Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature.

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Intraoperative Seizures During Awake Craniotomy for Brain Tumor Resection.

Background Intra-operative seizures (IOS) can occur during awake craniotomies (AC) for brain tumors. They can potentially result in an increased risk of morbidity; however, literature is scarce on IOS, its risk factors, and predictors. This study aims to ascertain the frequency of IOS in patients undergoing AC and determine possible IOS predictors. Methods In this retrospective study, we reviewed the records of all patients who underwent AC for tumor resection at a single university hospital between January 2016 and December 2020. IOS was defined as any seizure, including partial or generalized, experienced by any patient at any time from the beginning of the procedure till the end of surgery. Results Two hundred patients underwent AC during the study period. Seven (3.5%) patients experienced IOS. Compared to the non-seizure group, no significant correlation existed with any demographic variable. No significant difference was seen between the initial complaints presented by the two groups. In addition, the post-operative course of the seizure group did not significantly differ from the non-seizure group. Due to the low frequency of IOS in our cohort, an extensive analysis to determine predictors could not be performed. Conclusion In this study, we observed a low frequency of IOS (3.5%) during AC. The possible predictors and risk factors must be further investigated in large cohorts; to help limit the consequences of this possible intraoperative complication.

Successful Resuscitation and Management of Cardiac Arrest in Pregnancy Due to Undiagnosed Severe Mitral Stenosis: A Case Report.

Maternal collapse is a rare, potentially fatal event with associated feto-maternal morbidity and mortality. We report a case of severe mitral stenosis without any prior symptoms, that presented as acute cardiac decompensation leading to maternal collapse and cardiac arrest. A 35-year-old female in her 28th week of gestation presented to the emergency room with a four-hour history of per-vaginal discharge and leaking of amniotic fluid. Her past history, physical examination, and laboratory workup were unremarkable. An initial diagnosis of pre-term premature rupture of membranes (PPROM) was made and she was managed conservatively. Within four hours of the presentation, she developed shortness of breath, which gradually worsened, and the anesthesia team was requested to assess the patient. Upon arrival, the patient was in severe respiratory distress. She collapsed soon after and started frothing copiously from the mouth. Pulse was absent and cardio-pulmonary resuscitation (CPR) commenced. Endotracheal intubation was performed and the obstetric team was asked to prepare for a perimortem cesarean section, which was completed four minutes after the commencement of CPR and the baby was delivered alive and well with an APGAR score of 7 and 8 at one minute and five minutes of birth, respectively, and birth weight of 1.1 kg. CPR continued for 16 minutes after which a return of spontaneous circulation was achieved. Due to the unavailability of an ICU bed, the patient was shifted to OR where she stayed for the next five hours for further resuscitation. After a two-month-long ICU course, the patient was discharged in stable condition; her baby was discharged after a month of hospital stay. The expertise of anesthesiologists as resuscitators and peri-operative physicians helped in successful resuscitation, saving not just one but two lives in the process.

Awake Craniotomy for Resection of Intracranial Meningioma: First Case Series From a Low- and Middle-Income Country.

Introduction Awake craniotomy (AC) has emerged as a better modality for resection of intra-axial brain tumors. The advantages are not just related to the preservation of neurological function, but also include early recovery, short hospital stay and possibly lower costs. However, data on AC for meningioma resection is deficient, likely because of concerns related to intra-operative pain and blood loss. Methods All patients who underwent AC, using awake through-out technique for resection of meningioma, during the last five years, were included in the study. Non-probability consecutive sampling technique was employed. Variables for demographics, and details of diagnosis and surgical procedure were recorded. The outcomes measured were length of hospital stay, worsening of neurological function during surgery and significant intra-operative or post-operative pain. Results Seventeen patients underwent AC for resection of meningioma during the study period. Eleven of these were grade I meningioma, and six were grade II meningioma. The mean age was 45.8 ± 10.5 years. Presenting complaints were variable, with seizures being the most common (n = 7; 41.2%). The mean duration of surgery was 180.8 ± 36.2 minutes and median estimated blood loss was 450 ml (IQR: 225 ml - 737.5 ml). The mean length of stay in the hospital was 3.1 ± 1.3 days. Only one patient had a prolonged hospital stay of seven days, because of post-operative seizures. Eleven patients (58.3%) had convexity meningioma, 4 (33.3%) had parasagittal meningioma and 1 each had a parafalcine and anterior skull-base meningioma. Simpson grade I resection was performed in 6 (41.7%) patients, grade II resection in 10 (50%) patients, and grade III resection in 1 (5.9%) patient. None of our patients had deterioration in their neurological deficits after surgery and no one required emergency intubation, conversion of surgery to general anesthesia, or redo exploration. Conclusion AC may be considered a safe modality for surgical resection of convexity and parasagittal meningioma, with no significant risk of intra-operative or post-operative pain, although it requires more evidence. It can be offered to patients who are at higher risk, or are not willing to undergo general anesthesia. Ultimately, it might also be beneficial in terms of reducing overall costs.

