Cerebrospinal fluid proteins in idiopathic intracranial hypertension: An exploratory SWATH proteomics analysis.

PURPOSE: The pathogenesis of idiopathic intracranial hypertension (IIH) is currently poorly understood. This exploratory study aimed to identify potential cerebrospinal fluid (CSF) biomarkers in IIH cases compared to controls using SWATH-MS proteomics approach. EXPERIMENTAL DESIGN: CSF samples were collected prospectively from IIH cases and control subjects which were subjected to SWATH-MS based untargeted proteomics. Proteins with fold change > 1.5 or < 0.67 and p-value < 0.05 were considered significantly differentially expressed. Data are available via ProteomeXchange with identifier PXD027751. Statistical analysis was conducted in R version 3.6.2. RESULTS: We included CSF samples from 33 subjects, consisting of 13 IIH cases and 20 controls. A total of 262 proteins were identified in Proteinpilot search. Through SWATH analysis, we quantified 232 proteins. We observed 37 differentially expressed proteins between the two groups with 24 upregulated and 13 downregulated proteins. There were two differential proteins among overweight versus non-overweight IIH cases. Network for 23 proteins was highly connected in the interaction analysis. CONCLUSIONS AND CLINICAL RELEVANCE: Neurosecretory, neuroendocrine, and inflammatory proteins were predominantly involved in causing IIH. This exploratory study served as a platform to identify 37 differentially expressed proteins in IIH and also showed significant differences between overweight and non-overweight IIH patients.

Effect of nitrous oxide on clinical outcome in patients undergoing cerebellopontine tumor surgery under sevoflurane anesthesia: a randomized controlled trial.

Nitrous oxide (N2O) is a unique anesthetic agent that has both advantages and disadvantages, especially in neurosurgical patients. Various studies evaluating the use of N2O in different surgical populations have been inconclusive so far. In this prospective, single-blinded, randomized study, 50 patients of either sex, aged 18-60 years, were enrolled and randomly allocated into N2O or N2O free group. Data including demographics, intraoperative vitals, blood gases, intravenous fluids, anesthetic drug consumption, brain condition, emergence and recovery time, duration of surgery and anesthesia, duration of postoperative ventilation, perioperative complications, condition at discharge, and duration of intensive care unit & hospital stay were recorded. There was no significant difference in intensive care unit or hospital stay between the groups. However, a significant difference in intraoperative heart rate and mean arterial pressure was observed. The incidence of intraoperative tachycardia and hypotension was significantly higher in the N2O free group. Other intra- and post-operative parameters, perioperative complications, and conditions at discharge were comparable. Use of N2O anesthesia for cerebellopontine tumor surgery in good physical grade and well-optimized patients neither increases the length of intensive care unit or hospital stay nor does it affect the complications and conditions at discharge. However, future studies in poor-grade patients with large tumors and raised intracranial pressure will be required to draw a definitive conclusion.

Managing Traumatic Brain Injury During the Coronavirus Disease 2019 Pandemic-A Case-Matched Controlled Analysis of Immediate Outcomes.

OBJECTIVE: The primary objective of this study was to evaluate the outcome of patients with traumatic brain injury (TBI) during the coronavirus disease 2019 (COVID-19) pandemic and to compare their outcome with case-matched controls from the prepandemic phase. METHODS: This is a retrospective case-control study in which all patients with TBI admitted during COVID-19 pandemic phase (Arm A) from March 24, 2020 to November 30, 2020 were matched with age and Glasgow Coma Scale score-matched controls from the patients admitted before March 2020 (Arm B). RESULTS: The total number of patients matched in each arm was 118. The length of hospital stay (8 days vs. 5 days; P < 0.001), transit time from emergency room to operation room (150 minutes vs. 97 minutes; P = 0.271), anesthesia induction time (75 minutes vs. 45 minutes; P = 0.002), and operative duration (275 minutes vs. 180 minutes; P = 0.002) were longer in arm A. Although the incidence of fever and pneumonia was significantly higher in arm A than in arm B (50% vs. 26.3%, P < 0.001 and 27.1% vs. 1.7%, P < 0.001, respectively), outcome (Glasgow Outcome Scale-Extended) and mortality (18.6% vs. 14.4% respectively; P = 0.42) were similar in both the groups. CONCLUSIONS: The outcome of the patients managed for TBI during the COVID-19 pandemic was similar to matched patients with TBI managed at our center before the onset of the COVID-19 pandemic. This finding suggests that the guidelines followed during the COVID-19 pandemic were effective in dealing with patients with TBI. This model can serve as a guide for any future pandemic waves for effective management of patients with TBI without compromising their outcome.

