Correspondence J Neurosurg Anesthesiol  Volume 29, Number 3, July 2017

case 2, occlusion of the P1 segment by a
temporary clip in the operation room or
balloon occlusion in the radiology suite
may cause ischemia in the midbrain and
the thalamus, especially in the cortico-
spinal bers, the occulomotor nerve nu-
cleus. Both MEP and VEP monitoring
will be very useful in detecting ischemia
resulting from the P1 segment. Patients
with PCA infarcts usually have hemi-
anopia, hemiparesis, and sensory dis-
turbances.4 As literature does not exist
on this subject, we believe that in pa-
tients undergoing PCA aneurysm endo-
vascular coiling or surgical clipping, the
intraoperative evoked potential mon-
itoring modality must take into con-
sideration the location of the temporary
clip/balloon occlusion; monitoring with
both MEP and VEP was more eective
in detecting ischemia.
Nilima R. Muthachen, DM
(Neuroanaesthesia)
Manikandan Sethuraman,
MD, PDCC, (Neuroanesthesia)
Department of Anesthesiology, Division
of Neuroanesthesiology, Sree Chitra
Tirunal Institute for Medical Sciences and
Technology, Trivandrum, Kerala, India
REFERENCES
1. Hamada J, Morioka M, Yano S, et al. Clinical
features of aneurysms of the posterior cerebral
artery: a 15-year experience with 21 cases.
Neurosurgery. 2005;56:662670.
2. Wang H, Du R, Stary J, et al. Dissecting
aneurysms of the posterior cerebral artery: current
endovascular/surgical evaluation and treatment
strategies. Neurosurgery. 2012;70:15811588.
3. Goehre F, Jahromi BR, Hernesniemi J, et al.
Characteristics of posterior cerebral artery
aneurysms: an angiographic analysis of 93
aneurysms in 81 patients. Neurosurgery.
2014;75:134144.
4. Kumral E, BayulkemG, Akyol A, et al.
Mesencephalic and associated posterior cir-
culation infarcts. Stroke. 2002;33:22242231.
has practice implications (up to 90%
prevalence in strabismus surgeries; inu-
ence on the functional outcome4). Latest
research implies a strong correlation be-
tween the depth of anesthesia and TCR,5
underlining treatment with deeper nar-
cosis instead of anticholinergic drugs.2
The aim of this study was to evaluate
and review the standard treatment of
TCR, with special reference to the depth
of anesthesia.
A systematic literature review
was performed from January 1995 to
October 2015, using the terms
trigemino-cardiac reex, trigeminal
cardiac reex, and oculocardiac re-
ex in PubMed (MEDLINE) and
EMABASE (OvidSP) databases. TCR
was dened as a >10% decrease in heart
rate or induced arrhythmia; inclusion
criteria were the fulllment of 2 major
criteria (plausibility and reversibility)3
and availability of the exact cerebral state
index (CSI)/bi-spectral index score (BIS)
values and exact values of hemodynamic
changes. Data extraction were made by 2
independent reviewers (k > 0.8).
Three of the 4 articles included
reported a clinical prevalence of TCR
during strabismus and neurosurgery.58
Because of strong dierences (TCR-
type, age, procedure, anesthesia), only 2
TABLE 1. Analysis of All Patients6,7
CSI/BISr50 All
Patients
Patients (n) 88
TCR (n) 20
Non-TCR (n) 68
Atropine as treatment 1 (1.4)
(n [%])
Signicance of bold value is provided by the w2-test.
BSI indicates bi-spectral index score; CSI, cerebral state index; NNT, number needed to treat; RR, relative
risk; TCR, trigemino-cardiac reex.
studies were included nally.6,7 The 144
patients included were divided into 2
groups: 1 with deeper anesthesia (CSI/
BIS <50) (n = 88) and 1 with light
anesthesia (CSI/BIS > 50) (n = 56)
(Tables 1 and 2). Anesthesia was
maintained by volatile narcotics only
(sevourane/desurane). As in some
clinics, it is still common to pretreat
patients with anticholinergic drugs to
lower their vagal potential and thereby
the prevalence of TCR; 84 patients
were premedicated with atropine i.m.
