Download PDF
CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2021; 08(02): 139-141
DOI: 10.1055/s-0040-1710298
Case Report

Isolated Bradycardia During Aneurysmal Clipping: Rebleed or Trigeminocardiac Reflex?

Nidhi Singh
1   Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Kiran Jangra
1   Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Sabina Regmi
1   Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Apinderpreet Singh
2   Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

The most common cause of nontraumatic subarachnoid hemorrhage is the rupture of intracranial aneurysm. After initial bleed, the risk of rebleeding is highest in the early postictal period and this rebleed is strongly associated with poor neurological outcome. The major goal of anesthesia in these surgeries is to prevent the rebleed. If rebleeding occurs prior to the craniotomy, it results in the acute rise of intracranial pressure and usually presents as bradycardia and hypertension (Cushing’s reflex). Here we reported a case where rebleeding presented unusually as isolated bradycardia without associated hypertension and was mistaken as trigeminocardiac reflex. The surgeon was informed about the event and they planned to proceed. After craniotomy, despite all the efforts the brain was persistently tight and surgery could not be completed. Postoperative scan showed rebleeding and the patient died after a few days in ICU.

We highlighted in this case report the fact that isolated transient bradycardia may also be the presentation of rebleed with closed cranial vault. It is not always necessary to see all the features of Cushing’s traid in every patient. If bradycardia occurs before the craniotomy, the surgeon should be notified, the severity of bleed should be assessed, and further management should be planned according to the severity of bleed.

Keywords

bradycardia - Cushing’s traid - intracranial aneurysm - rebleeding - trigeminocardiac reflex


Publication History

Article published online:
01 June 2020

© 2020. Indian Society of Neuroanaesthesiology and Critical Care. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 

  • References

  • 1 Larsen CC, Astrup J. Rebleeding after aneurysmal subarachnoid hemorrhage: a literature review. World Neurosurg 2013; 79 (02) 307-312
    CrossrefPubMedGoogle Scholar
  • 2 Faried A, Sendjaja AN, Melia R, Arifin MZ. Bradycardia without hypertension and bradypnea in acute traumatic subdural hematoma is a sensitive predictor of the Cushing triad: 3 case reports. Interdiscip Neurosurg 2016; 6: 84-86
    CrossrefPubMedGoogle Scholar
  • 3 Yumoto T, Naito H, Yorifuji T. et al. Cushing’s sign and severe traumatic brain injury in children after blunt trauma: a nationwide retrospective cohort study in Japan. BMJ Open 2018; 8 (03) e020781
    CrossrefPubMedGoogle Scholar
  • 4 Leon-Ariza DS, Leon-Ariza JS, Nangiana J, Vargas Grau G, Leon-Sarmiento FE, Quiñones-Hinojosa A. Evidences in neurological surgery and a cutting edge classification of the trigeminocardiac reflex: a systematic review. World Neurosurg 2018; 117: 4-10
    CrossrefPubMedGoogle Scholar
  • 5 Radhakrishnan N, Chouhan RS, Kapoor I, Mahajan C.. Intraopera-tive predissection aneurysm rupture: no less than a catastrophe!. J Neuroanaesth Crit Care 2019 Doi: DOI: 10.1055/s-0039-1700588.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Chowdhury T, Petropolis A, Wilkinson M, Schaller B, Sandu N, Cappellani RB. Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract 2014; 2014: 595837
    PubMedGoogle Scholar