Skip to main content Accessibility help
  • Print publication year: 2011
  • Online publication date: May 2011

Case 18 - Neuroprotectionduring surgical clip ligation of cerebral aneurysms

from Section I - Neuroanesthesia


Bradycardia and even asystole may occur suddenly during posterior fossa surgery and requires immediate evaluation and treatment in order to prevent potential ischemia and major neurologic complications. Trigeminocardiac reflex (TCR) commonly manifests as bradycardia and hypotension in response to mechanical stimulation of any of the branches of the trigeminal nerve. This chapter presents a case study of a 53-year-old female with a history of progressive headaches and a syncopal episode was found to have a right-sided tentorial mass consistent with a falcine meningioma. The tentorial nerves arise from the intracranial portions of ophthalmic branch (V1) and course into the dura of the parieto-occipital region and the posterior third of the falx, where there is a converging and bilaterally overlapping innervation at its midpoint. When stimulation of the falx results in the TCR, cessation of the surgical manipulation in that area is the first step in correcting the hemodynamic instability.


1. A. J. Molyneux, R. S. Kerr, J. Birks et al.; ISAT Collaborators. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009; 8(5): 427–33. Epub 2009 Mar 28.
2. P. H. Manninen, A. W. Gelb. The anesthetic management of patients during posterior fossa aneurysm surgery. In C. G. Drake, S. J. Peerless, J. A. Hernesniemi (eds.), Surgery of Vertebrobasilar Aneurysms. London, Ontario Experience on 1767 Patients. Vienna: Springer-Verlag; 1996, pp. 280–4.
3. T. Randell, M. Niemelä, J. Kyttä et al. Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage: the Helsinki experience. Surg Neurol 2006; 66: 382–8.
4. B. J. Hindman, E. O. Bayman, W. K. Pfisterer et al. No association between intraoperative hypothermia and supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping cerebral aneurysm surgery: findings from the Intra-operative Hypothermia for Aneurysm Surgery Trial. Anesthesiology 2010; 112: 86–101.
5. E. S. Nussbaum, L. A. Sebring, I. Ostanny et al. Transient cardiac standstill induced by adenosine in the management of intraoperative aneurysmal rupture: technical case report. Neurosurgery 2000; 47: 240–3.
6. A. Tuttolomondo, R. Di Sciacca, D. Di Raimondo et al. Neuron protection as a therapeutic target in acute ischemic stroke. Curr Top Med Chem. 2009; 9(14):1317–34.
7. M. M. Todd, B. J. Hindman, W. R. Clarke, J. C. Torner. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 2005; 352: 135–45.
8. G. L. Clifton, J. Y. Jiang, B. G. Lyeth et al. Marked protection by moderate hypothermia after experimental traumatic brain injury. J Cereb Blood Flow Metab 1991; 11: 114–21.
9. Y. Feng, P. G. Rhodes, A. Bhatt. Hypoxic preconditioning provides neuroprotection and increases vascular endothelial growth factor A, preserves phosphorylation of Akt-Ser-473 and diminishes caspase-3 activity in neonatal rat hypoxic-ischemic model. Brain Res 2010; 1325: 1–9.
10. R. L. Williams-Karnesky, M. P. Stenzel-Poore. Adenosine and stroke: Maximising the therapeutic potential of adenosine as a prophylactic and acute neuroprotectant. Curr Neuropharmacol 2009; 7: 217–27.
11. G. E. Hardingham. Coupling of NMDA receptor to neuroprotective and neurodestructive events. Colworth Medal Lecture. Biochem. Soc. Trans. 2009; 37: 1147–60.
12. J. Dhawan, H. Benveniste, M. Nawrocky, S. D. Smith. Transient focal ischemia results in persistent and widespread neuroinflammation and loss of glutamate NMDA receptors. Neuroimage 2010; 51: 599–605.
13. P. Banks, N. P. Franks, R. Dickinson. Competitive inhibition at the glycine site of the n-methyl-d-aspartate receptor mediates xenon neuroprotection against hypoxia–ischemia. Anesthesiology 2010; 112: 614–22.
14. J. J. Pasternak, D. G. McGregor, W. L. Lanier et al. Effect of nitrous oxide use on long-term neurologic and neuropsychological outcome in patients who received temporary proximal artery occlusion during cerebral aneurysm clipping surgery. Anesthesiology 2009; 110: 563–73.
15. B. Sims, M. Clarke, W. Njah, E. S. Hopkins, H. Sonthiemer. Erythropietin-induced neuroprotection requires cystine glutamate exchanger activity. Brain Res 2010; 1321: 88–95.