Incidence of posterior vessel wall puncture during ultrasound guided vascular access: Short axis versus long axis approach.

BACKGROUND AND AIMS: Posterior vessel wall puncture (PVWP) is a common complication of ultrasound (US) guided central venous cannulation. We evaluated and compared the frequency of PWVP of internal jugular vein using short axis (SA) and long axis (LA) approach of US-guided needle cannulation. As a secondary objective incidence of carotid puncture was assessed. MATERIAL AND METHODS: Prospective, single-blinded, cross over, observational study at Urban Level I Neuroanesthesiology and Critical Care Department. Residents receiving standard education on ultrasound-guided central venous cannulation were asked to place an US-guided catheter using either short axis or long axis approach on a human torso mannequin. During the procedure, the path of the needle was carefully observed by the investigator for any PVWP and carotid puncture without interference with the placement procedure. The confidence level of the resident for the intraluminal placement of the needle tip was measured on a 10-point Likert scale. RESULTS: Forty residents participated in the study. The incidence of PVWP in SA and LA group was 40% and 17.5% respectively and was statistically significant (p = 0.026). There was no incidence of carotid artery puncture in either of the group. The mean confidence of intraluminal placement of needle was significantly higher in the LA group (8.32) as compared to the SA group (5.95). CONCLUSION: Lower incidence of PVWP was seen in LA as compared to the SA approach during US-guided IJV cannulation in phantom in residents having previous experience of CVC (central venous cannulation) in landmark technique only. Participants were more confident about intraluminal needle placement in the LA group compared to the SA group.

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.

An investigation to the prolonged requirement (>7 days) of vasopressors in cervical spinal cord injury patients-a retrospective analysis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The primary aim was to identify the number of patients requiring vasopressors beyond the first week of cervical spinal cord injury (SCI). Secondary objectives were to note the type, duration and doses of vasopressors and any association between prolonged vasopressors use and outcome. SETTING: Neurosurgical intensive care of a tertiary trauma care centre. METHODS: After Ethical approval we retrospectively collected the data of patients of isolated cervical SCI admitted to neurosurgical intensive care from January to December 2017. Vasopressor requirement for sepsis or cardiac arrest was excluded. RESULTS: Out of 80 patients analysed, 54 (67.5%) received vasopressors. The prolonged requirement of vasopressors was observed in 77.7%. Our preferred agent was dopamine (64.8%). We found out that longer requirement (in days) of high dose of dopamine was associated with higher survival (p = 0.03). CONCLUSION: Our results describe a significant portion of cervical SCI patients need ongoing vasopressor to maintain a mean arterial pressure >65 mm of Hg beyond first week. We observed patients who required longer duration of high dose dopamine had a higher chance of survival suggesting some unknown mechanism of high dose of dopamine. This is first such observation, further studies are needed to substantiate.

Prognostic Value of Serially Estimated Serum Procalcitonin Levels in Traumatic Brain Injury Patients With or Without Extra Cranial Injury on Early In-hospital Mortality: A Longitudinal Observational Study.