Frequency of early postoperative adverse events (AEs) in adult patients undergoing elective neurosurgical intervention at tertiary care center in Pakistan.

OBJECTIVE: The postoperative period is critical in neurosurgical patients, where the incidence of postoperative AEs is significantly high. Most of events occurs during recovery phase and has got relation to anaesthetic management. The objective of study was to determine frequency of early AEs in elective neurosurgical patients. METHODS: This cross sectional study was conducted at our tertiary care center. The duration of study was one year, from August 2017-July 2018. The data was collected using predesigned proforma. The assessment was done on arrival in recovery room (T1) and then at forty five minutes (T2), twenty-fourth hour (T3) and forty-eighth hour (T4) postoperatively. RESULTS: Total ninety-five patients were included. Overall, five hundred and forty AEs were recorded at T1, T2, T3 and T4. Anaesthesia related events like pain, postoperative sore throat, hoarseness, shivering and hypothermia were the commonest (73%). There was a gradual decline in incidence of these events over period of 48 hours. There was no effect of age, sex, BMI and blood loss on incidence of AEs. CONCLUSIONS: Postoperative pain, PONV and shivering were frequently reported AEs. We did not identify the impact of age, sex, BMI, comorbid or type of surgery in terms of having these events.

Post operative sore throat: Comparison between Macintosh versus Video Laryngoscope in patients intubated by trainee anaesthetists - A Randomised Control Trial.

OBJECTIVES: Postoperative sore throat (POST) is a common complication related to endotracheal intubation. The aim of this study was to compare the incidence of POST in patients intubated by trainee anaesthetist using Video Laryngoscope™ (VDL) or Conventional Macintosh Laryngoscope (CL). METHODS: Total 110 patient scheduled for elective laparoscopic cholecystectomy were included from main operating room of Aga Khan University Hospital between June 2017-2018. The standardized perioperative protocol was used for general anaesthesia. Selected patients were randomly allocated into conventional laryngoscopy (CL) group or video laryngoscopy (VDL) group. The evaluation of sore throat was done at 1st, 12th and 24th hour postoperatively using a ten-point visual analogue scale. RESULTS: The demographic characteristics, including intubation time, related complications or any other maneuver required were similar between the groups. The incidence of POST at 1st hour was 47% patients in CL group and 38% in VDL group (p=0.335). At 12th hour, 34.5% patients in CL and 38% in VDL reported POST (p=0.692). Similarly at 24th hour, 25% patients in CL and 16% in VDL group reported POST (p=0.669). CONCLUSIONS: There was no significant difference in incidence of POST for patients intubated by trainee anaesthetists using either CL or VDL. Objective evidence of training and laryngoscope technique can impact of POST.

Anaesthetic management of patients undergoing deep brain simulation: A retrospective review of 8 cases from a tertiary care center of Pakistan.

OBJECTIVES: To review anaesthesia related outcome, perioperative complications and overall length of stay (LOS) in hospital for patients who had deep brain stimulation (DBS). METHODS: The study was retrospective review of patients medical records diagnosed with Parkinson disease (PD) and underwent DBS at The Aga Khan University Hospital, Karachi from 2017-2019. Data was reviewed from file notes and patient chart and recorded on predesigned Performa. Frequency and percentages were used to present the data. RESULTS: All patients were anaesthetized using Sleep-Awake-Sleep technique (SAS). Dexmedetomidine was mainly used for conscious sedation. Bispectral index monitor (BIS) was used to monitor the depth of sedation, and kept between 70-85 during sedative phase. All patients had successful intraoperative neurological monitoring, stimulation, and placement of electrodes. Total duration of anesthesia varied significantly in between the patients. Maximum duration was 600 minutes. None of our patient had any intraoperative event related to anaesthetic management. Overall five patients had some adverse events during ward stay. Mean LOS in hospital was four days. CONCLUSION: Anaesthetic management of DBS is well-tolerated. It requires dedicated team. The SAS technique is excellent for intraoperative neurophysiological monitoring. Careful selection of sedative agents and monitoring depth of anaesthesia using BIS would be beneficial in terms of improving related outcomes.

