Neurogenic Bradycardia in Perioperative of Neurosurgery: A Dreadful Complication 2 Cases and Literature Review

Case Report

Austin J Anesthesia and Analgesia. 2023; 11(1): 1109.

Neurogenic Bradycardia in Perioperative of Neurosurgery: A Dreadful Complication 2 Cases and Literature Review

Masad Ilyass*, Abouelalaa KH, Elbouti AN, Fakri AH, Elwali AB and Bensghir MU

Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.

*Corresponding author: MASAD Ilyass Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.

Received: November 24, 2022; Accepted: January 20, 2023; Published: January 27, 2023

Abstract

Neurogenic bradycardia which can lead to cardiac arrest is a rare, but well-recognized complication of anesthesia.

Abstract

Neurogenic bradycardia which can lead to cardiac arrest is a rare, but well-recognized complication of anesthesia.

we report the cases of two patients admitted for craniotomy who presented intraoperative bradycardia due to TrigeminoCardiac Reflex and Hypothalamic stimulation immediately reversible after cessation of stimulation.

The importance of having the knowledge, vigilance, equipment and skills to quickly deal with such a case will be critical to the survival of the patient.

Keywords: Neurogenic bradycardia; Craniotomy; Trigemino Cardiac Reflex; Hypothalamic stimulation

Introduction

Today, patients safety is an important pillar of patients care, advances in therapeutics, management guidelines, and technological devices and close monitoring allowed to detect, and quickly treat cardiac arrest and peri arrest arrhythmias.

Neurogenic bradycardia which can lead to cardiac arrest is a rare, but well-recognized complication of anesthesia.

we report the cases of two patients admitted for craniotomy who presented intraoperative bradycardia.

Case 1

A 40-year-old patient, weighing 65 kg, was admitted to the neurosurgery department for occipital headache accompanied by vomiting and reduced visual acuity that had progressed in the past 9 months. He had no specific history nor had any comorbidities. All the requested radiological and biological assessments that were carried out were within normal limits. The patient was diagnosed on MRI with a dermoid cyst in the magna cistern displacing the fourth ventricle; therefore, a retro mastoid suboccipital craniotomy and tumor excision were planned.

After admission to the operating room, we proceeded with the induction with 200 μg intravenous Fentanyl and 160 mg Propofol. Orotracheal intubation was facilitated by the administration of 100 mg of rocuronium intravenously.

The anesthesia was maintained with sevoflurane in a mixture of oxygen and nitrous oxide (50/50) as well as with intermittent boluses of fentanyl 1 μg / kg and rocuronium 0.2 mg / kg depending on the needs. The patient was placed prone and the operation started.

After 90 minutes the Anesthesiologist and the nurse were alerted by sudden asystole without any prior prodrome which spontaneously resolved followed by a transient episode of bradycardia which occurred which also resolved spontaneously. 8 minutes later, a second episode of bradycardia occurred and was complicated by a new asystole. The neurosurgeon was notified and 0.5 mg of atropine was administered intravenously. The heart rate has returned tonormal. Mean arterial pressure (MAP) dropped from 80 to 50 mm Hg. A bolus of neosynephrine (3 mg) was given. The mean arterial pressure increased to 85 mm Hg and tumor dissection was resumed. Another episode of sudden asystole

occurred four minutes later and Heart rate increased after stopping the stimulus. The bradycardia stopped with the surgical stimuli stopping, indicating that the surgical manipulation of the brain was the probable cause. After this event, it was decided to end the operation and resume it later. The operation continued afterwards and took place without significant incidents. The patient was subsequently transferred to intensive care for postoperative monitoring and he was extubated without any incident 8 hours later and he returned to the ward after an 18-hour stay in intensive care.

Case 2

A 45-year-old patient was admitted to the neurosurgery department for a reduced unilateral vision in her right eye evolving for more than 4 months. Magnetic resonance imaging revealed a homogeneous mass of 2 × 2 cm over the suprasellar region. The patient was diagnosed with suprasellar meningioma and a bi-frontal craniotomy with tumor excision was planned in a supine position.

All preoperative examinations, including the EKG and Chest X-Ray, were normal. On the day of the operation, the patient was pre-medicated with 0.2 mg of glycopyrrolate intramuscularly one hour before the operation. Routine monitors have been set up. The basal heart rate was 78 bpm and the blood pressure was 130/80 mmHg. General anesthesia was induced with fentanyl 2 μg/ kg, propofol 1.5 mg / kg and tracheal intubation was facilitated with rocuronium 1 mg / kg. The trachea was intubated using a 7.5 mm cuff portex endotracheal tube. Anesthesia was maintained with sevoflurane in a mixture of oxygen and nitrous oxide (50:50) and intermittent boluses of fentanyl and vecuronium as needed. Dexmedetomidine was also administered just before the incision (1 bolus of μg / kg over 10 min followed by an infusion of 0.4-0.5 μg /kg / min). Invasive intraoperative monitoring was established and included central venous pressure and arterial pressure, using the right femoral vein and left artery, respectively. The patient was maintained at a mean arterial pressure of 65-70 mmHg.

During retro chiasmatic dissection, a sudden severe bradycardia (30 beats /min) with hypotension (mean arterial pressure 50 mmHg) occurred. The surgeon was immediately informed. After removing the stimulus, the heart rate and blood pressure returned to normal. These transient hemodynamic disturbances occurred twice. No pharmacological intervention was performed. After this excision cardiac event, the operation took place without any other incident.

Citation: Ilyass M, Abouelalaa KH, Elbouti AN, Fakri AH, Elwali AB, et al. Neurogenic Bradycardia in Perioperative of Neurosurgery: A Dreadful Complication 2 Cases and Literature Review. Austin J Anesthesia and Analgesia. 2023; 11(1): 1109.