Sequential mechanical thrombectomies in acute bilateral middle cerebral artery strokes: A case report and review of literature.

Simultaneous occlusion of both middle cerebral arteries (MCAs) is very rare and usually devastating. Few case reports are available in the literature where bilateral thrombectomy was done simultaneously to remove the clot. High NIH stroke scale with a low level of consciousness can be a clue for the diagnosis. Timely intervention is necessary to decrease morbidity and mortality in these patients. We also reviewed the existing literature where mechanical thrombectomies were done for bilateral MCA stroke in PubMed, Google Scholar, Cochrane, and Embase. Herein, we report a case of 47-year-old female having rheumatic heart disease presented with simultaneous bilateral MCAs occlusion, treated with mechanical thrombectomies successfully.

A Global Review of the Perioperative Care of Patients With Aneurysmal Subarachnoid Hemorrhage Undergoing Microsurgical Repair of Ruptured Intracerebral Aneurysm.

INTRODUCTION: To describe the perioperative care of patients with aneurysmal subarachnoid hemorrhage (aSAH) who undergo microsurgical repair of a ruptured intracerebral aneurysm. METHODS: An English language survey examined 138 areas of the perioperative care of patients with aSAH. Reported practices were categorized as those reported by <20%, 21% to 40%, 41% to 60%, 61% to 80%, and 81% to 100% of participating hospitals. Data were stratified by Worldbank country income level (high-income or low/middle-income). Variation between country-income groups and between countries was presented as an intracluster correlation coefficient (ICC) and 95% confidence interval (CI). RESULTS: Forty-eight hospitals representing 14 countries participated in the survey (response rate 64%); 33 (69%) hospitals admitted ≥60 aSAH patients per year. Clinical practices reported by 81 to 100% of the hospitals included placement of an arterial catheter, preinduction blood type/cross match, use of neuromuscular blockade during induction of general anesthesia, delivering 6 to 8 mL/kg tidal volume, and checking hemoglobin and electrolyte panels. Reported use of intraoperative neurophysiological monitoring was 25% (41% in high-income and 10% in low/middle-income countries), with variation between Worldbank country-income group (ICC 0.15, 95% CI 0.02-2.76) and between countries (ICC 0.44, 95% CI 0.00-0.68). The use of induced hypothermia for neuroprotection was low (2%). Before aneurysm securement, variable in blood pressure targets was reported; systolic blood pressure 90 to 120 mm Hg (30%), 90 to 140 mm Hg (21%), and 90 to 160 mmHg (5%). Induced hypertension during temporary clipping was reported by 37% of hospitals (37% each in high and low/middle-income countries). CONCLUSIONS: This global survey identifies differences in reported practices during the perioperative management of patients with aSAH.

Initial Results of a Direct Aspiration First-Pass Technique to Treat Acute Ischemic Stroke Patients in Nepal.

Objective Endovascular therapy has become the mainstay of treatment of acute ischemic stroke (AIS) due to large vessel occlusion. A direct aspiration first-pass technique (ADAPT) using large bore aspiration catheters has been introduced as a rapid, simple method for achieving good revascularization and good clinical outcomes. The aim of this study was to assess the safety and efficacy of ADAPT in the treatment of AIS due to large-vessel occlusion in the Nepali patient population. Materials and Methods Retrospective data were collected for all consecutive patients treated for AIS with ADAPT from March 2019 through January 2021 at two hospitals. Outcomes were successful revascularization (modified thrombolysis in cerebral infarction score of 2b-3), time to revascularization, procedural complications, and good clinical outcome (modified Rankin Scale score of 0 to 2) and mortality at 90 days. Statistical Analysis Retrospective data were collected and descriptive statistics were calculated. Results Sixty-eight patients treated for AIS with ADAPT were included. The median National Institutes of Health Stroke Scale score at presentation was 13 (IQR 10-13.25). The median time from arterial puncture to revascularization was 40 minutes (IQR 30-45). Successful revascularization was achieved in 54 patients (79.4%). No cases of symptomatic intracranial hemorrhage occurred. At 90-day follow-up, good clinical outcome was achieved in 57 patients (83.8%), and 4 patients died (5.9%). Conclusion A direct aspiration first pass technique appears to be a fast, simple, safe, and effective method for the management of AIS in the Nepali patient population.

Peripheral Nerve and Plexus Blocks for Hip Surgery in a Nonagenarian with Severe Cardiac Disease.

