**10. Conclusion**

In the present paper, we illustrated the clinical relevance of the TCR on skull base surgery as well as neuroscience and discussed its management. Further clinical studies may help to describe the only partly understood reflex arc in more details on the one hand and to develop more precise prophylactic as well as intraoperative treatment options on the other hand. Such more expensive study designs will lead to better evidence in different aspects of the TCR research. But we have currently already good tools, like several thinking models that help, for example, to have already preoperatively an idea about the potential prevalence of TCR occurrence in a specific region of surgery and in specific patients. To additionally better understand the resilience of the non-TCR cases will further help to better understand the complexity of TCR occurrence and open the door for TCR research II. Anyway it will be exciting to follow the further research on this interesting and important topic of skull base surgery

### **Author details**

Tumul Chowdhury1 , Belachew Arasho2 , Nora Sandu3 , Cyrill Meuwly4 and Bernhard Schaller3,5\*


2 University of Addis Abbeba, Ethiopia


#### **References**

importance of the TCR: It is now possible to preoperatively have a really good risk stratification

These thinking model have certainly to be checked out and adapted when needed in the future [see for example 37], but we have now a good basis canalize and generalize our information and knowledge. This will lead that the TCR goes away from an interesting and important

Following the increasing complexity of our today's hospitals, there is also the need to adapt the TCR prevalences to the new reality. It is and remains, without any doubt, important to uncover risk factors and to make root analysis of TCR occurrence. But in a next step, we have also to look on what is going well in the non-TCR cases and to uncover what makes

phenomenon to a real and important fact of the skull base surgery.

**Figure 2.** Treatment recommendation for trigeminocardiac reflex[35].

of the occurrence of the TCR.

104 Abnormal Heart Rhythms

[1] Schaller B, Probst R, Strebel S, Gratzl O. Trigeminocardiac reflex during surgery in the cerebellopontine angle. J Neurosurg 1999;90:215-20.


[16] Chowdhury T, Meuwly C, Sandu N, Cappellani RB, Schaller B. Coronary spams in neurosurgical patients and role of trigeminocardiac reflex. Neuro Res Int 2014;2014: 974930.

[2] Schaller B. Trigeminocardiac reflex: A clinical phenomenon or a new physiological

[3] Schaller B, Cornelius JF, Prabhakar H, Koerbel A, Gnanalingham K, Sandu N, et al. The trigeminocardiac reflex: An update of the current knowledge. J Neurosurg Anes‐

[4] Chowdhury T, Sandu N, Meuwly C, Cappellani RB, Schaller B. Trigeminocardiac re‐ flex: Differental behaviour and risk factors in the course of the trigeminal nerve. Fu‐

[5] Chowdhury T, Sandu N, Schaller B, Meuwly C. Peripheral trigeminocardiac reflex.

[6] Kratschmer F. Ueber Reflexe von der Nasenschleimhaut auf Athmung und Kreislauf.

[7] Kratschmer F. On reflexes from the nasal mucous membrane on respiration and cir‐

[8] Widdicombe J. Reflexes from the lungs and airways: Historical perspectives. J Appl

[9] Ashner B. Über einen bisher noch nicht beschriebenen Reflex, vom Auge auf Krei‐ slauf und Atmung. Verschwinden des Radialispulses bei Druck auf das Auge. Wien

[10] Dagnini G. Interno ad un reflesso provocato inalcuni emplegica collo stimolo della come e colla pressione sul bulbo oculare. Bull Sci Med (Bologna) 1908;8:380.

