The SIH-EBP Score: A grading scale to predict the response to the first epidural blood patch in spontaneous intracranial hypotension.

BACKGROUND: To develop and validate an easy-to-use scoring system to predict the response to the first epidural blood patching in patients with spontaneous intracranial hypotension. METHODS: This study recruited consecutive patients with spontaneous intracranial hypotension receiving epidural blood patching in a tertiary medical center, which were chronologically divided into a derivation cohort and a validation cohort. In the derivation cohort, factors associated with the first epidural blood patching response were identified by using multivariable logistic regression modeling. A scoring system was developed, and the cutoff score was determined by using the receiver operating characteristic curve. The findings were verified in an independent validation cohort. RESULTS: The study involved 280 patients in the derivation cohort and 78 patients in the validation cohort. The spontaneous intracranial hypotension-epidural blood patching score (range 0-5) included two clinical variables (sex and age) and two radiological variables (midbrain-pons angle and anterior epidural cerebrospinal fluid collections). A score of ≥3 was predictive of the first epidural blood patching response, which was consistent in the validation cohort. Overall, patients who scored ≥3 were more likely to respond to the first epidural blood patching (odds ratio = 10.3). CONCLUSION: For patients with spontaneous intracranial hypotension-epidural blood patching score ≥3, it is prudent to attempt at least one targeted epidural blood patching before considering more invasive interventions.

The time sequence of brain MRI findings in spontaneous intracranial hypotension.

OBJECTIVES: To investigate the time sequence of brain magnetic resonance imaging findings of spontaneous intracranial hypotension. METHODS: We retrospectively reviewed the medical records and brain magnetic resonance imaging findings of consecutive patients with spontaneous intracranial hypotension hospitalized between January 2007 and December 2017. Patients were divided into quartiles based on intervals between initial spontaneous intracranial hypotension symptom onset and brain magnetic resonance imaging scan. Six categorical and five continuous brain magnetic resonance imaging findings were assessed, including venous distension sign, enlarged pituitary gland, diffuse pachymeningeal enhancement, mid-brain pons deformity, subdural fluid collection, flattening of pons, midbrain-pons angle, descent of cerebral aqueduct, mamillopontine distance, distance of suprasellar cistern, and distance of prepontine cistern. In addition, we also calculated the neuroimaging scores with a score ≥5 classified as 'high probability of spontaneous intracranial hypotension' and a score ≥3 as 'intermediate-to-high probability.' Then, we analyzed the linkage between the onset-neuroimaging interval and brain magnetic resonance imaging findings, as well as different neuroimaging scores. RESULTS: A total of 173 patients (57 males and 116 females) were included in the analysis, and the range of onset-neuroimaging interval was 1 to 89 days (median [interquartile range] = 17 [7 to 30 days]). We divided the patients into quartiles based on their onset-neuroimaging interval (the first quartile: 0-6 days; the second quartile: 7-16 days; the third quartile: 17-29 days; the fourth quartile: ≥30 days). Among brain magnetic resonance imaging findings, the incidence of venous distension sign was high (>75%), with no difference among quartiles (p = 0.876). The incidence of diffuse pachymeningeal enhancement (p = 0.001), severe midbrain-pons deformity (p = 0.001), and subdural fluid collection (<0.001) followed a significant stepwise increase from the first quartile to fourth quartile. Patients with shorter onset-neuroimaging intervals were less likely to have neuroimaging scores ≥5 (<17 vs. ≥17 days: 72.9% vs. 86.4%; odds ratio = 2.3 [95% CI 1.1-5.1], p = 0.028), but not neuroimaging scores ≥3 (<17 vs. ≥17 days: 92.9% vs. 92.0%, p = 0.824). CONCLUSIONS: The emergence of brain magnetic resonance imaging findings of spontaneous intracranial hypotension depended on disease duration and appeared sequentially. When using brain magnetic resonance imaging findings or neuroimaging scores for diagnostic purposes, the onset-neuroimaging interval should be considered.