The hemodynamic alterations and stress response associated with anesthesia and surgery are often poorly tolerated by elderly patients. Regional anesthesia techniques are useful in the elderly as they provide excellent perioperative analgesia with minimal hemodynamic perturbations. We report the case of a 90-year-old man with valvular heart disease and severe left ventricular systolic dysfunction, who underwent dynamic hip screw fixation of fractured femur neck under combined pericapsular nerve group block, lumbar plexus block, and para-sacral sciatic nerve block. We are not aware of any previous report of the combination of these blocks used for surgical anesthesia in hip fracture surgery. Keywords: Geriatric; hip fracture; pericapsular nerve group block; regional anesthesia.

Effect of Tranexamic Acid on Blood Loss and the Quality of Surgical Field in Transsphenoidal Pituitary Surgeries: Double-Blind Placebo-Controlled Randomized Control Trial.

Background and Aims: Pituitary adenomas are common intracranial neoplasms and several cases require surgery, radiotherapy or radiosurgery. Transsphenoidal access to the pituitary gland is the commonest surgical approach. In microscopic or endoscopic approach to the pituitary, even modest bleeding can significantly worsen the surgical field for the neurosurgeon, lengthen intra-operative time and lead to potentially catastrophic complications. Methods: The investigators hypothesized that administration of tranexamic acid (TXA) would improve the quality of the surgical field and reduce bleeding during transsphenoidal surgery (TSS) of pituitary tumors. Fifty American Society of Anesthesiologists (ASA) physical-status 1 or 2 patients undergoing TSS were randomized into two groups: T and P. Patients in Group T received 25 mg/kg bolus of TXA followed by intraoperative infusion of 1 mg/kg/hour, while those in Group P received a matching saline infusion. The operating neurosurgeon, and the anesthesiologist, who managed the patient and collected data, were blinded to the test drug. Surgical field quality was assessed using the Boezaart scale. A single neurosurgeon performed all the surgeries to ensure consistency in estimating the quality of the surgical field. Results: The median Boezaart score (interquartile range) was 3 (1.0) in Group T and 3.0 (1.5) in Group P (P = 0.03). There was an absolute blood loss reduction of nearly 32% with TXA use. Blood loss in Group T was 334 ± 101 mL, compared to 495 ± 226 mL in Group P (P = 0.002). Conclusion: The administration of TXA significantly improved the quality of surgical field and reduced blood loss in patients undergoing TSS.

Post-traumatic Pseudoaneurysm of the Internal Carotid Artery with Intractable Epistaxis: A Case Report.

Epistaxis is a common otorhinolaryngology emergency. There are several treatment modalities for epistaxis, but bleeding from the internal carotid artery necessitates a particular treatment technique. We report a case of a 22-years old man who presented to us recurrent episodes of epistaxis and blurry vision in the right eye for one month. The patient had undergone maxillo-facial surgery following a road traffic accident one year back. Bleeding episodes were occasionally severe with blood loss of up to 800 to 1000ml. These episodes were managed conservatively with posterior nasal packing and frequent blood transfusions. A computed tomography-angiography revealed a pseudoaneurysm arising from the cavernous segment of the right internal carotid artery which was managed successfully by embolization of the aneurysm sac with coils. Despite the rarity of internal carotid artery pseudoaneurysm in individuals with a history of trauma, doctors must be aware of the possibility. Timely identification and treatment of a pseudoaneurysm can save a person's life.

Rational Use of Oxygen in COVID-19 Pandemic - Are We Doing Enough?

During the episodes of large case surge of COVID-19, the health care system of many nations have struggled, more so in nations with resource limitations. Recently, Nepal and the neighboring nation India are being hit hard by the pandemic. Management of patients with moderate and severe COVID-19 remains largely supportive, with oxygen therapy being the cornerstone of the management. Procurement, maintenance of oxygen supply system, coupled with avoiding misuse and wastage of oxygen is of paramount importance to better utilize the scarce resources amidst the peaks of a pandemic. Nepal needs to adopt policies to make best use of its stores and supplies with a collective effort from all stakeholders to save additional lives.

Middle cerebral artery occlusion due to cardiac tissue following catheter ablation in Wolff-Parkinson-White syndrome.

Catheter ablation is a commonly performed procedure in patients with Wolff-Parkinson-White syndrome. A 56-year-old man developed an acute ischemic stroke immediately after undergoing radiofrequency catheter ablation of the left-sided accessory pathway. Neuroimaging revealed complete occlusion of the proximal middle cerebral artery. Mechanical thrombectomy (MT) was performed with successful retrieval of the thrombo-embolus. Histopathological examination of the thrombo-embolus confirmed organic cardiac tissue. The patient was later discharged from the hospital with no neurologic deficit. There is no report of successful MT in patients with large-vessel occlusion because of the embolization of cardiac tissue after catheter ablation. This report highlights the need to remain vigilant for signs of stroke after any cardiac intervention.

