Journal of Ophthalmology

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“…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].…”

Section: Case Reportmentioning

confidence: 99%

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

Alaa¹,

Soghakhawari²,

Will³

et al. 2022

Neurosurg Cases Rev

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Background: Cardiac arrest is a rare intraoperative complication with few cases reported during neurosurgery. Proposed causes of PEA cardiac arrest in this setting include medications, irrigation, coronary vasospasm, and elicitation of the trigeminocardiac reflex.Case description: Here, we report the case of a 52-yearold man who suffered an intra-operative pulseless electrical activity (PEA) cardiac-arrest while undergoing elective clipping of a right MCA bifurcation aneurysm through pterional craniotomy.

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“… 200 Manipulation of the temporalis muscle during orbitozygomatic craniotomy produced reproducible, consistent asystole. 201 …”

Section: Influence Of Anesthesiologistmentioning

confidence: 99%

The Oculocardiac Reflex: A Review

Arnold¹

2021

OPTH

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Background A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination. Methods World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response. Results With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR. Conclusion Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.

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Trigeminocardiac Reflex: Case Report and Literature Review of Intraoperative Asystole in Response to Manipulation of the Temporalis Muscle

Cited by 9 publications

References 21 publications

Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial

Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial

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

The Oculocardiac Reflex: A Review

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