Brain volume changes in spontaneous intracranial hypotension: Revisiting the Monro-Kellie doctrine.

OBJECTIVES: In the application of the Monro-Kellie doctrine in spontaneous intracranial hypotension, the brain tissue volume is generally considered as a fixed constant. Traditionally, cerebral venous dilation is thought to compensate for decreased cerebrospinal fluid. However, whether brain tissue volume is invariable has not yet been explored. The objective of this study is to evaluate whether brain tissue volume is fixed or variable in spontaneous intracranial hypotension patients using automatic quantitative methods. METHODS: This retrospective and longitudinal study analyzed spontaneous intracranial hypotension patients between 1 January 2007 and 31 July 2015. Voxel-based morphometry was used to examine brain volume changes during and after the resolution of spontaneous intracranial hypotension. Brain structure volume was analyzed using Statistical Parametric Mapping version 12 and FMRIB Software Library v6.0. Post-treatment neuroimages were used as surrogate baseline measures. RESULTS: Forty-four patients with spontaneous intracranial hypotension were analyzed (mean [standard deviation] age, 37.8 [8.5] years; 32 female and 12 male). The whole brain tissue volume was decreased during spontaneous intracranial hypotension compared to follow-up (1180.3 [103.5] mL vs. 1190.4 [93.1] mL, difference: -10.1 mL [95% confidence interval: -18.4 to -1.8 mL], p = 0.019). In addition, ventricular cerebrospinal fluid volume was decreased during spontaneous intracranial hypotension compared to follow-up (15.8 [6.1] mL vs. 18.9 [6.9] mL, difference: -3.2 mL [95% confidence interval: -4.5 to -1.8 mL], p < 0.001). Longer anterior epidural cerebrospinal fluid collections, as measured by number of vertebral segments, were associated with greater reduction of ventricular cerebrospinal fluid volume (Pearson's r = -0.32, p = 0.036). CONCLUSION: The current study found the brain tissue volume and ventricular cerebrospinal fluid are decreased in spontaneous intracranial hypotension patients. The change in ventricular cerebrospinal fluid volume, but not brain tissue volume change, was associated with the severity of spinal cerebrospinal fluid leakage. These results challenge the assumption that brain tissue volume is a fixed constant.

Correlations among brain and spinal MRI findings in spontaneous intracranial hypotension.

OBJECTIVES: Several brain and spinal magnetic resonance imaging signs have been described in spontaneous intracranial hypotension. Their correlations are not fully studied. This study aimed to explore potential mechanisms underlying cerebral neuroimaging findings and to examine associations among spinal and brain magnetic resonance imaging signs. METHODS: We conducted a retrospective review of magnetic resonance myelography and brain magnetic resonance imaging records of patients with spontaneous intracranial hypotension. Categorical principal component analysis was employed to cluster brain neuroimaging findings. Spearman correlation was employed to analyze associations among different brain neuroimaging findings and between brain and spinal neuroimaging findings. RESULTS: In patients with spontaneous intracranial hypotension (n = 148), categorical principal component analysis of brain neuroimaging signs revealed two clusters: Cerebral venous dilation and brain descent. Among all brain magnetic resonance imaging signs examined, only midbrain-pons angle associated with anterior epidural cerebrospinal fluid collection length (surrogate spinal cerebrospinal fluid leak severity) (n = 148, Spearman's ρ = -0.38, p < .001). Subgroup analyses showed that the association between midbrain-pons angle (within brain descent cluster) and spinal cerebrospinal fluid leak severity was presented in patients with convex margins of the transverse sinuses (n = 122, Spearman's ρ = -0.43, p < .001), but not in patients without convex margins (n = 26, Spearman's ρ = -0.19, p = .348). The association between severity of transverse sinus distension and spinal cerebrospinal fluid leak severity was only presented in patients without convex margins (n = 26, Spearman's ρ = 0.52, p = .006). CONCLUSION: This study indicates that there are two factors behind the brain neuroimaging findings in spontaneous intracranial hypotension: Cerebral venous dilation and brain descent. Certain brain neuroimaging signs correlate with spinal cerebrospinal fluid leakage severity, depending on different circumstances.

