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Table of Contents    
LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 3  |  Page : 696-697

Cardiac Asystole During Deep Brain Stimulation Surgery


1 Department of Anaesthesiology, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
2 Department of Neurology, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
3 Department of Neurosurgery, P D Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India

Date of Web Publication6-Jul-2020

Correspondence Address:
Dr. Charulata S Sankhla
Department of Neurology, P D Hinduja National Hospital, Mumbai - 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.289005

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How to cite this article:
Dhokte N, Sankhla CS, Ratan C, Sankhe M. Cardiac Asystole During Deep Brain Stimulation Surgery. Neurol India 2020;68:696-7

How to cite this URL:
Dhokte N, Sankhla CS, Ratan C, Sankhe M. Cardiac Asystole During Deep Brain Stimulation Surgery. Neurol India [serial online] 2020 [cited 2020 Aug 13];68:696-7. Available from: http://www.neurologyindia.com/text.asp?2020/68/3/696/289005




Subthalamic deep brain surgery (DBS) is an accepted treatment modality for Parkinson's disease (PD) with motor fluctuations. The complications associated with DBS are stroke and seizures. Rare complications include arrhythmias, tension pneumocephalus, symptomatic bradycardia and hypotension, venous air embolism, and asystole.

We describe a case of a 60-year-old PD patient who had a period of asystole due to trigeminocardiac reflex during deep brain surgery.

The trigeminocardiac reflex occurs due to stimulation of distal branches as well as central component of the trigeminal nerve. The patient may have bradycardia, hypotension, apnea, increased gastric motility, and cardiac asystole. The afferent arm of this reflex is trigeminal nerve and the efferent component is due to the stimulation of the vagus nerve. The bradycardia resolves with intravenous atropine, removal of the precipitating stimulus, and application of topical anesthetic agent on the dura.[1]

A female was diagnosed with PD since 7 years. She also had 5 years history of hypertension and 3 years history of dyslipidemia which were well controlled. She could climb two flights of stairs easily. She had no chest pain or any other cardiac symptoms prior to surgery. She had undergone uneventful hysterectomy a year ago. Her hemogram, renal, and liver function tests were normal. Electrocardiogram (ECG) and echocardiogram were normal. She was advised subthalamic nucleus (STN) deep brain surgery due to motor fluctuations and worsening “off” periods. On the day of surgery she was given scalp blocks bilaterally with 2% lignocaine with adrenaline and 0.5% bupivacaine in a ratio of 1:3. Total volume of 30 mL was injected. Leksell (stereotactic) frame was applied, and a computed tomography scan was performed to obtain accurate anatomical location of the subthalamic nucleus. The patient was continuously monitored during this period and was then transferred back to the operation room. Intravenous infusion of dexmedetomidine 0.2 μg/kg/h was started and stopped on completion of burr hole. After uneventful right STN electrode placement left-sided procedure was started, and burr hole was drilled on the left side. During microelectrode placement, the heart rate suddenly dropped from 64 beats/min to 40, which quickly decreased to 20 and finally asystole, along with hypotension. The procedure was immediately stopped and elecrodes were withdrawn. The patient was unresponsive, and eyes were rolled up. Chest compressions were started and she was given intravenous atropine 0.6 mg. She reverted back to sinus rhythm. She regained consciousness. Subsequent placement of left STN electrode was uneventful. She was observed in intensive care unit for 24 h without any further episodes of bradycardia.

A single case of sudden asystole during DBS surgery has been reported in the literature, wherein the authors mention Bezold–Jarisch reflex as the most probable cause. Bezold–Jarisch reflex is a cardioinhibitory reflex triggered due to hypovolemia or spinal anesthesia-induced hypotension.[2] The cause of asystole was attributed to hypovolemia and the beach-chair position for surgery. Bezold–Jarisch reflex is unlikely as the cause of asystole in our patient since the patient was supine and hydrated.

The dorsal region of the spinal trigeminal tract receives input from hypoglossal and vagus nerves, and projections have been seen between the vagus and trigeminal nuclei. The vagal nerve provides parasympathetic innervation to the heart, vascular smooth muscle, and abdominal viscera. Vagal stimulation via these connections with trigeminal nerve stimulation possibly accounts for the vagal reflex response of asystole seen in this patient. This is confirmed by the observation that the reflex was inhibited by the anticholinergic effects of atropine.[3]

The trigeminocardiac response can occur during awake craniotomy. This unsuspected complication can put an unintubated patient at risk. This response is commonly seen on stimulation of the trigeminal nerve during the craniofacial surgery. However, this has not been described in patients undergoing deep brain stimulation surgery. In our patient, this occurred during the second stage of DBS implant when the dura was pierced.

Awareness of this complication during awake deep brain stimulation surgery and prompt corrective steps will prevent the morbidity and mortality.[4]

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prabhu VC, Bamber NI, Shea JF, Jellish WS. Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy. Clin Neurol Neurosurg 2008;110:1064-7.  Back to cited text no. 1
    
2.
Nguyen HS, Woehlck H, Pahapill P. An unusual case of asystole occurring during deep brain stimulation surgery. Case Rep Neurol Med 2016;2016:8930296.  Back to cited text no. 2
    
3.
Bauer DF, Youkilis A, Schenck C, Turner CR, Thompson BG. The falcine trigeminocardiac reflex: Case report and review of the literature. Surg Neurol 2005;63:143-8.  Back to cited text no. 3
    
4.
Sriganesh K, Pandey P. Transient cardiac asystole induced by electrocautery during excision of a cerebellopontine angle tumor. Neurol India 2013;61:554.  Back to cited text no. 4
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