Potential Barriers amongst Health Care Professionals of Pakistan in managing COVID-19 patients.

OBJECTIVES: To evaluate basic knowledge of Health Care Professionals (HCPs) of Pakistan in managing COVID 19 patients. It includes information regarding infection control measures, administrative and professional support. This was followed by evaluation of psychological factor that can act as a barrier in effective management of these patients. METHODS: The survey was conducted on line using Google Form. After approval from hospital ethical committee survey link was disseminated to HCPs using social media. RESULTS: Four hundred fifteen HCPs were participated. Most of them were younger than 30 years and majority of them were postgraduate trainees. Results showed gaps in the knowledge about basic infection control measure like donning/doffing and understanding about high-risk procedures. On job training, professional and administrative support is compromising. Many of HCPs are anxious nowadays, having symptoms related to burn out with logical reasons behind. Even with all those hurdles they are committed and ready to volunteer themselves. CONCLUSION: The HCPs of Pakistan needs urgent attention for providing them Formal training regarding infection control measure. Administrative and professional support is required from institutions and scientific societies. Online teaching modules and webinar is a suitable option. The symptoms of burn out are significant and would increase with passage of time. This needs to be supported by occupational health committees.

Utilization of awake craniotomy for supra-tentorial tumor resection during pregnancy: A technique useful for fetal-maternal wellbeing.

Meningioma is the benign tumor that can also occurs during pregnancy. We are reporting a case of 29 years, 13th weeks pregnant lady, who underwent supratentorial craniotomy using awake through out approach. The case report highlights the challenges we faced during anaesthetic management, which includes psychological preparation, institution of scalp block and successful neurological monitoring. Technique proven to be useful considering pregnancy related physiological and tumor related pathological changes, the impact of which lies directly on maternal & fetal wellbeing.

Anaesthetic Management of Cerebral Arterio-venous Malformation Excision Using Awake Craniotomy: Initial Experience of Two Cases.

This case series summarises the successful management of two cases with cerebral arterio-venous malformation (AVM). In first patient, it was located superficially in right frontal cortex, while the second one had this in left parieto-temporal region. Both were excised successfully using awake craniotomy. The patients had their assessment and psychological preparation by neuro-anesthetist and neurosurgeon. Along with the routine monitoring, invasive arterial line, and bispectral index monitoring was used to monitor the sedative effect of propofol. Intraoperative analgesia was provided using scalp block. The anaesthetic management was helpful in facilitating intraoperative neurological monitoring using verbal and motor responses. Patients remained pain-free and hemodynamically stable during resection phase. The postoperative period showed adequate pain control, decreased postoperative nausea/vomiting and shorter length of stay in the hospital. Both patients had 100% obliteration of AVM confirmed via cerebral angiography.

An Awake Throughout Approach for Awake Craniotomy: A Perspective from a Resource-Limited Country.

BACKGROUND: An awake throughout (AT) approach for awake craniotomy is mostly under utilized. The purpose of this study was to review the efficacy of the technique at our tertiary care center. The primary objective was to identify the incidence of perioperative complications. The secondary objective was to review the patients' satisfaction, satisfaction of surgical team, length of stay (LOS) in special care unit (SCU), and overall LOS in the hospital. METHODS: The study was a retrospective review of patients data. All patients were treated with the AT technique. This included preoperative assessment, psychologic preparation, and institution of scalp block. The incidence of perioperative complications, including satisfaction of surgical team was noted. The patients' satisfaction and the LOS in SCU and in the hospital was also recorded. RESULTS: In total, the data from 55 patients were reviewed. Their mean age was 41 years, and 63% were reported to have seizures at presentation. The AT approach was successful in 100% of cases. The incidence of intraoperative seizures was 7.4%, of vomiting was 5.4%, and of conversion to general anesthesia was 0%. The surgical team was able to perform gross total resection in 53% of patients and rated a satisfaction score of 8 out of 10. Postoperative seizures occurred in 5.4% of patients and vomiting in 3.6%. The mean LOS in SCU was 1.2 days, and the overall hospital LOS was 4 days. The patients remained fully satisfied, as evidenced by a mean satisfaction score of 8.6. CONCLUSION: An AT approach might be very useful in resource-limited setups because of the low incidence of complications, the use of resources, and significant surgeon and patient satisfaction.

