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 Table of Contents  
Year : 2021  |  Volume : 35  |  Issue : 3  |  Page : 248-250

A rare event of trigeminocardiac reflex during mandibular branch of trigeminal nerve radiofrequency ablation

1 Center for Pain Releif, Hyderabad, Telangana, India
2 Epione Pain Clinic, Center for Pain Relief, Hyderabad, Telangana, India

Date of Submission15-May-2021
Date of Decision07-Sep-2021
Date of Acceptance09-Sep-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Sahitya Valli Gotety
Flat No: 202, Pearl Heights Apartments, Near Indian Bank, Lakshmi Nagar Colony, Pillar 118, Attapur, Rajendranagar, Hyderabad - 500 048, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_48_21

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We at Our Pain Clinic witnessed a rare event of recurrent bradycardia and hypotension during radiofrequency ablation of mandibular division of trigeminal nerve. A 48-year-old lady with trigeminal neuralgia in left V3 distribution was posted for V3 division rhizotomy under fluoroscopy. The patient had transient episodes of bradycardia and hypotension during the procedure. The patient had transient episodes of bradycardia and hypotension during the procedure. HR and BP were reverted to baseline with injection atropine and intravenous fluids. This response is most likely attributed to trigemino cardiac reflex, which occurs due to inadvertent stimulation of trigeminal nerve.

Keywords: Bradycardia, hypotension, mandibular branch, radiofrequency ablation, trigeminocardiac reflex

How to cite this article:
Dara S, Gotety SV, Chandra M. A rare event of trigeminocardiac reflex during mandibular branch of trigeminal nerve radiofrequency ablation. Indian J Pain 2021;35:248-50

How to cite this URL:
Dara S, Gotety SV, Chandra M. A rare event of trigeminocardiac reflex during mandibular branch of trigeminal nerve radiofrequency ablation. Indian J Pain [serial online] 2021 [cited 2022 May 29];35:248-50. Available from: https://www.indianjpain.org/text.asp?2021/35/3/248/334103

  Introduction Top

Trigeminal neuralgia (TN) is a unilateral facial pain disorder that is characterized by brief, electric-shock-like pains abrupt in onset and termination and is limited to the distribution of one or more divisions of the trigeminal nerve. The revised International Classification of Headache Disorders-3 suggest three variants: (a) classical TN, often caused by microvascular compression at the trigeminal root entry to the brainstem; (b) TN with concomitant persistent facial pain; and (c) symptomatic TN, caused by a structural lesion other than vascular compression.[1] Pain attacks can occur spontaneously or can be triggered by nonnoxious stimuli, such as talking, eating, washing the face, brushing teeth, shaving, a light touch, or even a cool breeze. TN has a prevalence of 0.1–0.2/1000 and an incidence ranging from four to 20 cases/100,000 people/year affecting both sexes, with a female-to-male ratio around 3:2.[2]

Among the available treatment modalities, TN radiofrequency ablation (RFA) is a safe and effective method for the treatment of TN. The mortality risk is extremely low with this modality, making it very appealing for elderly, frail patients, or the ones where other comorbidities enhance the risk of open neurosurgical therapy.[3]

Trigeminocardiac reflex (TCR) is commonly defined as suggested by Meuwly et al. as a sudden drop in HR and mean arterial BP (MABP) of more than 20% as compared with baseline values, evoked by a physical (mechanical, electrical) or chemical manipulation of any of the branches of the trigeminal nerve.[4]

Described below is an event of TCR encountered during RFA of V3 Division of trigeminal ganglion.

