Adverse reactions to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine depict a tropism for neural structures. This narrative review was aimed to discuss published data on the spectrum of neurological side effects of SARS-CoV-2 vaccines, which were accorded emergency use authorization. The majority of the neurological manifestations of SARS-CoV-2 vaccination are usually mild, brief, self-limiting, and easily manageable. Rarely, these side effects can be of serious nature and require hospitalization. High vigilance helps in early identification and treatment of these complications leading to good outcomes. The reported incidence of neurological complications in vaccinated population is a miniscule, and the overall benefits of the vaccine outweigh the risks of side effects. However, it is crucial to conduct larger collaborative multicenter studies to prove or reject the causal association between the SARS-CoV-2 vaccines and the postvaccination neurological side effects. Herein, we have tried to summarize the various neurological manifestations related to SARS-CoV-2 vaccines published in the literature from 2021 to mid-2023.

Moderate to severe traumatic brain injury (TBI) represents one of the most important causes of death and disability. Although morbidity and mortality in these patients are principally due to their primary pathology, non-neurological complications, including respiratory dysfunction, are frequent contributors. Therefore, all TBI patients with moderate and severe brain damage are managed with invasive mechanical ventilation. Notwithstanding the fact that mechanical ventilation to support respiration is a life-saving intervention in critically ill patients, weaning becomes progressively more difficult with the increasing duration of ventilation. Ventilator-induced diaphragmatic dysfunction (VIDD) is believed to be one of the major contributors to the weaning difficulties in intensive care unit (ICU) patients. It significantly influences the duration of mechanical ventilation, weaning failure, morbidity, and mortality. The combination of prolonged mechanical ventilation and the effects of extended immobility in the ICU causes significant changes to muscle fibers, reducing both respiratory and peripheral muscle strength.[1] Administration of muscle relaxants and/or steroids in mechanically ventilated patients further exaggerates the VIDD. The prevalence of diaphragm dysfunction has been reported to be twofold higher than the prevalence of ICU-acquired weakness.[2] Although VIDD has received considerable attention in critically ill patients in general ICU, it has not attracted sufficient diligence in the moderate to severe TBI patient population despite their requirement for prolonged mechanical ventilation.[3]

Every academic society desires to have an official mouthpiece in the form of a scientific journal. The Indian Society of Neuroanaesthesiology and Critical Care (ISNACC), established in 1999 and registered with the Society of Registrar at Delhi-NCR on October 24, 2001, is no different. The decision to start a journal by the ISNACC was not a very smooth affair. It took 15 long years after ISNACC was established to make a decision in this context. The usual concerns of possible failure in maintaining continuity after initiation were there in the minds of the members. For the first time, it was discussed at length during the general body meeting (GBM) at the Convention Center of National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, on the side lines of the 5th Annual Conference of the ISNACC (2004). The first Newsletter Editor of ISNACC, Dr. Neelam Ganguly of Sir Ganga Ram Hospital, New Delhi, mentioned that the newsletter would be converted to a regular journal in the future. It was also decided to publish scientific articles twice a year in the newsletter as part of that plan. Subsequently, Prof. Hari Hara Dash, Founder President of ISNACC, was tasked with creating a newsletter that formulated the idea of a journal. After a long gap, in the 2011 ISNACC mid-term executive meeting at Bhopal, Dr. Pragati Ganjoo of GB Pant Hospital, Delhi, raised the issue; however, most members felt it was too early to initiate a journal.

Background: Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Materials and Methods: Forty patients of 18–65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. Results: The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. Conclusions: This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. Clinical Trial Registry: CTRI/2016/10/007350.

Moyamoya disease (MMD) is caused by stenosis or occlusion of internal carotid artery in brain, thereby reducing its blood supply. To augment blood flow, brain develops abnormal anastomotic vessels with deranged carbon dioxide reactivity and tendency to bleed. Moyamoya syndrome (MMS) is the name given to MMD when the latter results from secondary to some associated disease. Occurrence of MMS secondary to sickle cell anemia (SCA) presents unique challenges to neuroanesthesiologists. Management of various physiological parameters for cerebral revascularization surgery for MMD under general anesthesia necessitates vigilant and balanced control of various physiological variables, as the manipulation of a particular physiological variable for one pathology may adversely impact the same physiological variable for the associated disease, which will result in poor outcome of the patient. Therefore, optimum outcome of MMS is determined by a watchful balancing of various physiological parameters under anesthesia.

Extravasation injury (EVI) is an iatrogenic complication of venous cannulation. Usually innocuous but occasionally it engenders sequelae. Its severity is determined by various physicochemical properties of infusate. A 50-year-old patient developed leg EVI from crystalloids infused through a pressurized digital infuser (PDI), likely from cannula tip displacement during positioning for craniotomy. We ignored checking gravity-aided free-fluids flow before switching on PDI. Following surgery, the patient had an edematous leg with bullae and epidermal peelings from severe extravasation and burns, respectively. Doppler revealed patent leg arteries. Therefore, EVI was conservatively managed, with complete recovery. Apparently, increased local tissue pressure from extravasation produced conditions of peripheral circulation sufficiency predisposing the leg to thermal injury from the forced-air warmer. On inspecting PDI postoperatively, its upper-pressure alarm limit was 300 mmHg, which prevented it from sounding alarm during extravasation.