0.01 mg/kg.
There was a signicantly lower
prevalence of TCR in the CSI/BIS r50
group (22.7%) than in the CSI/BIS >
50 group (67.9%) (w2 [1, N = 144] =
28.976, P = 7.3289E 8), demonstrat-
ing a 2.21 times higher risk for TCR
under light anesthesia (Tables 1 and
2). The same signicant dierence was
seen in patients with atropine pre-
treatment; the prevalence in the CSI/
BIS r50 group was 21.4% and in
the CSI/BIS > 50 group 71.4% (w2
[1, N = 84] = 19.788, P = 9.0E 6).
In this analysis, we highlight
light anesthesia as an independent risk
factor for a higher prevalence of pe-
ripheral TCR and a signicantly lower
use of atropine as the treatment for
CSI/BIS > 50 All
Patients RR NNT v2
56
38 0.334 2.21 P = 7.3289E8
18
4 (2.9)

The Trigemino-cardiac
Reflex: Is Treatment With TABLE 2. Analysis of Patients With Atropine Pretreatment6,7
Atropine Still Justified? CSI/BISr50 CSI/BIS > 50
Pretreated Patients Pretreated Patients RR NNT v2
To JNA Readers: Patients (n) 56 28
Trigemino-cardiac reex (TCR) is TCR (n) 12 20 0.299 2 P = 9.0E6
Non-TCR (n) 44 8
a well-established brainstem reex13 that Atropine as 0 0
treatment (n)
The authors have no funding or conicts of BSI indicates bi-spectral index score; CSI, cerebral state index; NA, not available; NNT, number needed to
interest to disclose. treat; RR, relative risk; TCR, Trigemino-cardiac reex.
DOI: 10.1097/ANA.0000000000000324

372 | www.jnsa.com Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.

J Neurosurg Anesthesiol  Volume 29, Number 3, July 2017
bradycardia in deep anesthesia. We,
therefore, recommend adequate depth
of anesthesia to prevent the occur-
rence of TCR in high-risk procedures.
We also recommend the following
standard treatment of TCR: 1. im-
mediately cease surgical manipulation;
2. reassess the depth of anesthesia; 3.
administer anticholinergic drugs only
in case of persistent asystole or repet-
itive TCR.
Cyrill Meuwly, MMed*
Tumul Chowdhury, MD, DM,
FRCPCw
Ricardo Gelpi, MD, PhDz
Paul Erne, MD*
Bernhard Schaller, MD, PhD, DSCy
*Department of Research, University
Hospital Basel, Basel, Switzerland
wDepartment of Anaesthesiology and
Perioperative Medicine, University of
Manitoba, Winnipeg, Canada
zDepartment of Pathology, University of
Buenos Aires, Buenos Aires, Argentina
yDepartment of Research, University of
Southampton, Southampton, UK
REFERENCES
1. Schaller B, Probst R, Strebel S, et al.
Trigeminocardiac reflex during surgery in
the cerebellopontine angle. J Neurosurg.
1999;90:215220.
2. Chowdhury T, Ahuja N, Schaller B. Severe
bradycardia during neurosurgical procedure:
depth of anesthesia matters and leads to a
new surrogate model of the trigeminocardiac
reflex: a case report. Medicine (Baltimore).
2015;94:e2118.
3. Meuwly C, Golanov E, Chowdhury T, et al.
Trigeminal cardiac reflex: new thinking model
about the definition based on a literature
review. Medicine (Baltimore). 201594:e484.
4. Hahnenkamp K, Honemann CW, Fischer LG,
et al. Effect of different anaesthetic regimes on
the oculocardiac reflex during paediatric stra-
bismus surgery. Paediatr Anaesth. 2000;10:
601608.
5. Meuwly C, Chowdhury T, Sandu N, et al.
Anesthetic influence on occurrence and
treatment of the trigemino-cardiac reflex: a
systematic literature review. Medicine (Bal-
timore). 2015;94:e807.
6. Karaman T, Demir S, Dogru S, et al. The
effect of anesthesia depth on the oculocar-
diac reflex in strabismus surgery. J Clin
Monit Comput. 2015.
