Efficacy of transcutaneous cardiac pacing for transient asystole caused by trigeminocardiac reflex: illustrative case

BACKGROUND: Trigeminocardiac reflex (TCR) is a brainstem reflex caused by stimulation of the trigeminal nerve, which results in bradycardia, hypotension, and asystole. TCR can occur during any neurosurgical procedure. Initially, it is managed via the immediate removal of the stimulus from the trigeminal nerve. If asystole persists after intravenous atropine or glycopyrrolate, chest compression or transcutaneous cardiac pacing may be considered. The authors present the first case of TCR that was successfully managed with transcutaneous cardiac pacing. OBSERVATIONS: A 51-year-old man presented with aneurysmal subarachnoid hemorrhage. Although he had no history of cardiac disease and there were no abnormal findings on electrocardiography, transient asystole due to TCR occurred during craniotomy. The patient’s heart rate spontaneously recovered after the immediate discontinuation of the procedure. The authors completed aneurysm clipping with transcutaneous cardiac pacing because intravenous atropine was not effective in preventing TCR. There were no complications associated with intraoperative asystole or transcutaneous cardiac pacing, and the patient was discharged without neurological deficits. LESSONS: TCR can be appropriately managed with the immediate discontinuation of intraoperative procedures. Furthermore, transcutaneous cardiac pacing may be considered for persistent TCR with poor response to intravenous atropine or glycopyrrolate.