Transsellar trans-sphenoidal encephalocele with cleft lip, cleft palate and agenesis of corpus callosum.

Basal encephalocele is a rare congenital malformation. Among basal encephaloceles, the transsellar, trans-sphenoidal encephalocele is the least common subtype. We present the case of a newborn female, who presented to us with cleft lip and cleft palate. Diagnostic neuroimaging revealed the presence of transsellar trans-sphenoidal encephalocele along with agenesis of the corpus callosum. There are very few case reports of trans-sphenoidal encephalocele with corpus callosum agenesis in a patient with midline cleft lip and palate. In this report, we discuss the clinico-radiological findings of this extremely rare condition and present a brief review of the literature.

Anesthesiology and Critical Care Response to COVID-19 in Resource-Limited Settings: Experiences from Nepal.

It is difficult to predict the future course and length of the ongoing COVID-19 pandemic, which has devastated health care systems in low- and middle-income countries. Anesthesiology and critical care services are hard hit because many hospitals have stopped performing elective surgeries, staff and scarce hospital resources have been diverted to manage COVID-19 patients, and several makeshift COVID-19 units had to be set up. Intensive care units are overwhelmed with critically ill patients. In these difficult times, low- and middle-income countries need to improvise, perform indigenous research, adapt international guidelines to suit local needs, and target attainable clinical goals.

Management of Stroke During COVID-19 Pandemic: The Challenges in Nepal.

The COVID-19 pandemic has significantly affected health care delivery globally. COVID-19 is associated with varied neurological manifestations including acute ischemic stroke. In densely populated South Asian nations like Nepal that have suboptimal baseline health care systems, we foresee unique challenges during this pandemic to ensure effective stroke management as well as the safety of health care workers involved in the management of stroke patients. Keywords: COVID-19; health care workers; safety; stroke management.

Mucormycosis: An unanticipated progeny of COVID-19.

The rapid surge of COVID-19 cases in the second wave of the pandemic has crippled the healthcare delivery system in Nepal and neighboring countries. Unlike in the first wave of the pandemic, several cases of mucormycosis have been reported in patients with COVID-19 from Nepal and India. In this report, we briefly describe the clinical presentation, diagnosis, and risk factors for mucormycosis and explore why patients with COVID-19 are at an increased risk for developing the infection. As treatment of mucormycosis is challenging and consumes a lot of resources, prevention of mucormycosis is pivotal in low-income countries like Nepal. We also highlight some basic steps that are easy to perform and important to reduce the risk of infection.

Successful Treatment of Giant Intracranial Aneurysm Using Flow-Diverter Device: First Experience in Nepal.

Giant intracranial aneurysms are defined as aneurysms that measure over 25 mm in the greatest dimension. They are rare vascular lesions that preferentially involve regions with high-velocity blood flow, such as the cavernous and supraclinoid segments of the internal carotid artery, the middle cerebral artery, the vertebrobasilar region, and the basilar apex. The treatment of giant aneurysms is challenging and associated with high rates of morbidity and mortality. Flow-diverter devices have revolutionized their treatment in recent times. We report the successful management of two patients with giant cavernous internal carotid artery aneurysms using flow-diverter devices for the first time in Nepal. Keywords: Endovascular; flow-diverter devices; giant aneurysm.

Giant Cerebral Tuberculoma Masquerading as Malignant Brain Tumor - A Report of Two Cases.

Giant cerebral tuberculoma is an uncommon but serious form of tuberculosis. We report two patients who had a single, large lesion on magnetic resonance imaging (MRI) of the brain. Both patients underwent neurosurgery for the excision of the mass lesion as neuroimaging findings were suggestive of a brain tumor. Tuberculoma was later diagnosed on histopathological examination. We want to highlight that cerebral tuberculomas can mimic malignant brain tumors, as the clinical, laboratory, and radiologic features of cerebral tuberculomas are nonspecific.

Mechanical Thrombectomy for Basilar Artery Occlusion Stroke: A Case Report.

Posterior circulation strokes are potentially devastating events that carry a significant risk of morbidity and mortality. Acute basilar artery occlusion stroke is a rare posterior circulation stroke that needs emergent management. We report the case of a 67-year-old woman who developed an acute basilar artery occlusion. We achieved complete recanalization of the occluded basilar artery and its branches with endovascular mechanical thrombectomy. It is possible to achieve excellent results with mechanical thrombectomy in acute basilar artery occlusion if timely diagnosis and reperfusion can be done. We are not aware of any previous publication from Nepal describing this technique in acute basilar artery occlusion.

Perspective of Doctors for COVID-19 Pandemic Readiness in Government Hospitals of Nepal.

