PRESenting a Challenge: Posterior Reversible Encephalopathy Syndrome in Pediatric Patients With Guillain-Barré Syndrome: A Case Series and Review of Literature.

BACKGROUND: Guillain-Barré syndrome (GBS) is an autoimmune disorder characterized by demyelination of peripheral nerves. GBS-associated posterior reversible encephalopathy syndrome (PRES) is a rare and potentially life-threatening complication in the pediatric population. We aimed to report and analyze the clinical features, management, and outcomes of three cases of GBS-associated PRES in our setting in the light of the existing literature. METHODS: Medical records of 75 pediatric patients with GBS were reviewed for autonomic changes and GBS-associated PRES. Thirty-one developed dysautonomia while three were identified to have PRES. Clinical, radiological, laboratory, and treatment data were collected and analyzed. RESULTS: All three patients were male and presented with symptoms of acute flaccid paralysis and respiratory distress requiring mechanical ventilation. All three patients experienced various complications, including hypertension, seizures, and hyponatremia, and were subsequently diagnosed with PRES. Multimodal intensive care resulted in patient improvement and discharge in an ambulatory state after an average of 104 days of care. CONCLUSIONS: GBS-associated PRES is a rare and potentially life-threatening complication that can occur in pediatric patients with GBS. Our findings suggest that early recognition, prompt intervention, and multimodal intensive care can improve patient outcomes. Further studies are needed to determine optimal treatment strategies for GBS-associated PRES.

Expanding the spectrum on brain-heart interactions in cerebellopontine angle surgeries.

Lesions at the cerebellopontine angle (CP angle) are associated with various brain-heart interactions, which can include those from stimulation of the fifth cranial nerve along the scalp incision in a retrosigmoid suboccipital surgical approach. A 27-year-old male patient with recently diagnosed hypertension (on calcium channel blocker) underwent left CP angle lesion decompression. Transient episodes of bradycardia, hypotension, and bradypnea were observed from the skin incision onward, exacerbated during tumor manipulation. Most episodes subsided with cessation of the surgical stimulus while some required intervention. Postoperatively, blood pressure decreased below the pre-operative levels. Thus, trigeminocardiac reflex can occur as early as the skin incision even in a retrosigmoid approach due to stimulation of the mandibular division, when specific risk factors exist. Such episodes may serve as early warning signs for subsequent intraoperative occurrences. Brainstem compression can be a possible etiology of hypertension in young patients. It underscores the importance of considering brain-heart interactions in surgical interventions involving the CP angle.

Mimics of Guillain-Barré Syndrome in Pediatric Patients Admitted to the Neuro-Intensive Care Unit of a Tertiary Care Hospital-A Case Series.

Guillain-Barré syndrome is the most common cause of acute flaccid paralysis in children, but several diseases mimic GBS. We aimed to identify and report the clinical pointers and battery of tests required to differentiate Guillain-Barré syndrome from its observed mimics in the pediatric population admitted to our neuro-critical care unit. We conducted a retrospective record analysis of all pediatric patients admitted over ten years from 2008-2018, whose initial presentation was compatible with a clinical diagnosis of GBS. Eighty-three patients were at first treated as GBS, of which seven (8.4%) were found to have an alternate diagnosis-three cases of paralytic rabies, one case each of acute disseminated encephalomyelitis, cervical myeloradiculopathy, neuromyelitis optica, and a case of community-acquired Staphylococcus aureus pneumonia associated sepsis. Neurophysiological and neuro-virological testing, central nervous system imaging, and sepsis screening helped to confirm the alternate diagnosis. Our case series provides knowledge of subtle clinical differences along with the mindful use of diagnostic testing to facilitate the accurate diagnosis of GBS mimics.

Pneumothorax in Acute Neurologically Ill COVID-19 Positive Patients: A Brief Report.

Background: Pneumothorax is reported as a complication of coronavirus disease-2019 (COVID-19). The present report describes the incidence, clinical characteristics, and outcomes of pneumothorax in acute neurologically ill COVID-19 positive patients admitted to the COVID-19 neuro-intensive care unit (CNICU). Methods: In this retrospective study, pneumothorax was identified by reviewing chest radiographs of acute neurologically ill patients with and without associated COVID-19 admitted to the CNICU and non-COVID-19 NICU, respectively, from July to November 2020. The clinico-epidemiological characteristics of acute neurologically ill COVID-19 positive patients with pneumothorax are described. Results: The incidence of pneumothorax was 17% (8/47) in acute neurologically ill COVID-19 positive patients in the CNICU and 14.6% (6/41) in patients who received mechanical ventilation (MV). In contrast, the incidence of pneumothorax in acute neurologically ill non-COVID-19 patients admitted to the NICU was 3.7% (7/188) and 0.69% (1/143) in patients receiving MV. Conclusion: In our study, the incidence of pneumothorax was higher in patients with concomitant neurological and COVID-19 diseases than in acute neurologically ill non-COVID-19 patients managed during the same period in the ICUs.