BACKGROUND: Traumatic brain injury (TBI) is associated with majority of trauma deaths, and objective tools are required to understand the severity of injury. The application of a biomarker like procalcitonin (PCT) in TBI may allow for assessment of severity and thus aid in prognostication and correlation with mortality and outcome. AIMS: The primary objective is to determine the correlation between PCT concentrations with TBI outcomes (mainly in terms of mortality) at intensive care unit (ICU)/hospital discharge. Secondary objectives are to evaluate correlation with associated extra cranial injuries and complications during hospital stay. METHODS: In total, 186 TBI patients aged > 18 years with minimum survival for at least 12 h admitted to the ICU at the level 1 trauma center were prospectively included in the study and divided into two groups: TBI with and without extra cranial injuries. All admitted patients were treated according to the standard institutional protocol. The PCT levels were obtained on admission, on day 2, and 5. Clinical, laboratory, diagnostic, and therapeutic data were also collected. Primary mortality is defined as death related to central nervous system (CNS) injury, while secondary mortality defined as death related to sepsis or extracranial cause. RESULTS: Median PCT levels at admission, day 2, and day 5 in TBI patients with extracranial injuries were 3.0, 0.83, and 0.69 ng/ml. In total, primary mortality was observed in 18 (9.7%) patients, while secondary causes were attributable in 20 (12.3%) patients. Regression analysis for primarily CNS cause of mortality showed PCT cutoff level at admission more than 5.5 ng/ml carried sensitivity and specificity of 75%, but for secondary cause (sepsis) of mortality, PCT cutoff values on day 2 > 1.15 ng/ml were derived significant with sensitivity of 70% and specificity of 66%. No significant association of parameters like length of ICU stay, Glasgow outcome scale (GOS), and primary/secondary mortality with the presence of extracranial injuries in TBI patients as compared with TBI alone was noted. CONCLUSION: This observational study demonstrates the poor correlation between PCT concentrations with outcome at days 1, 2, and 5 post-injury. The predicted relationship between PCT levels and outcome was not confirmed, and that these results do not support the prognostic utility of PCT biomarker in this population for outcome (mortality) assessment in TBI patients with or without extracranial injuries.

Perioperative Analgesia in Neurosurgery (PAIN): A national survey of pain assessment and management among neuroanesthesiologists of India.

BACKGROUND: Perioperative pain assessment and management in neurosurgical patients varies widely across the globe. There is lack of data from developing world regarding practices of pain assessment and management in neurosurgical population. This survey aimed to capture practices and perceptions regarding perioperative pain assessment and management in neurosurgical patients among anesthesiologists who are members of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) and evaluated if hospital and pain characteristics predicted the use of structured pain assessment protocol and use of opioids for postoperative pain management. METHODS: A 26-item English language questionnaire was administered to members of ISNACC using Kwiksurveys platform after ethics committee approval. Our outcome measures were adoption of structured protocol for pain assessment and opioid usage for postoperative pain management. RESULTS: The response rate for our survey was 55.15% (289/524). One hundred eighteen (41%) responders informed that their hospital setup had a structured pain protocol while 43 (15%) responders reported using opioids for postoperative pain management. Predictors of the use of structured pain protocol were private setup (odds ratio [OR] 2.64; 95% confidence interval [CI] 1.52-4.59; P = .001), higher pain intensity (OR 0.37; 95% CI 0.21-0.64; P < .001) and use of pain scale (OR 7.94; 95% CI 3.99-15.81; P < .001) while availability of structured pain protocol (OR 2.04; 95% CI 1.02-4.05; P = .043) was the only significant variable for postoperative opioid use. CONCLUSIONS: Less than half of the Indian neuroanesthesiologists who are members of ISNACC use structured protocol for pain assessment and very few use opioids for postoperative pain management in neurosurgical patients.

Emergency neurological procedures during COVID-19 pandemic: Practical issues.

The novel coronavirus disease 2019 (COVID-19) has emerged as a global pandemic. A significant number of these patients would present to hospitals with neurological manifestations and neurosurgical emergencies requiring urgent treatment. The anesthesiologists should be prepared to manage these cases in an efficient and timely manner in the operating room, intensive care units, and interventional neuroradiology suites. The clinical course of the disease is in an evolving stage. As we acquire more knowledge about COVID-19, new recommendations and guidelines are being formulated and regularly updated. This article discusses the anesthetic management of urgent neurosurgical and neurointerventional procedures. In addition, a brief overview of intrahospital transport of neurologically injured patients has been addressed.