Factors predicting response to the first epidural blood patch in spontaneous intracranial hypotension.

Spontaneous intracranial hypotension results from cerebrospinal fluid leakage. Currently, the treatment of choice for spontaneous intracranial hypotension is the epidural blood patch, which has a variable response rate and no clear outcome predictors. This study aimed to identify predictors for response rate of a first targeted epidural blood patch in patients with spontaneous intracranial hypotension. We reviewed cases of patients with spontaneous intracranial hypotension who received targeted epidural blood patch at our hospital between 1 January 2007 and 1 July 2014. The outcome measure was first epidural blood patch response. We analysed demographics, clinical manifestations, neuroimaging findings (non-contrast heavily T2-weighted magnetic resonance myelography and brain magnetic resonance imaging), and blood volume as potential outcome predictors. Significant predictors were tested and a decision tree was used to construct a predictive model. In total, 150 patients with spontaneous intracranial hypotension were included for final analyses. Their overall first targeted epidural blood patch response rate was 58.7%. Among patients with a greater injected blood volume (≥22.5 versus <22.5 ml), the response rate was higher (67.9% versus 47.0%, P = 0.01). In brain and spinal magnetic resonance imaging studies, significant predictors included anterior epidural cerebrospinal fluid collection length (<8 versus ≥8 segments; 72.5% versus 37.3%, odds ratio = 4.4, 95% confidence interval: 2.2-8.9, P < 0.001) and midbrain-pons angle (≥40° versus <40°; 71.3% versus 37.5%, odds ratio = 4.1, 95% confidence interval 2.1-8.3, P < 0.001). Decision tree analyses showed that patients with anterior epidural CSF collection involving <8 segments and an injected blood volume ≥22.5 ml had an 80.0% response rate. Patients with anterior epidural cerebrospinal fluid collection involving ≥8 segments and a midbrain-pons angle <40° had a 21.2% response rate. These three variables predicted first epidural blood patch response in 71.3% of patients. Brain and spinal neuroimaging findings and epidural blood patch blood volume can be used to predict targeted first epidural blood patch response in patients with spontaneous intracranial hypotension.

Treatment and prognosis of subdural hematoma in patients with spontaneous intracranial hypotension.

OBJECTIVE: The objective of this article is to elucidate the outcome, prognostic predictors and timing of surgical intervention for subdural hematoma (SDH) in patients with spontaneous intracranial hypotension (SIH). METHODS: Patients with SDH were identified retrospectively from 227 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, and treatment of SDH, which was later divided into conservative treatment, epidural blood patches (EBP), and surgical intervention. Poor outcome was defined as severe neurological sequelae or death. RESULTS: Forty-five patients (20%) with SDH (mean maximal thickness 11.9 ± 6.2 mm) were recruited. All 15 patients with SDH <10 mm achieved good outcomes by either conservative treatment or EBP. Of 30 patients with SDH ≥10 mm, patients with uncal herniation (n = 3) had poor outcomes, even after emergent surgical evacuation (n = 2), compared to those without (n = 27) (100% vs. 0%, p < 0.001). Fourteen patients underwent surgical evacuation, resulting in good outcomes in all 12 who received early intervention and poor outcomes in the remaining two who received delayed intervention after Glasgow Coma Scale (GCS) score ≤8 (100% vs. 0%, p = 0.01). CONCLUSIONS: Uncal herniation results in poor outcomes in patients with SIH complicated with SDH. In individuals with SDH ≥10 mm and decreased GCS scores, early surgical evacuation might prevent uncal herniation.

Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study.

