[Sphenopalatine ganglion block : a promising approach for headache and supratentorial intracranial surgery ?] / Le bloc du ganglion sphénopalatin : un traitement prometteur pour les céphalées et la chirurgie intracrânienne supratentorielle ?

We aimed to determine whether sphenopalatine ganglion block (SPGB) had a place as a treatment for headache, as well as its place as an anterior component of scalp block for supratentorial intracranial surgery. Using the keywords «sphenopalatine ganglion¼, «sphenopalatine ganglion block¼, «pain¼, «surgery¼ and «craniotomy¼ in PubMed and Google Scholar, we identified 14 relevant articles. The methods used to perform the block and the treatment of control groups differed between studies. The main outcomes studied were reduction in pain scores and hemodynamic variations during supratentorial intracranial surgery. All articles concluded that SPGB was equal or superior compared with other procedures. Although there are still several points to be studied, considering the ease of application, the low number of complications and the results of the studies, the use of SPGB for the headache treatment and in neurosurgery as an anterior component of scalp block seems appropriate.

Cette revue de la littérature narrative vise à déterminer la place du bloc du ganglion sphénopalatin (BGSP) comme traitement des céphalées ainsi que sa place comme composante antérieure du bloc de scalp pour la chirurgie intracrânienne supratentorielle. Avec les mots-clés «ganglion sphénopalatin¼, «bloc du ganglion sphénopalatin¼, «douleur¼, «chirurgie¼ et «crâniotomie dans PubMed et Google Scholar, nous avons identifié 14 articles pertinents. Les méthodes de réalisation du bloc ainsi que les traitements des groupes témoins différaient selon les études. Les résultats principaux étudiés étaient la réduction des scores de douleur ainsi que les variations hémodynamiques au cours de la chirurgie intracrânienne supratentorielle. Tous les articles ont conclu à la non-infériorité ou la supériorité du BGSP en comparaison à d'autres procédures. Bien que plusieurs points restent à étudier, compte tenu de la facilité d'application, du peu de complications et des résultats, l'utilisation du BGSP pour le traitement des céphalées et en neurochirurgie comme composante antérieure du bloc de scalp semble appropriée.

[Plasma biomarkers in traumatic brain injury : current status]. / Biomarqueurs plasmatiques dans le traumatisme crânien : état des lieux.

Traumatic Brain Injury (TBI) is a common trauma and a worldwide major cause of mortality or disability in both civilian and military populations. TBI is not a pathological entity in its own, but rather a pattern of heterogeneous traumas with diverse and varied mechanisms and clinical expressions. Therefore, no universal medical response can be settled to it. Instead, medical management must be tailored to each individual's specific needs. If the current identification and prognosis of TBI is basically based on neurological examination and computerized tomography, specific biomarkers could represent a valuable aid in this diagnostic and therapeutic challenge. The potential implications of these markers are broad, encompassing among others the detection of unsuspected TBI, the monitoring of trauma severity, short-, intermediate- and long-term prognosis and apprehension of the extent of the sequelae. This topic has received broad and growing interest over the past decade, and the current literature is extensive. This short narrative review summarizes the latest advances in the field of plasma biomarkers in TBI patients.

Le traumatisme crânien (TC) est une pathologie courante et une cause majeure de mortalité ou d'invalidité dans le monde, tant chez les civils que chez les militaires. Le TC ne constitue pas une entité pathologique à part entière, mais plutôt un ensemble de lésions hétérogènes dont les mécanismes et les expressions cliniques sont divers et variés. Par conséquent, aucune prise en charge universelle ne peut être établie et les traitements médicaux doivent être adaptés et ajustés à l'individu. Si, actuellement, l'identification et le pronostic des TC reposent essentiellement sur l'examen clinique neurologique et la tomodensitométrie, des biomarqueurs spécifiques pourraient représenter une aide précieuse dans ce défi diagnostique et thérapeutique. L'implication potentielle de ces marqueurs est vaste, avec un rôle à jouer, entre autres, dans la détection de la présence d'un TC insoupçonné, le suivi de la sévérité du traumatisme, le pronostic de morbi-mortalité à court, moyen et long termes, et la prédiction de la gravité et de l'étendue des séquelles. Ce sujet a suscité un intérêt large et croissant au cours de la dernière décennie, et la littérature actuelle est abondante. Cette brève revue narrative résume les dernières avancées dans le domaine des biomarqueurs plasmatiques lors d'un TC.

Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial.

BACKGROUND: The anesthetic management of supratentorial craniotomy (CR) necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated with substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control. METHODS: Sixty patients scheduled for elective CR were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (intervention group [group SB], n = 30) or the same volume of saline (control group [group CO], placebo group, n = 30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and state entropy of the electroencephalogram (SE), respectively. Mean arterial blood pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of scalp block performance (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), CR, and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analog scale [VAS]) were recorded 1, 3, 6, 24, and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using 2-tailed Student unpaired t tests, 2-way mixed-design analysis of variance (ANOVA), and Tukey's honestly significant difference (HSD) tests for post hoc comparisons as appropriate. RESULTS: Demographics and length of anesthetic procedure of group CO and SB were comparable. SP, SI, and CR were associated with a significantly higher MAP in group CO than in group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in group CO than in group SB during SP and SI, at least at 1 of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in group CO than in group SB, except for propofol Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in group CO than in group SB. CONCLUSIONS: In supratentorial craniotomies, SB improves hemodynamic control during noxious events and provides adequate and prolonged postoperative pain control as compared to placebo.

Incidence of Connected Consciousness after Tracheal Intubation: A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique.

BACKGROUND: The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice. METHODS: Two hundred sixty adult patients were recruited at six sites into a prospective cohort study of the isolated forearm technique after intubation. Demographic, anesthetic, and intubation data, plus postoperative questionnaires, were collected. Univariate statistics, followed by bivariate logistic regression models for age plus variable, were conducted. RESULTS: The incidence of isolated forearm technique responsiveness after intubation was 4.6% (12/260); 5 of 12 responders reported pain through a second hand squeeze. Responders were younger than nonresponders (39 ± 17 vs. 51 ± 16 yr old; P = 0.01) with more frequent signs of sympathetic activation (50% vs. 2.4%; P = 0.03). No participant had explicit recall of intraoperative events when questioned after surgery (n = 253). Across groups, depth of anesthesia monitoring values showed a wide range; however, values were higher for responders before (54 ± 20 vs. 42 ± 14; P = 0.02) and after (52 ± 16 vs. 43 ± 16; P = 0.02) intubation. In patients not receiving total intravenous anesthesia, exposure to volatile anesthetics before intubation reduced the odds of responding (odds ratio, 0.2 [0.1 to 0.8]; P = 0.02) after adjustment for age. CONCLUSIONS: Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.