Prevalence and Antibiotic Resistance Profile of Cerebrospinal Fluid Pathogens from Neurosurgical Patients from Level 1 Trauma Center in India.

INTRODUCTION: The purpose of this study was to investigate the prevalence of Postoperative central nervous system infections (PCNSIs) and antibiotic resistance profiles of causative organisms in trauma patients following neuroinvasive procedures. MATERIALS AND METHODS: This was a retrospective study conducted over a period of 4 years (2013-2017). All in-patients admitted under a neurotrauma unit meeting the inclusion criteria of PCNSIs were included in the study. Surgical site infections (SSIs) were defined according to the Centers for Disease Control and Prevention 2018 (CDC) criteria. We retrospectively examined the demographic characteristics, type of neurosurgery performed, laboratory data, causative organisms, and antimicrobial susceptibility testing results of patients who had positive cerebrospinal fluid cultures following craniotomy between January 2013 and December 2017. RESULTS: Of total 2500 patients operated during the study, 961 patients were screened for PCNSIs. The estimated prevalence (95% confidence interval) of PCNSIs which is a type of organ/space SSI was 7.2% (6.3-8.3). Males were predominantly affected (85.0%). The mean age (standard deviation) of patients was 31.9 (16.5) years. Of all the cultures sent for microbiological examination, 18.6% were positive. The proportion of Gram-negative bacteria causing PCNSIs was 91.6%. Multidrug-resistant (MDR) Acinetobacter baumannii (41%) was the most common organism isolated. Among Gram-positive bacteria, the most common organism was Staphylococcus aureus (5.5%). All the Gram-positive isolates were susceptible to vancomycin, teicoplanin, and linezolid. CONCLUSION: There is a high burden of PCNSI caused by MDR Acinetobacter baumannii can pose a major clinical challenge with only few antimicrobials left in the pipeline.

Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial.

BACKGROUND: There are studies comparing USG guided percutaneous dilatational tracheostomy (PDT) with bronchoscopy guided PDT. We have compared USG guided PDT to conventional landmark guided PDT using bronchoscopy in both the groups. OBJECTIVE: The primary outcome was the time of procedure and the secondary outcome was incidence of complications in USG guided PDT in comparision to the conventional PDT. MATERIALS AND METHODS: Seventy adult patients were randomly allocated in two groups, i.e., conventional landmark percutaneous dilatational tracheostomy (PDT) and ultrasonography (USG) guided PDT. Demographic data, injury severity score, time taken for the procedure, attempts of tracheal puncture, major and minor complications, and outcome were compared. RESULTS: The median time taken for the procedure was 12 minutes [min., max.; 8, 20] in conventional group 1 and 16 minutes [9, 24] in group 2 (USG guided) which was statistically significant. Minor bleeding was seen in 7 (20%) patients in group 1 and only in 4 patients (11.5%) in group 2. The rate of other complications and the long term outcome were similar in both the groups. CONCLUSION: The use of real time USG during PDT may confer advantage over conventional PDT when using bronchoscopy in terms of decreasing the incidence of minor bleeding but duration of the procedure gets prolonged. HOW TO CITE THIS ARTICLE: Aggarwal R, Soni KD, Goyal K, Singh GP, Sokhal N, Trikha A. Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial. Indian J Crit Care Med 2019;23(5):236-238.

Comparison of Effects of Manual and Mechanical Airway Clearance Techniques on Intracranial Pressure in Patients With Severe Traumatic Brain Injury on a Ventilator: Randomized, Crossover Trial.

