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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 554

Transient cardiac asystole induced by electrocautery during excision of a cerebellopontine angle tumor


1 Department of Neuroanesthesia, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

Date of Submission19-Aug-2013
Date of Decision25-Aug-2013
Date of Acceptance13-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Kamath Sriganesh
Department of Neuroanesthesia, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.121953

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How to cite this article:
Sriganesh K, Pandey P. Transient cardiac asystole induced by electrocautery during excision of a cerebellopontine angle tumor. Neurol India 2013;61:554

How to cite this URL:
Sriganesh K, Pandey P. Transient cardiac asystole induced by electrocautery during excision of a cerebellopontine angle tumor. Neurol India [serial online] 2013 [cited 2020 Sep 19];61:554. Available from: http://www.neurologyindia.com/text.asp?2013/61/5/554/121953


Sir,

Occurrence of bradycardia during surgeries in the cerebellopontine angle has been documented but occurrence of asystole is rare. The mechanism for bradycardia and asystole is from direct stimulation of sensory branches of trigeminal nerve causing trigemino-cardiac reflex (TCR). The classical features of TCR are bradycardia, hypotension, and apnea. [1] We describe a patient with bradycardia, arrhythmia, and repeated asystole during excision of a cerebellopontine angle lesion.

A 46-year-old lady was scheduled for excision of a cerebellopontine angle lesion. Standard anesthetic induction was performed and anesthesia was maintained with oxygen-nitrous-oxide-isoflurane mixture between 1 and 1.2 minimum alveolar concentration. During the final phase of tumor excision, there was bleeding from superior pole of the tumor bed, which was controlled using bipolar coagulation. She had an episode of arrhythmia [Figure 1]a during the use of cautery [Figure 1]b and bradycardia, which progressed to asystole [Figure 1]c. At the end of the use of bipolar cautery, heart rate and rhythm normalized [Figure 1]d. However, on reapplication of bipolar cautery, there were repeated episodes of asystole. These episodes stopped with discontinuation of electrocautery use. Following hemostasis with surgicell, rest of the surgery was uneventful and patient was extubated at the end of the surgery.
Figure 1: (a) Electrocardiogram showing arrhythmia during cerebello-pontine angle surgery before occurrence of asystole, (b) Shows intraoperative use of bipolar coagulation to control bleeding, (c) Shows occurrence of asystole during electrocoagulation, (d) Shows return of normal cardiac rhythm and rate following withdrawal of thermal stimulation

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There are several triggers that can lead to TCR. However, there were no such triggers (lighter plane of anesthesia, hypoxia, hypercapnia, or acidosis) in our patient. Though direct stimulation of the trigeminal nerve or its branches could have resulted in this response as is generally implicated, it is more likely that this response was the result of thermal stimulation from electrocautery. Bradycardia and sinus arrest following inadvertent stimulation of brain structures from high temperature (42°C) of the saline used for irrigation has been documented previously. [2] The heat produced from the bipolar cautery is often very high [3] and could have triggered asystole. One previous report too has suggested cauterization as cause for TCR. [4] Atropine was not used in this patient despite repeated episodes of asystole because patient had arrhythmia and administration of atropine could have aggravated arrhythmia and also increased blood pressure making achievement of hemostasis further difficult. Withdrawal of the offending source promptly corrected this manifestation. To conclude, this report highlights occurrence of arrhythmia and repeated asystole during surgery for a cerebellopontine angle lesion. Occurrence of arrhythmia, not described previously, may be an early warning sign of impending asystole. Electrocautery as a possible trigger for TCR should be borne in mind along with careful and vigilant monitoring during surgeries of this nature.

 
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1.Koerbel A, Gharabaghi A, Samii A, Gerganov V, von Gösseln H, Tatagiba M, et al. Trigeminocardiac reflex during skull base surgery: Mechanism and management. Acta Neurochir (Wien) 2005;147:727-33.  Back to cited text no. 1
    
2.Sinha PK, Neema PK, Manikandan S, Unnikrishnan KP, Rathod RC. Bradycardia and sinus arrest following saline irrigation of the brain during epilepsy surgery. J Neurosurg Anesthesiol 2004;16:160-3.  Back to cited text no. 2
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3.Sakatani K, Ohtaki M, Morimoto S, Hashi K. Isotonic mannitol and the prevention of local heat generation and tissue adherence to bipolar diathermy forceps tips during electrical coagulation. Technical note. J Neurosurg 1995;82:669-71.  Back to cited text no. 3
[PUBMED]    
4.Usami K, Kamada K, Kunii N, Tsujihara H, yamada Y, Saito N. Transient asystole during surgery for posterior fossa meningioma caused by activation of the trigemino-cardiac reflex. Neurol Med Chir (Tokyo) 2010;50:339-42.  Back to cited text no. 4
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