[11] Schaller BJ, Filis A, Buchfelder M. Trigemino-cardiac reflex in humans initiated by peripheral stimulation during neurosurgical skull-base operations. Its first descrip‐

[12] Chowdhury T, Sandu N, Sadr-Eshkevari P, Meuwly C, Schaller B. Trigeminocardiac

[13] Chowdhury T, Sandu N, Schaller B. New insights to the role of (Nor-)adrenaline and trigeminal cardiac reflex. In: Bennun A (ed), Adrenaline, Nova Science Publisher,

[14] Spiriev T, Sandu N, Kondoff S, Tzekov C, Schaller B. Tic and autonomic symptoms. J

[15] Spiriev T, Kondoff S, Schaller B. Cardiovascular changes after subarachnoid hemor‐ rhage initiated by the trigeminocardiac reflex-first description of a case series. J Neu‐

reflex: current trends. Expert Rev Cardiovasc Ther 2014;12(1):9-11.

culation. Translated by E. Ullmann. Respir Physiol 2001;127:93-104.

entity? J Neurol 2004;251:658-65.

thesiol 2009;21:187-95.

106 Abnormal Heart Rhythms

ture Neurolgy 2014;9:41-7.

Physiol 2006;101:628-34.

Am J Otolaryngol 2013;34(5):616.

Sber Akad Wiss Wien 1870;62:147-70.

Klin Wochenschr 1908;21:1529-30.

New York, USA, 2014; pp 71-80.

Neurosurg 2012;116(6):1397-8.

rosurg Anesthesiol 2011;23(4):379-80.

tion. Acta Neurochir (Wien) 2008;150:715-8.


[46] Sandu N, Spiriev T, Lemaitre F, Filis A, Schaller B. New molecular knowledge to‐ wards the trigemino-cardiac reflex as a cerebral oxygen-conserving reflex. Scientific‐ World Journal 2010;10:811-7.

[32] Schaller B, Filis A, Buchfelder M. Cardiac autonomic control in neurosurgery. Arch

[33] Schaller B, Buchfelder M. Trigemino-cardiac reflex: A recently discovered "oxygenconserving" response? The potential therapeutic role of a physiological reflex. Arch

[34] Schaller B, Cornelius JF, Sandu N, Ottaviani G, Perez-Pinzon MA. Oxygen-conserv‐ ing reflexes of the brain: The current molecular knowledge. J Cell Mol Med

[35] Arasho B, Sandu N, Spiriev T, Prabhakar H, Schaller B. Management of the trigemi‐ nocardiac reflex: facts and own experience. Neurology India 2009;57(4):375-80.

[36] Meuwly C, Golanov E, Sandu N, Schaller B. Trigeminocardiac reflex trigger point

[37] Meuwly C, Golanov E, Chowdhury T, Erne P, Schaller B. Trigeminocardiac reflex: New thinking model about the definition based on a literature review. Medicine (Bal‐

[38] Meuwly C, Chowdhury T, Schaller B. Topical lidocaine to suppress trigemino-car‐

[39] Sandu N, Sadr-Eshkevari P, Schaller BJ. Usefulness of case reports to improve medi‐ cal knowledge regarding trigemino-cardiac reflex in skull base surgery. J Med Case

[40] Chowdhury T, Cappellani RB, Schaller B. Chronic trigemino-cardiac reflex in patient with orbital floor fracture: Role of surgery and first description. J Neurosurg Anes‐

[41] Chowdhury T, Cappellani RB, Schaller B. Retrogasserian glycerol rhizolysis: First de‐ scription of occurrence trigeminocardiac reflex. J Neurosurg Anesthesiol 2014;26(1):

[42] Spiriev T, Tzekov C, Laleva L, Kostadinova C, Kondoff S, Sandu N, Schaller B. Cen‐ tral trigeminocardiac reflex in pediatric neurosurgery: A case report and review of

[43] Spiriev T, Prabhakar H, Sandu N, Tzekov C, Kondoff S, Laleva L, Schaller B. Use of hydrogen peroxide in neurosurgery: Case series of cardiovascular complications.

[44] Spiriev T, Kondoff S, Schaller B. Trigeminocardiac reflex during temporary clipping in aneurismal surgery: First description. J Neurosurg Anesthesiol 2011;23(3):271-2.