Outcome of patients with acute pancreatitis requiring intensive care admission: A retrospective study from a tertiary care center of Pakistan.

BACKGROUND AND OBJECTIVE: Acute pancreatitis (AP) is an inflammatory disease. Patients presenting with severe disease may require intensive care unit (ICU) admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome. METHODS: The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient's demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay (LOS) in ICU and hospital. RESULTS: Total 85 patients were identified of having AP requiring ICU admission. 56% of these cases were referred from emergency. Mean Ranson score (RS) was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48% of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52%, out of which 82% died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen (BUN), PH and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome. CONCLUSION: AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated.

Pre-Anaesthetic Assessment Of Intracranial Pressure Using Optic Nerve Sheath Diameter In Patients Scheduled For Elective Tumour Craniotomy.

Background: The objective of study was to determine the pre-anaesthetic status of intracranial pressure (ICP), using ultrasonographic measurement of optic nerve sheath diameter (ONSD) inpatient scheduled for elective tumour craniotomy. The secondary objective was to compare the diagnostic accuracy of ONSD guided rise in ICP with clinical and radiographic parameters. This is prospective observational study, conducted at single neurosurgical theatre of The Aga Khan University over a period of one year. Methods: After getting ethical approval and informed consent patient fulfilling inclusion criteria and planned for elective tumour craniotomy were enrolled in study. The clinical and radiographic signs predicting the status of ICP were recorded. The ultrasonographic measurement of ONSD was done using liner array probe. Value more than 5 mm was considered as abnormal. Results: Total 26 cases were enrolled. Seventy percent patients showed rise in ICP based on clinical parameters, while 65% diagnosed to have raised ICP on the basis of radiographic findings. The ultrasonographic measurement of ONSD predicted this rise in 61% of cases. The diagnostic accuracy of ONSD in detecting raised ICP in comparison to clinical and radiographic evidence was 87.5% respectively. Conclusions: The ultrasonographic-guided ONSD was used successfully for predicting the status of ICP in pre-induction phase of anaesthesia. It also showed good correlation in diagnosing rise in ICP as compared to clinical and radiographic parameters, which indicates that test can be used reliably in preoperative period for patients planned for tumour craniotomy.

Anaesthetic Management of Supratentorial Tumor Craniotomy Using Awake-Throughout Approach.

The authors are reporting an anaesthetic management of patient presenting with left parietal lobe space occupying lesion and scheduled for Awake-craniotomy. Awake-throughout approach using scalp block was planned. Among techniques reported for keeping patient awake during the surgery, this one is really underutilized. The successful conduct requires thorough preoperative assessment and psychological preparation. We used powerpoint presentation as a preoperative teaching tool. The anatomical landmark technique was used to institute scalp block, where individual nerves were targeted bilaterally. Patient remained stable throughout and participated actively in intraoperative neurological monitoring. Postoperative period showed remarkable recovery, better pain control, and shorter length of stay in hospital.

Severe Anaphylactic Reaction to Preoperative Aspiration Prophylaxis.

It is a case of severe anaphylactic reaction in a young female who had received aspiration prophylaxis preoperatively. Patient required intensive care and developed severe lactic acidosis. She responded very well to fluid and phenylephrine boluses and later on norepinephrine infusion.

Awake craniotomy for brain tumours in Pakistan: An initial case series from a developing country.

Awake craniotomy offers safe resection of brain tumours in eloquent area. Aga Khan University Hospital, Karachi, recently started the programme in Pakistan, and the current study was planned to assess our experience of the first 16 procedures. The retrospective study comprised all such procedures done from November 2015 to May 2016. Pre-operative and post-operative variables were analysed. Of the 16 patients, 11(68.75%) were males and 5(31.25%) were females. The overall median age was 37 years (interquartile range[IQR]: 23-62 years). The most common presenting complaint was seizures 8(50%), followed by headache6(38%). The common pathologies operated include oligodendroglioma and glioblastoma. Pre-operative mean Karnofsky Performance Status score was 76±10, which increased to 96±7 post-operatively at discharge. Besides, 2(12.5%) intra-operative complications were observed, i.e. seizure and brain oedema, in the series. The study had median operative time of 176 minutes (IQR: 115-352) and median length of stay of 4 days (IQR: 3-7).Awake craniotomy was highly effective in maintaining post-operative functionality of the patient following glioma resection. It was also associated with shorter hospital course and so lower cost of management.