Hirayama disease (HD) is a rare cervical flexion myelopathy associated with subclinical autonomic dysfunction (AD). Cardiovascular autonomic neuropathy (CAN), though uncommon, may predispose to perioperative instability. We report an 18-year-old male with HD undergoing cervical laminoplasty who developed profound post-induction and positional hypotension without compensatory tachycardia, despite normal preoperative bedside autonomic testing. Hemodynamics were was managed with vasopressors and targeted fluid therapy. Subsequent autonomic evaluation revealed early cardiovascular AD, with an Ewing battery score of 2.5. Heart rate variability (HRV) indicated sympathetic predominance with impaired parasympathetic modulation—findings suggestive of early CAN. This case highlights the presence of clinically silent cardiovascular AD in HD and its potential to cause significant anesthetic-related hypotension. Incorporating HRV analysis as a simple, non-invasive adjunct to conventional autonomic testing may improve preoperative risk stratification and guide anesthetic management in patients with HD.
Immune thrombocytopenic purpura (ITP) is traditionally considered a bleeding disorder; however, thrombotic events are increasingly recognized, particularly in patients treated with thrombopoietin receptor agonists (TPO-RAs). Cerebral venous thrombosis (CVT) is a rare but serious complication in this setting. We report a 40-year-old woman with chronic ITP and elevated antiphospholipid antibody (aPL) IgG who developed headache, vomiting, and blurred vision. MRI demonstrated a left parieto-occipital hemorrhagic infarct and CT venography confirmed thrombosis of a parasagittal cortical vein. Despite therapeutic anticoagulation, malignant cerebral edema necessitated emergency decompressive craniectomy under general anesthesia. The patient improved neurologically and was discharged ambulant with support. This case highlights the complex interplay between ITP, TPO-RA therapy, aPL, and CVT, and underscores key perioperative challenges.
Background Central venous catheters (CVCs) are routinely used in neurosurgical procedures despite an estimated incidence of line-related complications exceeding 15%. Our quality improvement initiative studied the usage and choice of CVCs and assessed the effect of feedback-based optimization of catheter choice without compromising safety. Methods This 3-phase study was conducted at a tertiary care hospital in South India. It included all patients admitted to the neuro-intensive care unit following elective cranial surgery with intraoperative CVC insertion. Phase 1 (3 months) studied the indication, choice of CVC, and duration of retention. Feedback was provided to the Neuroanaesthesia team, whose independent interpretation and practice modification constituted phase 2. In phase 3, the change in practice was documented. Comparative and subgroup analyses were performed using chi(2) , Fisher's exact, and Mann-Whitney U tests. Results In phase 1, 143 of 769 elective neurosurgical cases (19%) were included, compared with 210 of 869 cases (24%) in phase 3. Despite the significant increase in inotrope and transfusion need in phase 3, peripherally inserted central catheter (PICC) use significantly rose from 58 to 82%, effectively managing such cases with no documented complications. Anticipated blood loss was the most common indication (43%) for line insertion in phase 3. One catheter-related bloodstream infection occurred in phase 1 with a centrally inserted CVC. Conclusion PICC are safe, cost-effective alternatives to CVCs in elective neurosurgical procedures. A feedback-based quality improvement intervention significantly increased acceptance of PICC without compromising safety or perioperative management of complications.
Anesthetic management of elderly, frail patients with dilated cardiomyopathy (DCM) and severely reduced ejection fraction in the prone position is challenging due to high risks of perioperative cardiac events and difficulties in resuscitation. We present a case of a 70-year-old patient with multiple comorbidities diagnosed with L4-L5 infective spondylodiscitis and L5 vertebral collapse who successfully underwent lumbar laminectomy and decompression with instrumentation. Key elements contributing to successful management included comprehensive pre-anesthetic evaluation, optimization of cardiac and general health, detailed counseling regarding perioperative risks, thorough understanding of DCM pathophysiology, careful consideration of patient frailty, vigilant intraoperative hemodynamic monitoring, and effective postoperative analgesia. This case highlights essential strategies for managing high-risk patients with DCM in prone surgical positions.
