Sphenopalatine ganglion block for the treatment of spontaneous intracranial hypotension without demonstrable cerebrospinal fluid leak: A report of two cases.

Spontaneous intracranial hypotension (SIH) is a condition characterized by orthostatic headache associated with nausea, vomiting, tinnitus, vertigo, hypoacusis, neck pain/stiffness, and photophobia. Usual treatment includes bed rest, hydration, caffeine, analgesics, epidural blood patch, steroids, fibrin glue (N-butyl-cyanoacrylate), and surgical repair. In this series, we report two cases, who presented to us with features of SIH and were managed successfully with sphenopalatine ganglion block. This is a novel modality of management of SIH and has not been reported before.

Brain Regional Energy Metabolism in Patients with Traumatic Brain Injury: A Cerebral Microdialysis Guided Study.

BACKGROUND: In traumatic brain injuries (TBI), cerebral microdialysis (CMD)-derived parameters, especially the lactate to pyruvate ratio (LP ratio), have been utilized for cerebral perfusion optimization. The objectives were to identify cerebral ischemia as measured by CMD in TBI patients requiring decompressive craniectomy and to observe the correlation between cerebral perfusion pressure (CPP), intracranial pressure (ICP), and CMD variables in these patients. Our secondary aim was to observe the effect of CPP augmentation on ischemia biomarkers. METHODS: After the Institute Ethics Committee approvals, seven adult patients requiring decompressive craniectomy following TBI were enrolled and CMD data were obtained prospectively for 72 h. CPP was augmented by 20% with noradrenaline infusion if LP ratio >40. Correlations were done with bootstrapping (n = 500) to obtain the confidence intervals (CI) due to the small sample size. RESULTS: One patient had cerebral ischemia (median LP ratio of 265.5 and median pyruvate of 38 µmol/L), while another patient had non-ischemic mitochondrial dysfunction (median LP ratio 40.7 and median pyruvate 278.5). The coefficients of correlation between the LP ratio with CPP and ICP were r = -0.05 (CI = -0.14-0.03) and r = 0.09 (CI = -0.03-0.24), respectively. The coefficient of correlation between cerebral and blood glucose was r = 0.38, (CI - 0.35-0.14). Only two patients needed CPP augmentation, however, postaugmentation cerebral biochemistry did not change appreciably. CONCLUSION: CMD can identify cerebral ischemia, however, no correlations were observed between the LP ratio and CPP or ICP. CPP augmentation did not improve cerebral biochemistry. More studies are required to understand and treat cerebral metabolism in TBI.

Cervical epidural hematoma masquerading as thrombosis of intracranial flow diverter in situ: A diagnostic and therapeutic conundrum.

Cervical epidural hematoma (EDH) is a rare but very serious cause of acute neurologic compression that needs early diagnosis and rapid intervention. Acute hemiparesis is an infrequent presentation of cervical EDH and often mimics cerebrovascular accident. In this case, we describe the management of a case of cervical EDH presenting as acute hemiparesis in an elderly female patient which mimicked as thrombosis of intracranial flow diverter in situ. The report emphasizes that cervical EDH should be considered as differential diagnosis in patients who present with acute hemiparesis especially, who are on antiplatelets or anticoagulants. Also, in a patient considered high-risk for surgery, conservative management can be considered under close supervision and intensive monitoring, especially, in non-expanding hematoma and non-progressive neurological deterioration.

Retained fragmented needle in intravenous drug users: An institutional experience and treatment protocol.

Retained needle fragments can occur in intravenous drug user (IVDU), which can lead to significant morbidity and mortality. The aim of present study is to give an overview of our institutional experience and treatment protocol followed for such patients. IVDU with retained fragment of fractured needle were taken from the patient presenting in Emergency, Medicine and CTVS departments with history of IVDU, from January 2019 to December 2020. Six patients were found with retained broken needles. Detailed history, examination and investigations were done. The needle was removed under local anaesthesia successfully in all patients. IVDU with retained broken needle poses risk for catastrophic complications along with possibility of local complications. A systematic approach in managing such patients is required. These broken needles can be successfully retrieved as day care procedure. Lastly, IVDUs with fractured needles pose threat to the caregivers who should take caution to avoid iatrogenic injury.

Ventilatory Strategies in Traumatic Cervical Spinal Cord Injury: Controversies and Current Updates.