[45] Spiriev T, Tzekov C, Kondoff S, Laleva L, Sandu N, Arasho B, Schaller B. Trigeminocardiac reflex during chronic subdural haematoma removal: Report of chemical ini‐

tiation of dural sensitization. JRSM Short Rep. 2011;2(4):27.

within the skull base: Anatomical perspective 2015; in press.

Med Sci 2007;4:287-92.

108 Abnormal Heart Rhythms

Med Sci 2006;2:3-5.

timore) 2015;94:e484.

Rep. 2011;5:149.

86-7.

thesiol 2014;26(1):91-2.

diac reflex. Br J Anaesth. 2013;111(2):302.

the literature. J Med Case Rep. 2012;6:372.

JRSM Short Rep. 2012;3(1):6.

2009;13:644-7.


[58] Schaller B, Sandu N, Ottoviani G, Filis A, Noethen C, Buchfelder M. Transient asys‐ tole during endoscopic transsphenoidal surgery: An example of trigeminocardiac re‐

[59] Schaller BJ, Filis A, Buchfelder M. Trigemino-cardiac reflex in humans initiated by peripheral stimulation during neurosurgical skull-base operations. Its first descrip‐

[60] Schaller B, Filis A, Buchfelder M. Trigeminocardiac reflex in embolization of intracra‐

[61] Schaller BJ, Rasper J, Filis A, Buchfelder M. Difference in functional outcome of ipsi‐ lateral tinnitus after intraoperative occurrence of the trigemino-cardiac reflex in sur‐

[62] Filis A, Schaller B, Buchfelder M. Trigeminocardiac reflex in pituitary surgery. A pro‐

[63] Schaller BJ, Weigel D, Filis A, Buchfelder M. Trigemino-cardiac reflex during trans‐ sphenoidal surgery for pituitary adenomas: methodological description of a prospec‐

[64] Schaller BJ, Filis A, Buchfelder M. Detection and prevention of the trigeminocardiac

[65] Schaller BJ. Reflexive autonomic activation in skull base surgery. Nova Science Pub‐

[66] Rivard JC, Lebowitz PW. Bradycardia after alfentanil-succinylcholine. Anaesth An‐

[67] Starr NJ, Sethna DH, Estafanos FG. Bradycardia and asystole following rapid admin‐

[68] Schmeling WT, Kampine JP, Warltier DC. Negative chronotropic actions of sufenta‐ nil and vecuronium in chronically instrumented dogs pretreated with propanolol

[69] Blanc VF, Hardy JF, Milot J, Jacob JL. The oculocardiac reflex: A graphic and statisti‐

[70] Lang S, Lanigan DT, Van der Wal M. Trigeminocardiac reflexes: Maxillary and man‐

[71] Moonie GT, Ress EL, Elton D. The oculocardiac reflex during strabismus surgery.

[72] Rath GP, Dash HH, Prabhakar H, Pandia MP. Cardiorespiratory arrest during trige‐

reflex during skull base surgery. Acta Neurochir (Wien) 2007;149(3):33.

istration of sufentanil with vecuronium. Anesthesiology 1986;64:521-3.

cal analysis in infants and children. Can Anaesthet Soc J 1983;30:360-9.

dibular variants of the oculocardiac reflex. Can J Anaesth 1991;38:757-60

gery for vestibular schwannomas. Acta Neurochir (Wien) 2008;150(2):157-60.

nial dural arteriovenous fistula. AJNR Am J Neuroradiol 2008;29(7):E55.

flex. Pituitary 2009;12(3):271-2.

110 Abnormal Heart Rhythms

lisher, New York, USA, 2008; pp

Can Anaesthet Soc J 1964;11:621.

minal rhizolysis. Anaesthesia 2007;62:971-2.

and/or diltiazem. Anaesth Analg 1989;66:4-14.

alg. 1988;76:907.

tion. Acta Neurochir (Wien) 2008;150(7):715-7.

spective pilot study. Nervenarzt 2008;79(6):669-75.

tive skull base study protocol. Brain Res. 2007;1149:69-7.