Nasogastric tube (NGT) syndrome is a rare but potentially life-threatening complication of prolonged NGT placement. We report a 39-year-old woman with drug-resistant epilepsy who underwent anterior temporal lobectomy with amygdalohippocampectomy. Postoperatively, she developed status epilepticus requiring mechanical ventilation and NGT insertion. On postoperative day 8, after removal of the endotracheal tube, the patient developed inspiratory stridor and hypoxia, which were initially managed medically. A second extubation attempt was later given, which also failed, necessitating tracheostomy. Flexible laryngoscopy revealed a midline NGT in the postcricoid space, bilateral arytenoid edema, fixed vocal cords, and a narrowed glottic space—findings diagnostic of NGT syndrome. The tube was promptly removed, and she was managed with corticosteroids, antibiotics, and proton pump inhibitors. Five days later, her vocal cord mobility, checked with flexible fiberoptic laryngoscopy, had improved, and the tracheostomy was successfully decannulated. NGT syndrome is frequently underrecognized due to its nonspecific presentation and overlap with laryngeal edema or aspiration. A high index of suspicion, timely diagnosis, and prompt tube removal with airway stabilization are essential, emphasizing the critical need for early recognition in neurocritical care.
Background Endotracheal intubation is critical for securing a patient's airway during emergencies and general anesthesia. This study aims to compare the efficacy of the Split-type Postman and C-MAC video laryngoscopes for intubation under simulated restricted neck mobility, focusing on intubation time, success rates, and hemodynamic responses. Methods This prospective, hospital-based, randomized controlled trial included 50 American Society of Anesthesiologists physical status Classes I and II patients aged 18 to 60 years undergoing elective surgery under general anesthesia. Patients were randomly assigned to be intubated with the Split-type Postman or C-MAC video laryngoscope. The primary objective was to compare intubation times, while the secondary objectives included assessing first-attempt success rates, percentage of glottic opening scores, use of ancillary devices, and hemodynamic responses. Results The Split-type Postman video laryngoscope demonstrated significantly faster median times for glottis visualization (14.94 vs. 17.49 seconds) and tube placement confirmation (13.07 vs. 18.93 seconds) compared with the C-MAC video laryngoscope ( p -value <0.01). Total intubation time was shorter for the Postman group (27.64 vs. 36.69 seconds) with a p -value <0.01. Both groups exhibited comparable hemodynamic stability, with no significant differences in heart rate, systolic, diastolic, or mean arterial pressure at various time points postintubation. The first-attempt success rate with the C-MAC video laryngoscope was comparable ( p -value 0.584) with the Split-type Postman video laryngoscope, and it required less frequent use of ancillary devices such as bougie/stylet compared with the Split-type Postman video laryngoscope. Conclusion The Split-type Postman video laryngoscope offers faster intubation times than the C-MAC video laryngoscope, making it particularly advantageous in emergency situations. Both devices provide comparable hemodynamic stability and first attempt for successful intubation. Further research is recommended to validate these findings across diverse clinical settings. However, the Postman video laryngoscope may require additional tools for successful intubation.
Carotid hypersensitivity syndrome (CHS) is characterized by recurrent syncope in response to carotid sinus receptor stimulation. It is common in older adult males. Due to recurrent syncope and falls, these patients often present with acute-on-chronic subdural hematoma (SDH). Diagnosing CHS is often challenging, especially in patients with SDH who present with signs of elevated intracranial pressure. Proceeding to anesthetize the patient without evaluating the cause of syncope can lead to perioperative morbidity and mortality. Here, we report the perioperative management of an elderly gentleman who presented with recurrent syncope and falls leading to bilateral SDH and was systematically evaluated and diagnosed with CHS based on the head-up tilt test and carotid sinus massage. He underwent temporary cardiac pacemaker insertion followed by evacuation of bilateral SDH under monitored anesthesia care and a scalp block. Later, he underwent permanent cardiac pacemaker insertion for CHS. Coordinated multidisciplinary care facilitated faster recovery without morbidity.