7. Yi C, Jee D. Influence of the anaesthetic
depth on the inhibition of the oculocardiac
reflex during sevoflurane anaesthesia for
paediatric strabismus surgery. Br J Anaesth.
2008;101:234238.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
8. Etezadi F, Orandi AA, Orandi AH, et al.
Trigeminocardiac reflex in neurosurgical
practice: An observational prospective
study. Surg Neurol Int. 2013;4:116.
Intense Intraoperative
Thirst: A Neglected
Concern during Awake
Craniotomy Surgeries
To JNA Readers:
The advantages of optimal re-
section over the eloquent cortex, con-
stant communication with patients,
reduced hospital stay, less resource uti-
lization, and higher patient satisfaction1,2
have enhanced the popularity of the
awake craniotomy technique for tumor
excision, epilepsy, and deep-brain stim-
ulation surgeries. Commonly, these cases
are conducted under scalp block (with
local anesthetics) along with conscious
sedation using drugs such as opioids
(fentanyl, remifentanil), midazolam,
propofol, or dexmedetomidine. The ap-
plication of these unconventional tech-
niques has led to the emergence of newer
clinical dilemmas, which hitherto were
not observed under general anesthesia as
consciously sedated patients are able to
verbalize.
We wish to report our experi-
ences with 2 patients who were un-
dergoing awake craniotomies under
bilateral scalp blocks and intravenous
dexmedetomidine sedation. Midway
through the surgery, both the patients
started complaining of severe dryness
of mouth and demanded drinking
water. Severe thirst caused signicant
restlessness and anxiety in these pa-
tients. Repeated verbal explanations
and assurances failed to pacify these
patients and the surgery had to be
interrupted repeatedly. The distress
made the patients agitated and raised
apprehensions of them hurting them-
selves, as their heads were xed with
pins over frames. Ultimately, we had
to administer 2 small aliquots (10 mL
The authors have no funding or conicts of
interest to disclose.
DOI: 10.1097/ANA.0000000000000327
Correspondence
each) of water orally to placate them
and allow the completion of surgery.
Various factors make these pa-
tients prone to intraoperative dehy-
dration. Mandatory fasting before
surgery is one of the main reasons
causing dryness of the mouth and the
throat. The American Society of Anes-
thesiologists recommends fasting from
the intake of clear liquids for at least 2
hours before elective procedures re-
quiring general/regional anesthesia or
sedation/analgesia (ie, monitored anes-
thesia care).3 Avoiding unnecessary
prolongation of the fasting period and
allowing clear uids till the stipulated
period ensures adequate hydration per-
ioperatively. Diuretics (mannitol) used
to reduce the brain volume can poten-
tiate dehydration. High ambient tem-
peratures and low humidity caused by
overhead lights in operation theaters
enhance insensible losses from mucosal
surfaces. Thus, stringent regulation of
operation theaters temperatures and
humidity should be ensured, especially
in tropical climates, to provide opti-
mum comfort and prevent moisture
loss. Oxygen supplementation through
a face mask or nasal prongs should
utilize adequately humidied oxygen to
prevent drying of the oral mucosa.
Anticholinergic drugs such as glyco-
pyrrolate have antisialogogue eects
and can cause appreciable dry mouth.
Unless absolutely indicated, they should
be avoided during awake surgeries.
Dexmedetomidine, which is extensively
used during conscious sedation, in-
cludes dry mouth in its side-eect pro-
le.4Although uncommon, fentanyl
administration may cause xerostomia.5
The success of awake craniotomy
largely depends on patients cooperation.
Preventing distress and ensuring opti-
mum intraoperative comfort contributes
immensely to the smooth conduct of this
novel technique. With the widespread
use of conscious sedation for awake
craniotomies, underrated problems such
as intraoperative thirst are surfacing.
These scenarios should be anticipated
beforehand and should be explained
sympathetically during preoperative
counseling. The above-mentioned fac-
tors, which can aggravate intraoperative
thirst and dryness, should be modied
suitably according to the existing local
practices. In addition, as continuous
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