Ventilatory management of patients with traumatic cervical spinal cord injury (CSCI) is a complex and controversial area of critical care medicine. Despite significant advances in our understanding of the pathophysiology of CSCI and the development of novel interventions, there remains a lack of consensus about the optimal approach to ventilatory management in these patients. Some of the key controversies in CSCI ventilatory management include timing of tracheal intubation, non-invasive ventilation versus invasive ventilation, high versus low tidal volume, and early versus late tracheostomy. The objective of this review is to discuss the existing controversies and provide an insight on the current evidence.

Aneurysmal subarachnoid hemorrhage in a patient with dual autoimmune disorders. Perioperative challenges and management.

Autoimmune disorders (AIDs) are known to be associated with intracranial aneurysms; however, the coexistence of dual AIDs is a rare entity. Perioperative neuroanesthetic management of aneurysmal subarachnoid hemorrhage (aSAH) is typically complicated and challenging in such patients. In this report, we describe the successful management of a case of aSAH complicated by coexistent multiple sclerosis and systemic lupus erythematosus. A multidisciplinary team approach is warranted to manage such complicated cases.

Local Ulceration following Peripheral Neurolysis with Absolute Alcohol in Patients with Drug-Refractory Trigeminal Neuralgia: A Series of Four Cases.

A significant number of patients with trigeminal neuralgia (TGN) are refractory to first-line drugs and require interruption of the pain pathway by various percutaneous procedures. One such percutaneous technique involves an injection of absolute alcohol (AA) into the peripheral branches of the trigeminal nerve. This procedure is useful in elderly and medically compromised drug-refractory cases of TGN who are not interested in undergoing open neurosurgery. Peripheral neurolysis with AA is easy, quick, and safe. It may be carried out in the outpatient department; however, its use is not free from complications. Here, we report four such patients who were complicated with local necrosis and ulceration following administration of AA. The most probable attributable etiologies are sympathetic nerve involvement, intravascular injection of alcohol, vascular spasm of the terminal arteries, distal micro-emboli effect, and faulty technique, including repeated injections.

Experience on rhino-orbital mucormycosis from a tertiary care hospital in the first wave of COVID-19: An Indian perspective.

Background: To highlight the clinical presentations and management outcomes of rhino-orbital mucormycosis during first wave of COVID-19 pandemic in North India. Methods: A retrospective observational study. 15 patients with mucormycosis (orbital disease) who presented during short span of 3 months (October-December 2020) in a tertiary-care referral institution were analysed. Results: At presentation, 13 of 15 patients had uncontrolled diabetes. Four had history of COVID-19 infection. All patients had advanced orbital disease with sinusitis; cavernous sinus involvement was in nine and intracranial spread in three patients. Liposomal amphotericin-B was started and prompt orbital exenteration with sinus surgery was performed in 12 patients. All 12 patients survived with an average follow-up of 4.8 months. Conclusion: In the present series, cases with orbital spread of mucormycosis were mostly found in non-COVID uncontrolled diabetics. Exenteration was done in 80% of cases with advanced orbital disease. Prevention and early detection of infection at the stage of sino-nasal involvement might help to prevent spread and/or halt the orbital disease.

Comparison of Propofol and Ketofol on Transcranial Motor Evoked Potentials in Patients Undergoing Thoracolumbar Spine Surgery.

STUDY DESIGN: This was a double-blind randomized study. PURPOSE: The primary purpose was to compare the effects of propofol and ketofol on amplitudes and latencies of transcranial motor evoked potentials (TcMEPs) during thoracolumbar spine surgery. In addition, intraoperative hemodynamics and muscle power were compared. OVERVIEW OF LITERATURE: Propofol is commonly used during intraoperative TcMEP monitoring. However, propofol inhibits TcMEP amplitudes and causes hypotension in a dose-dependent fashion. METHODS: Amplitude and latency of TcMEPs were recorded bilaterally from the abductor pollicis brevis (APB) and abductor hallucis (AH) muscles in 38 adult American Society of Anesthesiologists I and II patients undergoing thoracolumbar spine surgery. Baseline recordings of TcMEPs in both groups were recorded under propofol infusion. Group X patients then received propofol and fentanyl (1 mcg/kg/hr), and group Y patients received ketofol and fentanyl (1 mcg/kg/hr). Bispectral index was maintained at 40-60 in both groups. Amplitude and latency were recorded at 30 minutes intervals for 2 hours. RESULTS: Propofol caused no significant changes in amplitude and latency in any muscle. In contrast, amplitude increased significantly at all time points in the bilateral APB muscles and 60, 90, and 120 minutes in the left AH muscle without changes in latency in response to ketofol. When the two groups were compared, ketofol induced significantly higher amplitudes at 60, 90, and 120 minutes in the (left) APB, at all time points in the (right) APB, and at 120 minutes in both AH muscles, compared with propofol. Blood pressures were lower and fluid and vasopressor requirements were higher in group X. Muscle power was similar between the two groups. CONCLUSIONS: Ketofol facilitates TcMEP amplitudes without affecting latency. Use of ketofol resulted in a better and more stable hemodynamic profile than did use of propofol.