Background Although respiratory dysfunction is commonly seen in patients with craniovertebral junction (CVJ) anomalies, pulmonary complications following CVJ surgery have not been extensively studied. We studied the incidence of postoperative pulmonary complications (PPCs) after CVJ surgeries and determined the risk factors. We also evaluated the association between the preoperative pulmonary reserve and PPC. Methods This prospective observational study was performed in 41 patients aged 12 to 65 years undergoing surgery for CVJ anomalies. The preoperative pulmonary reserve was assessed with bedside tests (breath holding time [BHT], single breadth count [SBC], and chest expansion) and using a spirometer (forced vital capacity [FVC], forced expiratory volume [FEV 1 ], FEV1/FVC, peak expiratory flow rate). Postoperatively, the incidence of PPC was assessed, and the duration of mechanical ventilation/tracheostomy was noted. Spirometry was repeated after 3 months. Results The incidence of PPCs was 26.8%, and respiratory support requirement was commonly seen (54.5%). Bedside PFTs, including BHT, SBC, and chest expansion ( p = 0.045, 0.001, and 0.012, respectively), along with blood loss ( p = 0.013), had a significant association with PPCs. Multivariate analysis revealed a significant association of PPC with blood loss. There was a decline in FEV1 in the postoperative period, followed by improvement after 3 months. Conclusion The incidence of PPC following CVJ surgery is relatively high (26.8%), and intraoperative blood loss is an independent risk factor. Bedside PFTs like chest expansion may be superior to spirometry tests in predicting the risk of PPC.
Optic nerve sheath diameter (ONSD) reflects the change in cerebrospinal fluid pressure. ONSD/eyeball transverse diameter (ETD) is a new ultrasonic indicator, devoid of influences of age, gender, and ethnicity. We studied the changes in the ocular sonographic parameters: ONSD, ETD, and ONSD/ETD ratio in patients of hydrocephalus before and after ventriculoperitoneal (VP) shunt placement and the factors associated with their changes. The parameters of ONSD, ETD, and ONSD/ETD were measured in 40 patients by a single observer with Sonosite machine at three time points: before induction of anesthesia, immediately after extubation, and at 24 hours of extubation to detect changes. We examined the association between changes in clinical characters before and after shunt insertion with the ocular sonographic parameters. ONSD at 24 hours after extubation, that is, 5.29 ± 0.26 mm, was substantially lower compared to the baseline value of 5.40 ± 0.31 mm (p < 0.01). Mean ONSD/ETD ratio at 24 hours after extubation, that is, 0.228 ± 0.01, was significantly reduced compared to the baseline value of 0.233 ± 0.01 (p < 0.01). No differences in the parameters were observed between the baseline and immediately after extubation. We did not observe any substantial changes in ETD across the three time points. The reduction in ONSD and ONSD/ETD parameters from baseline to 24 hours was significantly associated with headache (p = 0.00) and nausea and vomiting (p = 0.002). ONSD and ONSD/ETD ratio, both useful bedside parameters, reflect intracranial pressure (ICP) changes in patients undergoing VP shunt surgery. A decrease in the postoperative value of these parameters compared to preoperative values was consistent with relief of clinical symptoms, reflecting a reduction in ICP from successful surgery.
Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective therapeutic option for patients with medically refractory dystonia. However, accurate electrode placement is critical, particularly when the trajectory lies close to eloquent structures such as the optic radiations. Intraoperative neurophysiological monitoring using visual evoked potentials (VEPs) can aid in functional localization of the optic tract and enhance targeting accuracy. We report the case of a 62-year-old female with severe oromandibular dystonia and feeding impairment who underwent bilateral GPi DBS under general anesthesia with intraoperative VEP guidance. Cortical VEPs were first obtained using photic stimulation to confirm signal integrity and guide anesthetic titration. Direct optic tract stimulation was then performed using a 2-mm active-tip DBS electrode, with optic tract VEPs (oVEP) recorded to identify proximity to the optic tract. Microelectrode recordings and macrostimulation were used to identify dystonic firing patterns and confirm safe distance from the internal capsule. Final lead placement was guided by the site of maximal oVEP amplitude. Anesthetic depth was maintained at a bispectral index of 70 to 80 using dexmedetomidine, propofol, and desflurane, with careful opioid titration to preserve neurophysiological signals. The patient recovered without complications or awareness and remained neurologically stable postoperatively. This case highlights the feasibility of performing DBS under general anesthesia with intraoperative VEP guidance and emphasizes the importance of individualized anesthetic management and multidisciplinary coordination in complex movement disorder surgeries.