Normalization of low frontal regional cerebral oxygenation after evacuation of chronic subdural hematoma in a patient with bilateral internal carotid artery stenosis.

Near infrared spectroscopy (NIRS) technology is frequently used to measure regional cerebral tissue oxygen saturation (rSO2). The measurement of rSO2 has diverse range of clinical application for its easy bed-side applicability, continuous monitoring, interpretation and valuable information on cerebral oxygenation. However, it also has few technical limitations; absorption by skull tissues, presence of hematomas, and other pigments such as melanin, bilirubin can affect the rSO2 measurements and thus interfere with the accuracy of monitoring. We report a case wherein low values of frontal rSO2 normalized after evacuation of bilateral fronto-temporo-parietal (FTP) chronic subdural hematoma (CSDH) in a patient with bilateral internal carotid artery (ICA) stenosis.

Reliability of Pre-Induction Inferior Vena Cava Assessment with Ultrasound for the Prediction of Post-Induction Hypotension in Neurosurgical Patients Undergoing Intracranial Surgery.

Background: Hypotension is one of the most common complications following induction of general anesthesia. Preemptive diagnosis and correcting the hypovolemic status can reduce the incidence of post-induction hypotension. However, an association between preoperative volume status and severity of post-induction hypotension has not been established in neurosurgical patients. We hypothesized that preoperative ultrasonographic assessment of intravascular volume status can be used to predict post-induction hypotension in neurosurgical patients. Our study objective was to establish the relationship between pre-induction maximum inferior vena cava (IVC) diameter, collapsibility index (CI), and post-induction reduction in mean arterial blood pressure in neurosurgical patients. Materials and Methods: A prospective observational study was conducted including 100 patients undergoing elective intracranial surgeries. IVC assessment was done before induction of general anesthesia. Receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of maximum and minimum IVC diameter (IVCDmax and IVCDmin, respectively) and CI for prediction of hypotension. Results: Post-induction hypotension was observed in 41% patients. Patients with small IVCDmax and higher CI% developed hypotension. The areas under the ROC curve (AUCs) were 0.64 (0.53-0.75) for IVCDmax and 0.69 (0.59-0.80) for IVCDmin. The optimal cutoff values were1.38 cm for IVCDmax and 0.94 cm for IVCDmin. The AUC for CI was 0.65 (0.54-0.77) and the optimal cutoff value was 37.5%. Conclusion: Pre-induction IVC assessment with ultrasound is a reliable method to predict post-induction hypotension resulting from hypovolemia in neurosurgical patients.

Community Acquired Staphylococcus Aureus Necrotizing Pneumonia and Guillain Barre Syndrome: An Unusual Presentation in An Adolescent Patient.

Community-acquired Staphylococcus aureus (SA) pneumonia can present with multiple complications but has not been reported earlier to present as or lead to Guillain Barre syndrome (GBS). However, there are few case reports of GBS following SA infective endocarditis, polymyositis, and meningitis. We report an unusual presentation of GBS most probably secondary to community-acquired SA necrotizing pneumonia in a young immunocompetent adult. The clinical course, challenges in the management, and unfortunate death of the patient due to an unforeseen complication have been discussed. This report adds to the clinical knowledge of rare association of community-acquired SA necrotizing pneumonia and GBS.

Clinical Characteristics and Outcomes of Critically Ill Neurological Patients with COVID-19 Infection in Neuro-intensive Care Unit: A Retrospective Study.

