Can bradycardia pose as a “red herring” in neurosurgery? Surgical stress exposes an asymptomatic sick sinus syndrome: Diagnostic and management dilemmas

Bradycardia in neurosurgery is almost always assumed to be secondary to intracranial conditions, specifically raised intracranial pressure causing Cushing's reflex, the trigemino-cardiac reflex or brainstem lesions. We present a case of posterior fossa surgery in which persistent bradycardia developed in the postoperative period. A cardiac cause was initially overlooked since hydrocephalus was present preoperatively, which was initially assumed to be the cause of the bradycardia. The baseline pulse rate prior to surgery was 66 beats/minute. Only when repeated imaging revealed complete resolution of the hydrocephalus was a cardiology work up done and diagnosis of sick sinus syndrome established. The authors present an interesting case which demonstrates the need for a high degree of suspicion for such rare co-existing conditions. The diagnostic and management dilemmas are further discussed.