Tracheal diverticulum (TD) is a paratracheal air cyst communicating with the trachea through an ostium. Administering general anesthesia with positive pressure ventilation in TD carries the risk of diverticulum rupture, leading to complications. To mitigate these risks, it is crucial to seal/bypass the ostium using an endotracheal tube (ETT) cuff, which may require deeper placement. Deeper placement can increase the likelihood of unintended endobronchial intubation, particularly in patients with a short trachea. We describe here the fiberoptic bronchoscopy-assisted technique of intubation, where the TD ostium was successfully identified and sealed using a single-lumen ETT cuff in a 60-year-old man who underwent C4-T1 intramedullary tumor excision with an incidental TD. Anesthesiologists should have a detailed knowledge of the size, location of the ostium, the extent of TD, and its compressive effects on the trachea, which enables them to select an appropriate intubation technique using a correct size ETT to seal/bypass the orifice while preventing complications.
Acute pulmonary thromboembolism (PTE) is a life-threatening complication. Although uncommon, acute PTE can develop silently during prolonged immobility associated with long-duration surgery, particularly in high-risk patients. Prompt diagnosis and effective management can help in salvaging such patients. Here, we present the case of a 40-year-old African female who developed acute PTE soon after turning the patient from prone to supine position with continuous monitoring following spinal fusion surgery. This case report highlights an unusual presentation of acute PTE, which was managed successfully by both the neuroanesthesia and cardiac sciences teams. An integrated, multidisciplinary team approach was the key to her revival.
Cerebral arteriovenous malformations (AVMs) during pregnancy pose significant risks of hemorrhage, requiring careful multidisciplinary management. The optimal anesthetic and obstetric strategies remain unclear due to limited data. We report two cases of pregnant women with cerebral AVMs managed by a multidisciplinary team. Both patients underwent close neurological and fetal monitoring and elective cesarean deliveries under spinal anesthesia combined with norepinephrine infusion to maintain hemodynamic stability. The first case involved a primigravida with a large, unruptured right parietal AVM presenting with headache and transient visual symptoms. The second was a secundigravida presenting with seizures and subacute hemorrhages. Both deliveries were uneventful, with stable mean arterial pressures maintained intraoperatively, no hypertensive surges, and favorable maternal and neonatal outcomes. Postpartum plans included further neurovascular evaluation. These cases highlight the importance of individualized, multidisciplinary care in managing cerebral AVMs during pregnancy. Spinal anesthesia with norepinephrine infusion provided stable hemodynamic control and allowed continuous neurological monitoring, potentially reducing rupture risk. Further research is needed to establish standardized protocols.
Multimodal neuromonitoring plays a pivotal role in the prevention of perioperative stroke during microsurgical occlusion of an aneurysm. Several modalities are available for the same, and by appropriately combining them, depending on the vascular territory of interest, their diagnostic precision can be maximized. Any intraoperative change in evoked potentials during aneurysm clipping should be addressed immediately. A root cause analysis using a checklist can identify and rectify reversible causes, avoiding morbidity. In this report, we present a case of surgical clipping of a right middle cerebral artery aneurysm where the intraoperative somatosensory-evoked potential changes occurred secondary to an ipsilateral extradural hemorrhage. This is the first report describing such a rare phenomenon, and addressing it promptly led to a complete neurological recovery.
