Abstract

CR3-189

Intraoperative management of a patient with multiple episodes of asystole during epilepsy surgery due to trigeminal cardiac reflex

Richards S, Shibata G, Rouine-Rapp K
University of CA San Francisco, San Francisco, CA, USA

INTRODUCTION: The trigeminal cardiac reflex (TCR) can lead to a sudden decrease in heart rate, mean arterial blood pressure and cardiac arrhythmias.1 Cardiac arrest is rare in this setting.2 Advanced life support interventions of chest compressions and defibrillation are challenging in patients who undergo neurosurgery due to positioning, exposure, and skull pin fixation.3 We describe the intraoperative management of an 11-year-old boy with medically refractory epilepsy undergoing craniotomy for cortical resection, who had multiple episodes of asystole during dura penetration due to TCR.
METHODS: During the initial craniotomy surgery in the prone position, the patient had 2 episodes of bradycardia leading to asystole upon burr-hole penetration of the dura. These events were treated effectively with epinephrine, and the procedure was aborted. Given ongoing seizures, a multidisciplinary team formulated a plan for repeat surgery that was approved by the patient’s parents. Preoperative ECG and transthoracic echocardiogram were normal. Outpatient cardiac monitoring showed a range of sinus rhythm from 52-205 bpm, without pauses, AV block or malignant arrhythmias. An intraoperative plan was designed to aggressively treat episodes of intraoperative bradycardia with backup pacing utilizing both transcutaneous and transesophageal atrial pacing. In addition, the patient was postioned in the lateral position (instead of prone) to facilitate effective chest compressions, should they become necessary.
RESULTS: The patient underwent an inhalational induction with sevoflurane, tracheal intubation, placement of two peripheral IVs and an arterial line for monitoring. He was positioned laterally and his cranium was stabilized with pins. Transcutaneous cardiac pacing pads were placed, but testing resulted in unacceptable body movements while in pins. A transesophageal atrial pacing probe was inserted using change in ECG P-wave morphology and pacing capture to confirm successful placement. Intraoperatively, the patient had 3 episodes of bradycardia which were treated successfully with anticholinergic medication. There were no episodes of hypotension or asystole. Surgical resection of the epileptic focus was completed. At his three-month follow-up, the patient remained seizure-free.
DISCUSSION: Elective epilepsy surgery in a patient with intractable epilepsy was completed after extensive preoperative planning and aggressive intraoperative management of bradycardia in a patient with life-threatening TCR. During electrophysiologic studies, success of transesophageal atrial pacing is 93%; reported ranges of success in children and adults are 90 and 100%, respectively.4,5 Contact between the anterior esophagus and left atrium is necessary for effective atrial stimulation and may limit its use.
CONCLUSIONS: Elective neurosurgery may be feasible in pediatric patients with life-threatening TCR with careful preoperative planning and alternative intraoperative management such as patient positioning and transesophageal atrial pacing.