The spatial distribution and clinical correlation of cerebrospinal fluid leakage after lumbar puncture have not been determined. Adult in-patients receiving diagnostic lumbar punctures were recruited prospectively. Whole-spine heavily T2-weighted magnetic resonance myelography was carried out to characterize post-lumbar puncture spinal cerebrospinal fluid leakages. Maximum rostral migration was defined as the distance between the most rostral spinal segment with cerebrospinal fluid leakage and the level of lumbar puncture. Eighty patients (51 female/29 male, mean age 49.4 ± 13.3 years) completed the study, including 23 (28.8%) with post-dural puncture headache. Overall, 63.6% of periradicular leaks and 46.9% of epidural collections were within three vertebral segments of the level of lumbar puncture (T12-S1). Post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks (length 3.0 ± 2.5 versus 0.9 ± 1.9 segments, P = 0.001; maximum rostral migration 4.3 ± 4.7 versus 0.8 ± 1.7 segments, P = 0.002) and epidural collections (length 5.3 ± 6.1 versus 1.0 ± 2.1 segments, P = 0.003; maximum rostral migration 4.7 ± 6.7 versus 0.9 ± 2.4 segments, P = 0.015). In conclusion, post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks and epidural collections. Further, visualization of periradicular leaks was not restricted to the level of dural defect, although two-thirds remained within the neighbouring segments.

Spontaneous intracranial hypotension complicated by malignancyinduced disseminated intravascular coagulation: A case report.

PURPOSE: Spontaneous intracranial hypotension (SIH) is a rare type of headache. The association of SIH with malignancy and disseminated intravascular coagulation (DIC) has not previously been reported. CASE REPORT: A 60-year-old woman had orthostatic headache for more than one month before admission. MRI of brain showed diffuse pachymeningeal enhancement with bilateral subdural hematoma. MR myelography revealed epidural fluid collection and possible CSF leakage at the level of C5 to C6. DIC due to carcinoma of unknown origin was found based on evidence of malignant pleural effusion and multiple bone metastases. After correction of coagulopathy, the patient received an epidural blood patch. Unfortunately, follow-up brain MRI showed disease progression. The patient died of acute respiratory failure four weeks after admission. CONCLUSION: This is the first case report of an association between SIH and DIC due to malignancy. Further case studies are needed to provide further support of this association.

Outcomes and Prognosis of Non-Elderly Patients with Brain Metastases-A Prospective Cohort Incorporating Individualized Assessment of Heart Rate Variability.

Outcomes and prognostic factors among patients with brain metastases (BM) have been widely studied, but seldom for the non-elderly. Heart rate variability (HRV) is a physiological phenomenon and has been shown as a survival prognostic factor in cancer patients. This study aimed to evaluate the outcomes and prognosis among non-elderly BM patients with the incorporation of HRV analysis. Forty non-elderly BM patients treated using whole brain radiotherapy (WBRT) were studied from January 2010 prospectively with 5-min electrocardiography (ECG) recordings. Individualized HRV was generated by the ECG, and the time domain HRV index SDNN was chosen for survival analysis. The median overall survival (OS) for the entire group was 6.21 months. Univariate analysis revealed that a KPS < 80 (p = 0.019) and an SDNN < 10 ms (p = 0.007) demonstrated statistical significance for OS; multivariate analysis confirmed that a KPS < 80 (p = 0.004; HR = 3.060, CI = 1.437-6.517) and an SDNN < 10 ms (p = 0.010; HR = 2.664, CI = 1.262-5.624) were independent prognostic factors. Prospective studies for risk stratification among non-elderly BM patients based on our results are warranted to validate our findings.

Bilateral subdural hematomas caused by spontaneous intracranial hypotension.

Patients with both spontaneous intracranial hypotension (SIH) and subdural hematomas (SDH) are frequently undiagnosed. SIH may recur very often over a short interval or result in disastrous consequences if only the SDH is dealt with. We report a young adult with severe posterior nuchal pain; brain computed tomography showed bilateral SDH. He was discharged smoothly without any neurologic deficit after epidural blood patches were applied after proper and timely diagnosis. Patients with SIH complicated by SDH should not be overlooked. When patients complain of typical orthostatic headache without any history of trauma, SIH should be highly suspected. The therapeutic strategy for this type of SDH is different from those without SIH. We review the literature on the disease.