  Case Report Top

48-year-old lady, k/c/o HTN, Hypothyroidism, presented to pain clinic with a history of severe, sharp, piercing, paroxysmal electrical-like shock pain on the left side of her face, from tragus to the mandible and lower lip, since 1 year. The pain was triggered by talking, eating, and brushing teeth and the patient's Numerical Rate Scale score was 8/10. The pain was initially controlled with tablet carbamazepine 400 mg twice daily but was increased in intensity and duration with reduced remission periods for the past 2 months. Magnetic resonance imaging of the brain in fiesta view reported vascular loop of anterior inferior cerebellar artery abutting the trigeminal nerve, indicating type 1 TN (classical variety). Left trigeminal nerve V3 rhizotomy was planned. After proper counseling, written informed consent was obtained. 22 G intravenous (iv) cannula was secured and prophylactic iv antibiotic was administered, and the patient was shifted to the operation room and connected to the monitors (noninvasive blood pressure [BP], SpO2, heart rate [HR], respiratory rate [RR], 5 lead electrocardiographic).

Pre procedure, baseline vitals were HR: 110/min, BP: 160/90 mmHg, RR: 20/min, and SpO2:98% in room air.

Patient in supine, neck extended position, foramen ovale on Left side identified under Fluoroscopy in submental-vertex view, following which 1 mg iv midazolam was administered. After skin infiltration with 2 ml of 1%lidocaine, a 5 mm active curved tip radiofrequency (RF) needle was introduced and directed into the foramen ovale and the endpoint was confirmed in lateral view, as seen in [Figure 1] and [Figure 2]. The patient had an episode of bradycardia (PR – 29/min). The needle tip was immediately withdrawn by 1 mm and advised the patient to take a deep breath. HR improved to 90/min and BP – 125/58 mmHg. Once the vitals were stable, the needle was redirected into the foramen ovale, confirmed in lateral view under fluoroscopy. Sensory and motor stimulation at 50HZ, 0.3 V, and 2 HZ, 0.6 V, respectively, was done. Once the masseter muscle twitch was noted, V3 rhizotomy first lesion initiated at 60°C for 1 min, during which the patient's HR dropped to 34/min, BP: 94/40 mmHg. Immediately, the lesioning was stopped and injection atropine 0.4 mg and iv fluids were administered, following which the HR increased to 110/min, BP: 160/93 mmHg, and SpO2:96% with 3 L O2. Once the vitals stabilized, conventional RFA was carried out for 1 min. Post rhizotomy, corneal reflex was intact and there was no deviation of mouth. Subsequent lesioning was initiated at 70°C for 1 min, the patient had another episode of bradycardia HR: 40/min and BP (112/48 mmHg). RF lesioning was withheld and the patient was advised to take deep breaths and 0.4 mg of atropine was administered. Once the vitals improved, the RF lesioning was continued for 1 min. The patient was awake and communicating throughout the procedure. Post procedure, HR was 90/min, BP: 148/86 mmHg, and SpO2:97% in room air.
Figure 1: Submental Vertex View

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Figure 2: Lateral view

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Post procedure, the pain subsided, paresthesia in and around V3 distribution noted, and corneal reflex was intact. There was no deviation of the mouth. The patient was monitored in the recovery room for 2 h. Vitals remained stable (HR: 86/min, BP: 140/90 mmHg). Injection paracetamol 1 g was administered and later discharged the patient with antineuropathics and analgesics.

  Discussion Top

TN, also known as tic douloureux, is considered to be one of the most physical and psychological painful conditions a person might suffer. TN is caused by a neurovascular conflict which is compression of the trigeminal nerve or an underlying condition that affects this nerve.[5]

The TCR is a unique brain stem reflex that manifests as typical hemodynamic changes including a sudden decrease in both HR and MABP, cardiac arrhythmias, asystole, and other autonomic reactions such as apnea and gastric hypermotility.[6] The sensory nerve endings of the trigeminal nerve send neuronal signals via the gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. This afferent pathway continues along the short internuncial nerve fibers in the reticular formation to connect with the efferent pathway in the motor nucleus of the vagus nerve. Clinically, the TCR has been reported to occur during craniofacial surgery,[7] percutaneous balloon-compression for TN,[8] and tumor resection in the cerebellopontine angle.