Pneumocephalus following spinal surgery is a rare but significant complication, particularly in procedures involving durotomy. Its nonspecific presentation can be mistaken for anesthesia-related effects, delaying diagnosis. We report a 70-year-old female who underwent D4 laminectomy and excision of a D3-D4 intradural extramedullary tumor. In the immediate postoperative period, she developed progressively worsening frontal headache and nausea, unresponsive to standard analgesia. A computed tomography scan on postoperative day 1 revealed pneumocephalus in the basal cisterns and Sylvian fissures. Despite no evident cerebrospinal fluid leak after watertight closure or intraoperative nitrous oxide use, factors such as subtle dural microleaks, intraoperative head elevation, and the use of a subfascial drain may have contributed to intracranial air entry. Vacuum activation of the drain, though not confirmed, could not be ruled out. Conservative management with supine positioning, oxygen therapy, analgesics, and early drain removal led to full symptom resolution. This case highlights the need for early recognition of pneumocephalus in patients with severe postoperative headache particularly as headache severity has been shown to correlate with the extent of pneumocephalus. Heightened awareness and preventive intraoperative strategies are essential to mitigate this risk.
Background Sitting position used to be a favored position for posterior fossa surgery. Its use has declined owing to the increased incidence of life-threatening complications. Our center continues to practice sitting craniotomy, although less frequently. This study aimed to determine the incidence of perioperative complications during sitting craniotomy. Methods Medical records of 206 patients who underwent posterior fossa surgery in sitting position over a 10-year period were analyzed. Data on demographics, perioperative complications, and neurological status were recorded. Statistical analysis was done using the chi-square and the Wilcoxon rank-sum tests, and a p -value of < 0.05 was considered significant. Results Out of 206 eligible patients, 188 had near-complete data. A declining trend was observed in the use of the sitting position. Thirty-nine patients presented with episodes of venous air embolism (VAE) with an incidence of 20.7%. No correlation was found between cerebrospinal fluid draining procedures or previous craniotomy and the development of VAE. None of the patients reported other perioperative complications except one who developed tension pneumocephalus. Intraoperative brainstem handling was the most common reason (72%) for postoperative mechanical ventilation. At discharge, 166 (88.3%) patients had good neurological outcomes, while poor outcomes were seen in 4 and mortality in 15 (7.9%), respectively. Conclusion The incidence of perioperative complications with the sitting position was not unusually high to prevent its routine use. Moreover, the development of VAE was not associated with increased complications or patient mortality risk. The use of sitting craniotomy, while debatable, continues to be safe in expert hands.
Introduction Postoperative cognitive dysfunction (POCD) is a serious issue in geriatric patients undergoing general anesthesia procedures. Perioperative cognitive function assessment is vital for selecting anesthesia techniques in elderly patients. Methods This pretest-posttest cohort study assessed the effect of general anesthesia on POCD in geriatric patients >= 60 years from three government hospitals in Medan. Cognitive function was measured using the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment Indonesian version (MoCA-Ina) tests 1 day before and 3 days after surgery. Results Thirty-six patients were included, with an average age of 65.42 +/- 4.23 years. The majority were female (52.8%), with a high school education (50%), and worked as farmers/laborers (25%). The average surgery duration was 150 +/- 39.93 minutes. A significant decrease in MMSE (26.83 +/- 1.5 vs. 26.58 +/- 1.44) and MoCA-Ina (27.28 +/- 1.06 vs. 27.05 +/- 1.01) scores was observed 3 days postoperatively ( p < 0.05), with high correlation between the two tests (97.2%; p > 1.00). Conclusion General anesthesia significantly affects POCD in geriatric patients based on MMSE and MoCA-Ina scores.
Deep brain stimulation (DBS) for essential tremor (ET) poses challenges for both neurosurgeons and neuroanesthetists. ET with prominent postural and action tremors may respond better to DBS targeting the caudal zona incerta (cZI) than the traditional ventral intermediate nucleus. A key intraoperative concern is identifying the pyramidal tract side effect (PTSE) threshold, as a low threshold limits the therapeutic window. During awake DBS, macrostimulation helps assess benefits and side effects, including PTSE. Under general anesthesia (GA), however, patient feedback is unavailable. In such cases, intraoperative electromyography (EMG) can detect PTSE responses. We report a case of medication-refractory ET, treated with cZI-targeted DBS under GA. EMG monitoring successfully detected stimulation-induced PTSE, allowing estimation of the threshold without patient input. This highlights the value of EMG in asleep DBS for optimizing lead placement and minimizing side effects when awake testing is not possible.