BACKGROUND: There are insufficient data about clinical outcomes in critically ill neurological patients with concomitant coronavirus disease (COVID-19). This study describes the clinical characteristics, predictors of mortality, and clinical outcomes in COVID-19-positive neurological patients managed in a dedicated COVID-19 neurointensive care unit (CNICU). METHODS: This single-center, retrospective cohort study was conducted in critically ill neurological and neurosurgical patients with concomitant COVID-19 infection admitted to the CNICU at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, from July to November 2020. Patients' demographic, clinical, laboratory, imaging, treatment, and outcome data were retrieved from the manual and electronic medical records. Predictors of mortality and neurological outcome were identified using logistic regression. RESULTS: During the study period, 50 COVID-19-positive neurological patients were admitted to the CNICU. Six patients were excluded from the analysis as they were managed in the CNICU for <24 hours. A poor outcome, defined as death or motor Glasgow Coma Scale <5 at hospital discharge, was observed in 34 of 44 patients (77.27%) with inhospital mortality in 26 of 44 patients (59%). Worst modified sequential organ failure assessment (MSOFA) score, lactate dehydrogenase maximum levels (LDHmax), and lymphocyte count were predictors of inhospital mortality with an odds ratio (OR) of 1.88, 1.01, and 0.87, respectively, whereas worst MSOFA and LDHmax levels were predictors for poor neurological outcome with OR of 1.99 and 1.01, respectively. CONCLUSIONS: Mortality is high in neurological patients with concomitant COVID-19 infection. Elevated inflammatory markers of COVID-19 suggest the role of systemic inflammation on clinical outcomes. Predictors of mortality and poor outcome were higher MSOFA score and elevated LDH levels. Additionally, lymphopenia was associated with mortality. HOW TO CITE THIS ARTICLE: Surve RM, Mishra RK, Malla SR, Kamath S, Chakrabarti DR, Kulanthaivelu K, et al. Clinical Characteristics and Outcomes of Critically Ill Neurological Patients with COVID-19 Infection in Neuro-intensive Care Unit: A Retrospective Study. Indian J Crit Care Med 2021;25(10):1126-1132.

Electroconvulsive therapy services during COVID-19 pandemic.

The COVID-19 pandemic has hit the electroconvulsive therapy (ECT) services hard worldwide as it is considered an elective procedure and hence has been given less importance. Other reasons include the risk of transmission of infections, lack of resources, and the scarcity of anesthesiologists due to their diversion to intensive care units to manage COVID-19 patients. However, ECT is an urgent and life-saving measure for patients diagnosed with depression and other severe mental illnesses who have suicidality, catatonia, or require a rapid therapeutic response. COVID-19 pandemic is a significant source of stress for individuals due to its impact on health, employment, and social support resulting in new-onset psychiatric illnesses and the worsening of a pre-existing disorder. Hence, a continuation of the ECT services during the COVID-19 pandemic is of paramount importance. In this narrative review, the authors from India have compiled the literature on the ECT practice during the COVID-19 pandemic related to the screening and testing protocol, necessity of personal protective equipment, modification in ECT Suite, electrical stmulus settings, and anesthesia technique modification. The authors have also shared their experiences with the ECT services provided at their institute during this pandemic. This description will help other institutes to manage the ECT services uninterruptedly and make ECT a safe procedure during the current pandemic.

Use of Dexmedetomidine Along With Local Infiltration Versus General Anesthesia for Burr Hole and Evacuation of Chronic Subdural Hematoma (CSDH).

BACKGROUND: In neurosurgery, chronic subdural hematoma (CSDH) is a very common clinical entity. Both general anesthesia (GA) and local anesthesia with or without sedation are used for the surgical treatment of CSDH. Sedation with dexmedetomidine has been safely used for various diagnostic and therapeutic procedures. However, its effectiveness against GA has not been evaluated for surgical treatment of CSDH. We tried to compare dexmedetomidine sedation technique with the GA technique for surgical treatment of CSDH. MATERIALS AND METHODS: In this prospective-randomized study, 76 patients undergoing surgery for CSDH were divided into 2 groups using computer-generated randomized tables; Dex group ([n=38]; received IV bolus of dexmedetomidine 1 mcg/kg over 10 min followed by maintenance infusion 0.5 mcg/kg/h) and GA group ([n=38; of which 4 patients were dropped out]; received endotracheal intubation with balanced anesthesia). RESULTS: Both anesthesia techniques (Dex group; n=35/38 [92.1%] and GA group; n=34/34 [100%]) were successfully used for surgical treatment of CSDH. Significantly less time for anesthesia onset (14.2±4.2 vs. 20.5±3.4 min, P=0.001), total duration of surgery (77.1±23.9 vs. 102.7± 24.8 min, P=0.001), and recovery from anesthesia (7.4±5.9 vs. 13.2±6.5 min, P=0.004) was observed in the Dex group compared with GA group. Perioperative hemodynamic fluctuations were more common in the GA group as against the Dex group. Postoperative complications (n=2 vs. 9, P=0.021) and length of hospital stay (1.05±0.23 vs. 1.79±2.1 d, P=0.007) were significantly less in the Dex group as against the GA group. CONCLUSIONS: Dexmedetomidine sedation with local anesthesia is a safe and effective technique for burr hole and evacuation of CSDH. It is associated with significantly shorter operative time, lesser hemodynamic fluctuations, postoperative complications, and length of hospital stay, thus it is a better alternative to GA.