Mechanical stretch is the most powerful predisposing factor to incite TCR and induction of sudden stretch of peripheral branch of TN by local anesthetic. Mechanical stretch is the most powerful predisposing factor to incite TCR and induction of sudden stretch of peripheral branch of TN by local anesthetic. The most common risk factors for TCR include hypercapnia, hypoxemia, light plane of general anesthesia, age (commonly seen in children), and drugs (narcotics, beta-blockers). Mechanical stretch is the most powerful predisposing factor to trigger TCR and induction of sudden stretch of peripheral branch of TN by local anesthetic has also been reported to cause TCR. The highest incidence of bradycardia and hypotension in percutaneous TN procedures is described during percutaneous balloon compression.[9]

Thermal stimulation is also known to be a significant risk factor for TCR. Meng et al. have presented interesting data that various pressor responses could be provoked during RFA of TN and were found to be temperature dependent.[10]

Management of trigeminocardiac reflex

Management of trigeminocardiac reflex includes risk factor identification and modification, prophylactic treatment with either vagolytics or peripheral nerve blocks. In case of peripheral manipulations of the trigeminal nerve,cardiovascular monitoring throughout the procedure Is mandatoty. Treatment includes (a) cessation of the manipulation and (b) administration of vagolytic agents such as atropine; if unresponsive to atropine, epinephrine should be administered.[11]

  Conclusion Top

TN RFA is a safe and effective method for the treatment of TN. Trigemino cardiac reflex can be avoided by gentle manipulation around the nerve, continuous monitoring of the HR and BP throughout the procedure to detect its occurrence, cessation of the mechanical stimulus, and in severe cases of bradycardia and asystole administer atropine or adrenaline.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zakrzewska JM, Linskey ME. Trigeminal neuralgia. BMJ 2014;348:g474.  Back to cited text no. 1
Kataria S, Ahmed Z, Ali U, Ahmad S, Awais A. Trigeminal neuralgia induced headache: A case report and literature review. Cureus 2020;12:e9226.  Back to cited text no. 2
Doshi P, Parikh N. Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis. Indian J Pain 2018;32:113.  Back to cited text no. 3
  [Full text]  
Meuwly C, Golanov E, Chowdhury T, Erne P, Schaller B. Trigeminal cardiac reflex: New thinking model about the definition based on a literature review. Medicine (Baltimore) 2015;94:e484.  Back to cited text no. 4
Turton M, Malan-Roux P. Trigeminal neuralgia: Case report and literature review. Stomatol Dis Sci 2019;3:7. Available from: https://sdsjournal.com/article/view/3174. [Last accessed on 2021 May 06].  Back to cited text no. 5
Trigeminocardiac Reflex – An Overview | ScienceDirect Topics. Available from: https://www.sciencedirect.com/topics/medicine-and-dentistry/trigeminocardiac-reflex. [Last accessed on 2021May 06].  Back to cited text no. 6
Lübbers HT, Zweifel D, Grätz KW, Kruse A. Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg 2010;68:1317-21.  Back to cited text no. 7
Qin Q, Wang Y. Recurrent trigeminocardiac reflex in percutaneous balloon compression for trigeminal neuralgia: A case report. Medicine (Baltimore) 2020;99:e22467.  Back to cited text no. 8
Chowdhury T, Mendelowith D, Golanov E, Spiriev T, Arasho B, Sandu N, et al. Trigeminocardiac reflex: The current clinical and physiological knowledge. J Neurosurg Anesthesiol 2015;27:136-47.  Back to cited text no. 9
Meng Q, Zhang W, Yang Y, Zhou M, Li X. Cardiovascular responses during percutaneous radiofrequency thermocoagulation therapy in primary trigeminal neuralgia. J Neurosurg Anesthesiol 2008;20:131-5.  Back to cited text no. 10
Arasho B, Sandu N, Spiriev T, Prabhakar H, Schaller B. Management of the trigeminocardiac reflex: Facts and own experience. Neurol India 2009;57:375-80.  Back to cited text no. 11
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