A 56 year old woman of the Caucasian race, was scheduled for thyroidectomy due to multinodular goiter according to u/s assessment. She was euthyroidic with normal TSH, fT3 and fT4 under levothyroxine. Other medical history included arterial hypertension under 150 mg irbesartan, palpitations under 2.5 mg nebivolol. She was a current smoker with 40 p/y and a BMI 22.6 kg/m2 (52 kg). Prior surgery was a tonsillectomy 40 years ago for which she had no uneventful information about the surgery or the anesthesia itself. During clinical examination and history she denied any coronary artery disease symptoms, stroke, syncope, near-syncope, dizziness, unexplained falls and she had good physical status. She refused having allergies. During the airway assessment it was observed normal range of motion for head flexion and extension without any symptoms. Presurgical ECG was examined by a cardiologist and revealed normal sinus rhythm with normal PQ, QRS intervals with a HR of 70/min. Vital signs on hospital admission was BP 125/75 mmHg, HR 78/min, SpO2 98 %. No pathological signs were detected either in the thoracic x-ray or the lab blood tests - normal complete blood count, blood clotting test and basic electrolyte, renal and liver biochemistry. As far as the goiter is concerned, an ultrasound of the neck was performed which revealed an enlarged thyroid gland was. In details the right lobe sized 1.24 × 1 × 26 × 3.47 cm and the left lobe sized 0.83 × 0.93 × 2.58 cm. As pointed in the ultrasound, in the lower surface of the right lobe it was detected a nodule sized 1.62 × 1.37 cm with peripheral hematosis as well as two more cystic nodules sided 1.25 × 1 × 15 cm each. The goiter did not press the carotid vessels and was definitely not submersible. The goiter surely has taken part in the compression of the carotid sinus when the neck was extended, though it was not the absolute reason of the asystole. In accordance with literature guidelines about the administration of perioperative b-blocker [, ], the patient received nebivolol the day of the surgery along with p.o. 1.5 mg of bromazepam for premedication, ranitidine 150 mg, domperidone 10 mg and inhalation therapy with salbutamol-impratropium/budesonide since she was a current smoker. Irbesartan was witheld. The patient was connected to the monitor and her vital signs were BP 132/68 mmHg (non invasive BP), HR 65/min, SpO2 98 % on room air (FiO2 21 %) and respiratory rate 17/min. After intravenous access was managed and the patient was properly preoxygenated general anesthesia was induced with 100 μgr of fentanyl, 40 mg of lidocaine, 140 mg of propofol and 12 mg of cisatracurium. Approximately 3 min later the patient was easily intubated and connected to the anesthesia machine. General anesthesia was maintained with 40 % of oxygen and 1.9 % of sevoflurane targeting 1 MAC. Vital signs after the induction were BP 102/55 mmHg, HR 54/min, SpO2 97 %. Volume control ventilation was used targeting an end expiratory CO2 around 35 mmHg. The patient’s HR varied from 52 to 59/min with systolic BP measurements around 94–108 mmHg. The patient then was positioned for thyroidectomy, a roll was placed behind her shoulders so her torso would be elevated exposing the neck while the head was extended and positioned on a soft silicon pillow. Within few seconds the head was placed monitor’s HR alarm went on for bradycardia, 38/min. Immediately a pre filed syringe with 1 mg atropine was intravenously flushed. Heart rate deteriorated further reaching 10/min and finally a complete asystole was recorded on the monitor with no carotid pulse palpable. Cardiopulmonary resuscitation was immediately offered and a nurse supplied the second anesthesiologist with a pre filled syringe of 1 mg adrenaline. Asystole was still ongoing aproximately 45 s with no visible response to the already injected atropine. The first anesthesiologist performing CPR suspected that head extension was a possible trigger factor and raised the patient’s head to a neutral position before adrenaline was infused. Immediately after the patient’s head was raised monitor showed a heart rate of 79/min which after few seconds raised to 113/min. Adrenaline was withheld since the patients had a palpable carotid pulse and the next BP measurement was 157/78. The time proximity of asystole with the head extension gave the impression that the specific positioning created a tension to possibly both the carotid sinuses explaining the nonresponsiveness to atropine and why normal HR was immediately achieved only by elevating the head. Since the episode had a small duration it was decided that the surgery would be still continued. The patients’s head was then placed on an upper position using a higher pillow and thyroidectomy was performed uneventfully. At the end the patient was awakened and extubated with no neurological deficit. Basic biochemistry with troponin and postsurgical ECG revealed no pathological findings. In the post anesthetic care unit the patient was informed about the episode and again was asked for any kind of symptoms related to carotid sinus reflex-syndrome. She refused them all. She was given a signed paper about what happened and was strongly advised to inform the anesthesiologist at any possible future surgeries. The patient was referred to a cardiologist for further assessment.