Effect of Peri-operative Blood Transfusion on Neurological Outcome Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Study.

BACKGROUND: Anemia is a common complication of aneurysmal subarachnoid hemorrhage and is associated with unfavorable outcomes. Whether the physiological benefits of transfusion for anemia surpass the risk of blood transfusion remains to be determined. OBJECTIVES: The primary outcome was to evaluate the impact of peri-operative blood transfusion on the long-term neurological outcome, assessed by Glasgow Outcome Scale Extended at 3 months. The secondary outcomes included the impact of transfusion on the short-term neurological outcome, assessed by Modified Rankin Score at discharge/7 days, and on the incidence of vasospasm, infarction, re-exploration, tracheostomy, and length of hospital stay. MATERIAL AND METHODS: This prospective observational study was conducted on 185 patients with aneurysmal subarachnoid hemorrhage undergoing clipping of the aneurysmal neck. In our study, blood transfusion was administered to keep the target Hb around 10 g/dL. RESULTS: Unfavorable long-term outcome was found in 27/97 (28%) of patients who received a blood transfusion as compared to 13/74 (18%) of patients who did not receive a transfusion (P = 0.116). Patients receiving transfusion had more chances of an unfavorable outcome at discharge/7 days as compared to those not transfused [44/103 (43%) versus 22/80 (27%)], P = 0.025. There were increased chances of vasospasm, infarction, re-exploration, tracheostomy, and increased length of hospital stay in patients receiving transfusion (P < 0.05). CONCLUSIONS: The use of blood transfusion in patients with aneurysmal subarachnoid hemorrhage was associated with increased neurological complications and hence an unfavorable short-term outcome. However, when used judiciously as per the clinical requirements, blood transfusion did not have a significant effect on long-term neurological outcome.

Isolated ipsilateral abducens nerve palsy and contralateral homonymous hemianopsia associated with unruptured posterior cerebral artery aneurysm: A rare neurological finding.

Cranial nerve palsies can be presenting signs of intracranial aneurysms. There is a classic pairing between an aneurysmal vessel and adjacent nerves leading to cranial neuropathy. Isolated abducens nerve palsy can be a localizing sign of an unruptured vertebrobasilar circulation aneurysm. Aneurysms involving Anterior Inferior Cerebellar Artery (AICA) and Posterior Inferior Cerebellar Artery (PICA) have been reported to be associated with abducens nerve palsy. The symptoms in unruptured aneurysms are due to the mass effect on adjacent neurovascular structures. Most of the abducens nerve palsy resolves following microsurgical clipping. Here, we present a rare case of an unruptured Posterior Cerebral Artery (PCA) aneurysm presenting with abducens nerve palsy and diplopia associated with contralateral hemianopsia which markedly improved following endovascular coil embolization.

A comparative study of low voltage, low contrast cerebral computed tomography angiography with iterative reconstruction and conventional cerebral computed tomography angiography.

BACKGROUND: Cerebral computed tomography angiography (CTA) has revolutionized the diagnosis of neurovascular emergencies. Strategies to reduce radiation, a concern for cancer, involve tube voltage and current reduction but with increased noise and inferior image quality. Hence, the objective of the study was to evaluate the quality of images obtained through low-dose radiation and low-contrast volume CTA with an iterative reconstruction (IR) technique versus standard CTA without IR. METHODS: This prospective trial involved 100 adults requiring cerebral CTA for cerebrovascular diseases. They were split into two groups: one with 120 kVp tube voltage and 80 mL contrast using filtered back projection, and the other with 80 kVp and 30 mL contrast with IR. Evaluation criteria included attenuation values, signal-to-noise ratio, contrast-to-noise ratio, and subjective assessments. RESULTS: Compared to 120 kVp, 80 kVp showed higher vessel attenuation in the internal (272.91 ± 30.59 vs 405.52 ± 53.08; p < .001) and middle cerebral artery (247.55 ± 29.84 vs 372.55 ± 49.02; p < .001) regions. Brain parenchymal attenuation at the centrum semiovale was lower with 80 kVp (29.12 ± 1.87 vs 24.78 ± 2.94; p < .001), accompanied by higher noise. Signal-to-noise ratio (p < .001) and contrast-to-noise ratio (p < .05) were lower at 80 kVp. Image quality didn't significantly differ, and radiation exposure reduced significantly by 70% in the 80 kVp group, suggesting its diagnostic feasibility. CONCLUSIONS: The 80 kVp protocol for CTA of the cerebral vessels combined with lower contrast volume produces images with similar image quality with significant radiation effective dose and total iodine dose reduction. The 80 kVp protocol holds significant promise for replacing the standard 120 kVp protocol in cerebral CTA.

Capillary Hemangioma of the Maxillary Sinus: A Rare Cause of Massive Life-Threatening Epistaxis.

Hemangioma of the paranasal sinus is an infrequent condition. Two types of hemangioma are present at the nose; cavernous and capillary. Capillary hemangioma is rare in the sinonasal tract. Patients presented with massive epistaxis should think of nasal hemangioma. Resuscitation of patients is important and urgent Computerized Tomography scans should be performed which will help character and extension of any mass present at the nasal cavity. Initial nasal packing may help to prevent bleeding. We report a case of capillary hemangioma of a 30-year lady present with massive epistaxis initially controlled by Nasal packing. Her CT scan shows a homogenous mass at left maxillary sinuses and underwent left endoscopic sphenopalatine artery ligation and removal of the mass. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04046-z.