BACKGROUND: The study assesses the perspective of doctors working in government hospitals of Nepal regarding hospital preparedness for infection prevention measures, isolation services provisions, critical care service readiness, and training of staff for COVID-19 pandemic management. METHODS: This cross-sectional study was done in central, provincial, and local level health centers of the Government of Nepal to assess the perspective of medical doctors regarding COVID-19 pandemic readiness in their facility. Nonprobability sampling was used to collect 56 responses from doctors working in different hospitals of Nepal. An online survey was performed using a questionnaire tool, which was adapted from the guidelines of the World Health Organization and the Centers for Disease Control and Prevention. RESULTS: Most of the participants were medical officers with an MBBS degree (32) followed by anesthesiologists (10). Thirteen participants worked in central hospitals (23.2%), 24 in provincial hospitals (42.8%) and 19 in local health centers (33.92%). The availability of adequate facemask was 84% in central hospitals, which was higher than provincial hospitals (66.7%), and local level health centers (77.8%). There were only 53.8% trained critical care providers in central hospitals and 29.2% in provincial hospitals. Nearly 38.5% (5) of central hospitals had measures for airborne isolation in place, whereas this was only found in 8.3% (2) of provincial hospitals surveyed for critical care facilities. Overall, only 2 hospitals had the provision of a negative pressure room with air exchanges. Only 8 participants working in central hospitals (61.5%) and 14 working in provincial hospitals (58.3%) had performed hands-on training for donning and doffing personal protective equipment. CONCLUSIONS: The majority of medical doctors working in government hospitals of Nepal perceive that provision of facemask distribution, airborne isolation rooms, critical care preparedness, and hands-on training to staff were not adequate.

Endovascular treatment of complex vertebrobasilar junction aneurysms: A report of two cases.

INTRODUCTION: Vertebrobasilar junction (VBJ) aneurysms are uncommon posterior circulation aneurysms. The treatment of VBJ aneurysms is challenging and in most cases, endovascular management is preferred over neurosurgery. PRESENTATION OF CASE: We describe two patients with VBJ aneurysms who underwent successful neuro-interventional procedures. The first patient had concomitant basilar fenestration and was treated with balloon-assisted coiling. The second patient had difficult vascular anatomy and an anterior inferior cerebellar artery-posterior inferior cerebellar artery variant arising from the neck of the aneurysm. Braided stent-assisted coiling was done with transradial access. Both patients had a good neurologic recovery. DISCUSSION: Endovascular management of VBJ aneurysms is often complicated by anatomic difficulties like basilar fenestration, tortuosity of proximal vessels, atheromatous changes, and vascular stenosis. We achieved good post-procedure outcomes in both the patients. Optimal management of complex VBJ aneurysms often requires some modification to the usual interventional technique. CONCLUSION: VBJ aneurysms are generally treated with endovascular techniques. The transradial access, although rarely used by neurointerventionalists, has some distinct advantages over the transfemoral access, especially when dealing with right-sided VBJ aneurysms with marked tortuosity of proximal great vessels.

Effect of Stellate Ganglion Block on Intraoperative Propofol and Fentanyl Consumption in Patients with Complex Regional Pain Syndrome Undergoing Surgical Repair of Brachial Plexus Injury: A Randomized, Double-blind, Placebo-controlled Trial.

INTRODUCTION: Stellate ganglion block (SGB) is commonly performed to treat chronic painful conditions, such as complex regional pain syndrome (CRPS) and postherpetic neuralgia. However, whether it is effective in reducing anesthesia and analgesia requirement during surgery (acute pain) is not known. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists (ASA) physical status I and II patients with CRPS type II undergoing surgery for repair of brachial plexus injury were randomized (1:1) to receive SGB with either 10 mL of 0.5% bupivacaine (Group B) or a matching placebo (Group S) before induction of anesthesia. RESULTS: There was a significant reduction in the requirement of total intraoperative propofol (1659.7 ± 787.5 vs. 2500.7 ± 740.9 mg, P = 0.0003) and fentanyl (190.0 ± 82.5 vs. 327.3 ± 139.3, P = 0.0001) in Group B compared with Group S. Similarly, in Group B, the time to first analgesic was much longer (328 ± 219 vs. 64 ± 116 min, P = 0.000) and postoperative fentanyl requirement for 24 h was lesser compared to Group S (0.6 ± 1.1 vs. 2.1 ± 1.3 µg/kg, P = 0.000). CONCLUSION: SGB is effective in reducing the requirement of intraoperative propofol and fentanyl as well as decreasing opioid requirement in the postoperative period in patients with CRPS type II undergoing surgery.