Trigeminocardiac Reflex in Embolization of Intracranial Dural Arteriovenous Fistula

Abstract

SUMMARY:We report a case of immediate reproducible and reflexive response of asystole upon stimulation of Onyx injection during embolization of a tentorial dural arteriovenous fistula in a 53-yearold man. Upon recognition of the reflexive relationship between Onyx injection and increased vagal tone, the patient was given anticholinergic in an effort to block cholinergic hyperactivity. After atropine was given, no further dysrhythmias occurred. P revious articles have described trigeminocardiac reflex (TCR) during intracranial operations, ophthalmic surgery, and microcompression of the trigemimal ganglion. [1][2][3][4] We report a case of likely TCR seen upon mechanical stimulation of the middle meningeal artery in the spinosum foramen during embolization of a tentorial dural arteriovenous fistula (DAVF). This is the first case of TCR during transarterial embolization of DAVF. Case ReportA 53-year-old man presented with subarachnoid hemorrhage 2 years previously, and although conservative treatment was given at another hospital, headaches were still persistent. Cerebral angiograms were obtained and showed a DAVF fed by the right internal maxillary artery, the dorsal meningeal artery from the right meningohypophyseal trunk, and branches of the right posterior cerebral arteries. Venous outflow emptied into the right sigmoid sinus via the right dilated cerebellar cortical veins. Electrocardiogram (ECG) was normal. Recommendation was made for transarterial embolization of this lesion.Endovascular treatment was performed with the patient under standard anesthetic protocol. Anesthesia was induced with fentanyl (3 g/kg), followed by vecurium (1 mg/kg) and propofol (2 mg/kg). After the intubation of the trachea, the lungs were mechanically ventilated with a mixture of air and oxygen (FIO 2 ϭ 0.5). Anesthesia was maintained with renifentanyl (0.02 g/kg/min), and additional boluses of propofol (7 mg/kg/h) and vecurium (3 mg/h) were administered. A bilateral 6F femoral access was prepared, and the tip of a 6F guiding catheter was placed inside the right external carotid artery, while a 5F diagnostic catheter with continuous heparinized flush was positioned in the right vertebral artery for selective control angiograms. Using a road-mapping technique and fluoroscopic guidance, a Marathon microcatheter (ev3, Irvine, Calif.) was advanced over a 0.008-inch Mirage guidewire (ev3) in the right middle meningeal artery up to the fistula zone. Under biplane road-mapping, the catheter was slowly flushed with 0.25 mL of dimethyl-sulfoxide (DMSO) over 40 seconds, and this was followed by injection of Onyx 18 (ev3).The embolic material achieved antegrade filling of the malformation, but then formed a small reflux of several millimeters in length over the tip of the microcatheter. After waiting one minute for the reflux to solidify, the injection was continued gently. Again, some antegrade filling was achieved, but shortly, another short reflux was noted. This cycle was repeated until a plug of the embolic agent was obtained so that the ...

Complications Related to Percutaneous Transarterial Embolization of Intracranial Dural Arteriovenous Fistulas in 40 Patients

“…When stimulation causes trigemino- cardiac reflex (TCR), treatment of hemodynamic instability consists of ceasing Onyx injection, and anticholinergic drugs should be administered. 38 In 1 patient of our series, although Onyx was permeated well and cure could be achieved if Onyx injection was continued, TCR occurred and the heart rate decreased to 45 bpm. We had to cease Onyx injection, and atropine was administered transvenously.…”

“…Difficulty in microcatheter retrieval, reflexive bradyarrhythmia during Onyx injection, and trigeminal and facial nerve deficits caused by Onyx reflux have been described in the previous literature. 13,38 Reflexive Bradyarrhythmia This reproducible response occurred in 2 patients with tentorial DAVFs, Cognard IV. When stimulation causes trigemino- cardiac reflex (TCR), treatment of hemodynamic instability consists of ceasing Onyx injection, and anticholinergic drugs should be administered.…”

“…This long reflux may create sufficient proximal flow arrests to enable better distal penetration. 4,13,14,17,37,38 Consequently, when used in DAVFs, it may be more realistic to consider Onyx as a potential permanent embolic agent rather than expecting it to be surgically removed. In smaller arteriovenous fistulas, cure can be potentially attained with Onyx injection only.…”

“…Transarterial Onyx (ev3, Irvine, Calif) embolization is now an established method of treatment of DAVFs. 4,13,14,17,37,38 Onyx can often penetrate to the point of fistulization with distal ligation of multiple feeders. However, potential complications are associated with this procedure, and there is a lack of detailed information on such complications in the literature.…”

Trigeminocardiac Reflex in Neurosurgery - Current Knowledge and Prospects

“…In the past years, TCR has been reported to occur during several other neurosurgical procedures such as transsphenoidal surgery (Schaller, 2005a), Jannetta microvascular decompression (Schaller, 2005b), percutaneous radiofrequency thermocoagulation and percutaneous microcompression of the trigeminal ganglion (Meng, et al, 2008), neuroendovascular approaches in neurosurgery (Amiridze, et al, 2009, Lv, et al, www.intechopen.com Explicative Cases of Controversial Issues in Neurosurgery 4 2010, Lv, et al, 2007, Ong, et al, 2010, and during aneurysm clipping (Spiriev, et al, 2011a). As the TCR may have decisive impact on the surgical course as well as the postoperative functional outcome of neurosurgical patients with skull-base pathologies, the awareness of the TCR is essential for everyone involved in the treatment of those patients.…”