Effect of Lumbar Discectomy or Lumbar Decompression on Axial Back Pain: Results of a Meta-Analysis.

OBJECTIVE: This meta-analysis evaluated the impact of lumbar disk herniation and lumbar spinal stenosis (LSS) on axial back pain and the extent of improvement of axial and radicular pain following lumbar decompression and discectomy surgery in patients with low back pain (LBP). METHODS: A systematic search for published literature between January 2012 and January 2023 was made on PubMed, Google Scholar, and Cochrane library database on 31st January 2023. Original articles that included patients with lumbar disc herniation or LSS who underwent lumbar discectomy or lumbar decompression respectively were included in the study. RESULTS: A total of 71 studies including 16,770 patients with LBP undergoing lumbar discectomy or decompression surgery were included in the meta-analysis. The pooled standard mean difference between postoperative and preoperative: Visual Analog Scale scores for leg pain was -5.14 with 95% confidence interval (CI): -6.59 to -3.69 (P-value = 0) and for back pain was -2.90 with 95% CI: -3.79 to -2.01 (P value = 0), Numerical pain Rating Scale for leg pain was -1.64 with 95% CI: -1.97 to -1.30 (P-value<0.01) and for back pain was -1.58 with 95% CI: -1.84 to -1.32 (P-value <0.01), Oswerty Disability Index score was -4.76 with 95% CI: -6.22 to -3.29 (P-value = 0) and the Japanese Orthopaedic Association score was 3.45 with 95% CI: 0.02 to 6.88 (P value 0) at follow-up. CONCLUSIONS: This meta-analysis provides evidence that lumbar discectomy and decompression are effective in improving axial LBP in patients with lumbar disk herniation and LSS.

Comparison of Effects of Propofol and Sevoflurane on the Cerebral Vasculature Assessed by Digital Subtraction Angiographic Parameters in Patients Treated for Ruptured Cerebral Aneurysm: A Preliminary Study.

BACKGROUND: Studies have evaluated the effects of volatile and intravenous anesthetic agents on the cerebral vasculature with inconsistent results. We used digital subtraction angiography to compare the effects of propofol and sevoflurane on the luminal diameter of cerebral vessels and on cerebral transit time in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: This prospective preliminary study included adult patients with good-grade aSAH scheduled for endovascular coil embolization; patients were randomized to receive propofol or sevoflurane anesthesia during endovascular coiling. The primary outcome was the luminal diameter of 7 cerebral vessel segments measured on the diseased and nondiseased sides of the brain at 3 time points: awake, postinduction of anesthesia, and postcoiling. Cerebral transit time was also measured as a surrogate for cerebral blood flow. RESULTS: Eighteen patients were included in the analysis (9 per group). Baseline and intraoperative parameters were similar between the groups. Propofol increased the diameter of 1 vessel segment at postinduction and postcoiling on the diseased side and in 1 segment at postcoiling on the nondiseased side of the brain ( P <0.05). Sevoflurane increased vessel diameter in 3 segments at postinduction and in 2 segments at postcoiling on the diseased side, and in 4 segments at postcoiling on the nondiseased side ( P <0.05). Cerebral transit time did not change compared with baseline awake state in either group and was not different between the groups. CONCLUSIONS: Sevoflurane has cerebral vasodilating properties compared with propofol in patients with good-grade aSAH. However, sevoflurane affects cerebral transit time comparably to propofol.

Comparison of analgesic efficacy of continuous bilateral transversus abdominis plane catheter infusion with that of lumbar epidural for postoperative analgesia in patients undergoing lower abdominal surgeries.

BACKGROUND AND AIMS: Epidural analgesia (EA) and transversus abdominal plane (TAP) block have been part of multimodal analgesia techniques for postoperative pain relief in abdominal surgeries though EA has been established as gold standard. This study assesses and compares the analgesic efficacy of continuous bilateral TAP catheter infusion and lumbar epidural infusion. METHODS: In this randomised, single-blind, prospective, non-inferiority trial, 75 patients were randomised to receive a bolus dose of 15 ml, 0.25% bupivacaine followed by an infusion of 5-12 ml/h of 0.125% bupivacaine via lumbar epidural in EA group and a bolus dose of 0.4 ml/kg of 0.25% bupivacaine bilaterally via TAP catheter followed by continuous infusion at 5ml/h of 0.125% bupivacaine in TAP group postoperatively. VAS scores (primary objective) and sensory dermatome blockade were recorded at 1, 4, 8, 12 and 24 h. Total morphine consumption, PONV, incidence of hypotension and patient satisfaction scales were recorded at the end of 24 hours. RESULTS: The median VAS scores were comparable between the groups at 1, 4, 8, 12 and 24 hours both at rest (P = 0.11, 0.649, 0.615, 0.280 and 0.191, respectively) and on coughing (p = 0.171, 0.224, 0.207, 0.142 and 0.158, respectively). Total morphine consumption in 24 h between TAP and EA group was comparable (p = 0.366). There was no statistical difference in the incidence of hypotension, PONV and patient satisfaction scale. CONCLUSION: Continuous bilateral TAP block is as efficacious as the continuous lumbar epidural infusion in relieving postoperative pain in patients undergoing lower abdominal surgeries.