Instability of spontaneous breathing patterns in patients with persistent vegetative state.

We investigated the breathing patterns of 27 patients in a persistent vegetative state (PVS) and 15 normal control volunteers. During the baseline period breathing air, 15 patients (the PVS-IB) exhibited irregular breathing (IB), whereas the other 12 (the PVS-OB) displayed oscillatory breathing (OB). Both groups maintained an average value for tidal volume (V(T)), total breath duration (T(TOT)), minute ventilation (V (E)), oxygen saturation (SpO2) similar to the control, but the PVS-OB displayed significantly lower end-tidal CO2 tension (P(ET)CO2) than the control. The V(T), T(TOT), V (E) and P(ET)CO2 of the PVS-OB showed cyclic changes. The coefficients of variation of V(T), T(TOT) and V (I) were: PVS-OB>PVS-IB>control. Inhalation of 100% O2 significantly reduced the respiratory variability and prevented OB of the PVS-OB. We concluded that PVS patients display respiratory instability and that brain damage, hypocapnia, and/or increased loop gain of arterial chemoreceptors may contribute to the pathogenesis of OB, whereas brain damage presumably may be the cause of IB.

Breathing pattern variability: a weaning predictor in postoperative patients recovering from systemic inflammatory response syndrome.

OBJECTIVE: To investigate whether breathing pattern variability can serve as a potential weaning predictor for postoperative patients recovering from systemic inflammatory response syndrome (SIRS). DESIGN AND SETTING: A prospective measurement of retrospectively analyzed breathing pattern variability in a surgical intensive care unit. PATIENTS: Seventy-eight mechanically ventilated SIRS patients who had undergone abdominal surgery were included when they were ready for weaning. They were divided into success (n=57) and failure (n=21) groups based upon their weaning outcome. MEASUREMENTS AND RESULTS: Before weaning, tidal volume, total breath duration, inspiratory time, expiratory time, and peak inspiratory flow were continuously monitored for 30 min, while patients received 5 cmH2O pressure support weaning trial. After the patients successfully completed the trial, they were extubated. Successful weaning was defined as patients free from the ventilator for over 48 h, whereas a weaning failure was considered as reinstitution of mechanical ventilation within 48 h of extubation. The coefficient of variation and two values of standard deviation (SD1 and SD2; indicators of the dispersion of data points in the plot) obtained from the Poincaré plot of five respiratory parameters in the failure group were significantly lower than those in the success group. The area under the receiver operating characteristic curve of these variability indices was within the range of 0.73-0.80, indicating the accuracy of prediction. CONCLUSIONS: Small breathing pattern variability is associated with a high incidence of weaning failure in postoperative patients recovering from SIRS, and this variability may potentially serve as a weaning predictor.

Anesthetic management of intracranial hemorrhage from huge arteriovenous malformations in late pregnancy--a case report.

Intracranial hemorrhage (ICH) from an arteriovenous malformation (AVM) in pregnancy is quite rare and could lead to exceedingly high maternal and fetal morbidity and mortality. We report a 26-year-old woman at 36 weeks' gestation who sustained ICH due to two huge AVMs. For preventing from progressive increased intracranial pressure (IICP), Cesarean section under general anesthesia was performed successfully. Herein, we also discuss the anesthetic management after reviewing the related current literatures.