BACKGROUND: Physical therapist intervention can play a significant role in the prevention of mechanical and infectious complications in patients with traumatic brain injury (TBI) who are mechanically ventilated. OBJECTIVE: The objective of this study was to observe and compare the effects of manual and mechanical airway clearance techniques on intracranial pressure (ICP) and hemodynamics in patients with severe TBI. DESIGN: The design was a prospective, randomized, crossover trial. SETTING: The setting was a neurointensive care unit at a level 1 trauma center. PATIENTS: Forty-six adult patients aged 18 to 75 years, of either sex, with severe TBI, receiving mechanical ventilatory support with continuous ICP monitoring, and undergoing regular airway clearance techniques participated in this study. INTERVENTION: Two techniques were performed by a single trained physical therapist. Treatment A was a manual chest percussion technique and treatment B used a mechanical chest wall vibrator. Each treatment was applied for 10 minutes alternately, separated by an interval of 4 hours. MEASUREMENTS: ICP was measured from the start of intervention to 10 minutes postintervention. Secondary measurements included cerebral perfusion pressure, heart rate, mean arterial pressure (each from the start of the intervention until 10 minutes postintervention at 1-minute intervals), and arterial blood gas parameters (from just before the start of the intervention and 10 minutes postintervention). RESULTS: The increases in mean (95% CI) intracranial pressure of 2.4 (1.4-3.4) and 1.0 (0.2-1.8) mmHg, during and after the intervention with treatment A, respectively, were statistically significantly higher than for treatment B, irrespective of sequence. In contrast, a mean heart rate rise of 6.4 (3.3-9.5) beats/min and mean arterial pressure rise of 5.3 (2.0-8.6) mmHg were significantly higher only during the intervention phase of treatment A compared with treatment B. Peak mean values of ICP, heart rate, and arterial pressure were also significantly higher during treatment A. However, mean values of cerebral perfusion pressure or its degree of change were statistically comparable in both treatment groups. LIMITATIONS: Patients with high baseline ICP values (>20 mmHg) were excluded, and, because of the crossover design, the effect of individual technique on final (long-term) neurological or respiratory outcomes could not be studied. CONCLUSION: Manual chest percussion technique in patients with severe TBI was associated with statistically significant transient increases in ICP and hemodynamics, compared with the mechanical method. However, such transient increases in ICP by either technique were not clinically relevant in patients with moderate-to-severe TBI without intracranial hypertension on a mechanical ventilator.

Intraoperative Generalized Tonic-Clonic Seizure and Consequent Severe Brain Bulge During Functional Motor Cortex Mapping: A Case Report.

Intraoperative cortical and subcortical bipolar or monopolar mapping is the gold standard for neurosurgical procedures that involve lesions near functional or "eloquent" cortex. However, the classic Penfield stimulation has a higher intraoperative seizure rate than high-frequency short-train stimulation. As a result, high-frequency monopolar stimulation is now the most widely practiced technique. However, seizure-free mapping cannot be guaranteed even with high-frequency stimulation particularly at high current thresholds. We encountered a case of severe generalized tonic-clonic seizure and consequent severe brain bulge in an 8-year-old child during cortical mapping with the high-frequency protocol.

Early and rapid detection of UCHL1 in the serum of brain-trauma patients: a novel gold nanoparticle-based method for diagnosing the severity of brain injury.

The clinical diagnosis of traumatic brain injury (TBI) is based on neurological examination and neuro-imaging tools such as CT scanning and MRI. However, neurological examination at times may be confounded by consumption of alcohol or drugs and neuroimaging facilities may not be available at all centers. Human ubiquitin C-terminal hydrolase (UCHL1) is a well-accepted serum biomarker for severe TBI and can be used to detect the severity of a head injury. A reliable, rapid, cost effective, bedside and easy to perform method for the detection of UCHL1 is a pre-requisite for wide clinical applications of UCHL1 as a TBI biomarker. We developed a rapid detection method for UCHL1 using surface plasmon resonance of gold nanoparticles with a limit of detection (LOD) of 0.5 ng mL-1. It has a sensitivity and specificity of 100% each and meets an analytical precision similar to that of conventional sandwich ELISA but can be performed rapidly. Using this method we successfully detected UCHL1 in a cohort of 66 patients with TBI and were reliably able to distinguish mild TBI from moderate to severe TBI.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study.

BACKGROUND: The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. MATERIALS AND METHODS: Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 µg/kg followed by an infusion of 0.2-0.7 µg/kg/h (bispectral index target 60-80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). RESULTS: A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 µg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. CONCLUSION: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.