The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position.

Objective Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay. Materials and Methods Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18-60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients ( n = 15) served as control group and received SFT intraoperatively, while patients in group G ( n = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV AI ) and before extubation (CLV BE ). Statistical Analysis and Results CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p -value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G ( p -value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower ( p -value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable. Conclusion GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Thoracic Epidural Anesthesia for Modified Radical Mastectomy in a High-Risk Patient: A Case Report With Literature Review.

Surgery is one of the mainstays of treatment in breast cancers. Typically, modified radical mastectomy (MRM) is done under general anesthesia (GA). However, GA is not a reasonable choice in patients with multiple comorbidities and difficult airways. Thoracic epidural anesthesia (TEA) is a reasonable and safe alternative to GA as it involves blunting of stress response and avoidance of airway handling apart from hemodynamic stability, lower analgesic consumption, superior postoperative analgesia, reduced postoperative nausea and vomiting, earlier resumption of feeding, and shorter duration of hospitalization. We report a case of advanced breast cancer in a 57-year-old female with a co-existing difficult airway, bronchial asthma, and hypertension in whom MRM was conducted successfully under TEA. We also present a comprehensive review of literature on the use of TEA for MRM.

Transient Neurological Dysfunction and Intracranial Hypertension After Tourniquet Deflation in a Patient With a Head Injury: A Case Report.

A tourniquet is used during surgery to produce a bloodless surgical field and decrease intraoperative blood loss. Although useful, tourniquets are associated with various physiological alterations both during inflation and deflation phases which may be poorly tolerated in compromised patients. We report a case of transient neurological dysfunction and intracranial hypertension after tourniquet deflation in a 15-year-old patient with a head injury. Intracranial hypertension under general anesthesia was diagnosed based on bradyarrhythmia and elevated ultrasonographic optic nerve sheath diameter as compared to preoperative values.

Complications and Neurological Outcome following Intraoperative Aneurysm Rupture in Adult Patients Undergoing Intracranial Aneurysmal Clipping: A Retrospective Study.

Background Intraoperative aneurysmal rupture (IAR) is a catastrophic complication; however, its impact on neurological outcome is debatable. We studied the effects of IAR on intraoperative and postoperative complications and neurological outcome. Methods In this retrospective study, adult patients who underwent aneurysmal clipping over a period of 2 years were divided as follows: group R (with IAR) and group N (without IAR). Various perioperative parameters, intraoperative and postoperative complications were noted. Glasgow outcome scale (GOS) was noted at discharge from hospital and categorized as favorable (GOS IV and V) and unfavorable (GOS I, II and III). Collected data was statistically analyzed. Univariate and multiple logistic regression analyses were performed to identify predictors of IAR. A p value < 0.05 was considered significant. Results Thirty-two out of 195 (16.41%) patients suffered IAR, with majority involving anterior communicating artery aneurysm (46.88%). Duration of temporary clipping ( p < 0.001), volume of blood loss, and fluid and blood transfusion were significantly more in group R. Postoperatively, significantly more patients in group R developed intracranial hematoma, cerebral infarct, and required prolonged ventilatory support (≥5 days). Unfavorable neurological outcome was observed more in group R ( p = 0.013). In univariate analysis, blood loss > 500 mL, use of colloids, and duration of surgery > 5 hours were found to be associated with IAR. After multiple logistic regression analysis, only use of colloids and duration of surgery > 5 hours were the most predictive variables for IAR. Conclusions IAR is associated with serious intraoperative and postoperative complications and unfavorable neurological outcome.