The analgesic effect of oral morphine or pentazocine for extracorporeal shock wave lithotripsy.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) in these days is usually carried out on ambulatory or outpatient basis. With the application of a lithotriptor of modern version an appropriate yet cost-effective analgesia with minimal side effects for ESWL is mandatory. METHODS: The analgesic effect of oral morphine (30 mg) was compared with that of pentazocine (100 mg) in a prospective study comprising 100 patients undergoing ESWL with a lithotripter of improved version for urinary tract stones. All patients received orally lorazepam 1 mg as sedative together with the appointed tested drug 30 min before the procedure. The analgesic effects of both drugs were assessed having recourse to the pain scale and efficacy scale. RESULTS: There were 94% of patients in the pentazocine (mixed agonist-antagonist) group who felt satisfied with the regimen and stood the procedure well without resort to supplemental drug, as compared with the morphine (potent mu-agonist) group in which only 70% of patients did so. Although the adverse effect such as dizziness was found in the pentazocine group, the degree of sleepiness produced by its deeper sedation effect was to the advantage of patients during the lithotripsy procedure. There were no significant changes in intergroup mean blood pressure (MBP), but heart rate (HR) was higher and O2 saturation (SpO2) was lower in the pentazocine group after treatment. Both narcotics did not induce renal colic in our study. Also, pentazocine 100 mg plus lorazepam 1 mg given orally did not induce psychotomimetic reaction intraoperatively or postoperatively. CONCLUSIONS: We concluded that oral pentazocine at 100 mg plus lorazepam 1 mg, could offer satisfactory analgesia in patients undergoing ESWL for urinary tract stones with a lithotripter of improved version.

Heart rate variability is associated with survival in patients with brain metastasis: a preliminary report.

Impaired heart rate variability (HRV) has been demonstrated as a negative survival prognosticator in various diseases. We conducted this prospective study to evaluate how HRV affects brain metastasis (BM) patients. Fifty-one BM patients who had not undergone previous brain operation or radiotherapy (RT) were recruited from January 2010 to July 2012, and 40 patients were included in the final analysis. A 5-minute electrocardiogram was obtained before whole brain radiotherapy. Time domain indices of HRV were compared with other clinical factors on overall survival (OS). In the univariate analysis, Karnofsky performance status (KPS) <70 (P = 0.002) and standard deviation of the normal-to-normal interval (SDNN) <10 ms (P = 0.004) significantly predict poor survival. The multivariate analysis revealed that KPS <70 and SDNN <10 ms were independent negative prognosticators for survival in BM patients with hazard ratios of 2.657 and 2.204, respectively. In conclusion, HRV is associated with survival and may be a novel prognostic factor for BM patients.

Intracranial subdural hematoma coexisting with improvement in spontaneous intracranial hypotension after an epidural blood patch.

A 36-year-old male had spontaneous intracranial hypotension (SIH) presenting with refractory headache for 4 months. Multiple epidural blood patches (EBPs) yielded relief of symptoms, but the course was complicated, with asymptomatic intracranial subdural hematoma (SDH). Except for SDH, other radiological diagnostic signs of SIH were resolved and the patient's headaches improved after EBP. Owing to a mass effect and persistent cerebrospinal fluid (CSF) leakage, surgical repair of the spinal leakage was performed, but no cranial procedures were carried out. Postoperatively, the SDH completely resolved, but there was still CSF leakage at the level where surgery was performed. The patient has remained free of headache or other events for 3 years. It was reduction rather than elimination of the spinal CSF leak that yielded remission of SIH. In summary, intracranial SDH can be a complication of inadequately treated SIH (i.e. persistent minor CSF leakage). Management of SDH should focus on correction of the underlying SIH rather than craniotomy for hematoma evacuation.

Maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain: a randomized controlled study.

OBJECTIVE: To evaluate the effectiveness of the pulmonary recruitment maneuver (PRM) and intraperitoneal normal saline infusion (INSI) in removing postlaparoscopic carbon dioxide from the abdominal cavity to decrease laparoscopy-induced abdominal or shoulder pain after surgery. DESIGN, SETTING, AND PATIENTS: A prospective, randomized, controlled trial was conducted at Taipei Veterans General Hospital, Taipei, Taiwan, from August 1, 2009, through June 30, 2010. One hundred fifty-eight women undergoing laparoscopic surgery for benign gynecologic lesions were randomly assigned to 3 groups: the PRM group (n = 53), the INSI group (n = 54), and the control group (n = 51). INTERVENTIONS: Postoperative maneuvers included PRM and INSI. MAIN OUTCOME MEASURES: Evaluation of pain, including abdominal pain and shoulder pain, was performed at 12, 24, and 48 hours postoperatively. RESULTS: The frequency of postoperative shoulder pain at 24 and 48 hours was significantly decreased in the INSI group compared with that of either the PRM or control group (40.7% and 24.1% in the INSI group vs 66.0% and 50.9% in the PRM group [P = .009 and .004, respectively] or vs 72.5% and 54.9% in the control group [both P < .001]). Both methods significantly reduced the frequency of upper abdominal pain compared with the control condition (73.6% in the PRM group at 24 hours [P = .03] or 72.2% at 24 hours [P .02] and 44.4% at 48 hours [P = .01] in the INSI group vs 90.2% at 24 hours and 68.6% at 48 hours in the control group). CONCLUSIONS: Both PRM and INSI could effectively reduce pain after laparoscopic surgery, but INSI might be better for both upper abdominal and shoulder pain.

Bilateral tension pneumothorax and tension pneumoperitoneum secondary to tracheal tear in a patient with relapsing polychondritis.

Relapsing polychondritis (RP) is a rare disease that is characterized by recurrent inflammation and destruction of cartilage and connective tissues. RP can have significant airway pathology that may require procedures to maintain airway patency and thus may have serious implications for anesthesiologists. Anesthesiologists must be prepared to deal with the possible complications that may occur during airway manipulation in patients with RP. Here, we present a case of life-threatening bilateral tension pneumothorax and tension pneumoperitoneum that developed after a tracheal tear during Montgomery T-tube insertion in a patient with tracheal stenosis due to RP. Correct diagnosis was delayed due to a misdiagnosis of airway obstruction. As a result, we emphasize that bilateral tension pneumothorax should be considered during refractory cardiac arrest in patients with increased airway pressure. A high index of suspicion and adequate management are mandatory for patients to survive these life-threatening complications.

Spontaneous intracranial hypotension treated by epidural blood patches.

We present a case of spontaneous intracranial hypotension (SIH) diagnosed from the clinical symptoms and magnetic resonance imaging brain scans. After failure of conservative treatment, and lack of identification of the cerebrospinal fluid leak site, the headache was managed successfully and simply with two applications of an epidural blood patch (EBP). The strategy of our management for the patient was as follows: (1) application of an EBP to the lumbar epidural space initially and manipulating it into the proximity of the possible leak site; (2) a greater volume of autologous blood was injected at the second attempt of EBP; and (3) the patient was required to lie flat for at least 2 hours after the procedure. Better management of SIH is still developing. Traditionally, SIH is initially managed by conservative treatment. However, recent studies have shown that the success rate in arresting SIH after weeks or months of conservative treatment is not quite satisfactory. Hence, the EBP has proven to be more effective in treating SIH patients. Early EBP application may offer immediate relief of clinical symptoms. The role of the EBP in treating SIH patients should have greater emphasis and its application is worth recommendation.

Successful management of severe upper airway obstruction during emergence of anesthesia in consequence of fracture of deflated laryngeal mask airway due to biting--a case report.

Biting the laryngeal mask airway during general anesthesia in the absence of a bite block as a forestallment is a common but usually uncomplicated event. We report a young healthy adult female patient who underwent removal of fixation implant in the right elbow under general anesthesia, during the emergence of which she bit and severed the airway tube of the laryngeal mask airway (LMA) after cuff deflation and developed upper airway obstruction in consequence of air blockade by the displaced deflated LMA cuff remaining inside the mouth. Removal of residual part of the LMA in the mouth was successful with propofol re-anesthetization without molestation of 02 saturation. We discuss the management of this critical airway condition resulting from fracture of deflated LMA in the closed mouth.