infection, malnutrition, dehydration, tracheostomy, longer hospitalization longer intensive care unit (ICU) stays, contractures, and heterotopic ossification. PSH remains an under-recognized condition that is difficult to diagnose. A high index of suspicion is key to early diagnosis. The first step in diagnosis is to exclude conditions with similar symptoms, such as infection, sedation withdrawal, seizures, and pulmonary embolism. Clinical diagnostic tools (PSH assessment measure) have been proposed to assist clinicians in the reliable identification of PSH.8 Such tools incorporate a clinical feature scale that categorizes the severity of sympathetic signs during episodes and a diagnostic tool that gauges the likelihood of diagnosis of PSH based on the presence of characteristic features. These two components are combined in a score that reflects the degree of confidence in diagnosis of PSH. The feasibility and reliability of these tools have been recently validated by van Eijck et al.9 There is evidence that they may reduce the chances of misdiagnosis and favorably impact hospital length of stay and costs of hospitalization.10 The pathophysiology of PSH is poorly understood and the dominant theory suggests the failure of the central autonomic network. Disruption of descending pathways releases sympathetic responses from their normal inhibitory modulation. The consequence is that sympathetic responses to internal or external stimuli become exaggerated.11 The interruption of descending inhibitory modulation might also produce maladaptive changes in the spinal cord leading to excitatory interneuronal activity.12 These changes could help explain how non-noxious stimuli are perceived as noxious by brain.12 While formal evidence on treatment is scant and lacks methodological quality, PSH is a disorder that can be treated.13 Can episodes be prevented with pharmacological intervention? There is at least one retrospective study that claims so. Tang et al asserted that dexmedetomidine infusion has Paroxysmal sympathetic hyperactivity (PSH) is a syndrome of excessive and pathological adrenergic output to nociceptive or non-nociceptive (including environmental) stimuli. It is observed as a complication of various acute brain insults such as traumatic brain injury (TBI), stroke, anoxic brain injury, tumors, infections, autoimmune encephalitis, and acute hydrocephalus. It can manifest as a constellation of episodic, simultaneous symptoms such as tachycardia, hyperthermia, hypertension, tachypnea, and diaphoresis, often accompanied by dystonia and even motor posturing.1 Onset of these symptoms is usually fast, but resolution is slow, unless terminated by medication. Since the first description of this syndrome by Penfield,2 many names have been ascribed to it which has created puzzlement in its diagnosis as well as understanding of its pathophysiology. Some of the names associated with this condition over the years are “autonomic storm,” “sympathetic storm,” “hypothalamic dysregulation syndrome,” and “paroxysmal autonomic instability with dystonia.” In 2014, the International Brain Injury Association proposed the term “paroxysmal sympathetic hyperactivity.”3 Its overall incidence is 18% among various cohorts of patients admitted in neurocritical care with an incidence of 33% in severe TBI patients.4 According to Perkes et al, 80% of cases of PSH are observed after TBI, and the remaining 20% following other cerebral pathologies.5 The most consistent observation is that patients with PSH are frequently young and comatose. Pediatric patients appear more prone to develop PSH after anoxic–ischemic insults and with non-bacterial encephalitis.6 It is common that patients with PSH are erroneously suspected of having other diagnoses, and this may lead to unnecessary testing and sometimes inappropriate treatments, making an early and accurate diagnosis important.7 PSH may persist for weeks or months, and has been associated with worse clinical outcomes such as increased time of mechanical ventilation,

In the absence of cardiac pathology, premature ventricular contractions (PVCs) in neurosurgical patients frequently accompany subarachnoid hemorrhage, intracerebral hemorrhage, traumatic brain injury, or raised intracranial pressure. PVCs detected during preanesthesia assessment prompts detailed cardiac evaluation. Our 57-year-old patient, a case of left frontal meningioma, with controlled hypertension, diabetes and hypothyroidism, had normal preoperative ECG and potassium. However, immediately on anesthesia induction, she developed multiple refractory to treatment PVCs but with normal blood pressure. Anesthesia, which was maintained with sevoflurane and fentanyl, was deepened to exclude light anesthesia as the cause, without useful outcome. Two lignocaine boluses (100 mg each), followed by its infusion, also proved ineffective. Her blood gases and potassium, checked twice, were normal. Throughout, her hemodynamics remained stable. As soon as tumor was removed, the PVCs disappeared not to return. Her postoperative recovery was uneventful with normal ECG.

A 35-year-old female presented with headache in the third week postpartum period following uneventful cesarean delivery. She had left sided ptosis, pain, and numbness over left face since third trimester. Post-delivery magnetic resonance imaging revealed invading left sphenoid sinus meningioma. She was planned for combined endonasal and pterional craniotomy. Her preoperative investigations including sodium, glucose, and liver functions were normal. Intraoperatively during endonasal phase a high urine output (UO) with rising sodium were noticed which continued with worsening sodium (156 mEq/L after 3 h). Desmopressin 1 mcg IV administered which normalized UO for the rest of surgical duration with trends of declining sodium (149 mEq/L at the end of procedure). Her postoperative MRI was normal however desmopressin could not be discontinued because of increasing sodium and UO without it. She was discharged on oral desmopressin, hydrocortisone and levothyroxine. On her follow-up 3.5 months later she had normal sodium and normal UO.

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 (CLVAI) and before extubation (CLVBE). Statistical Analysis and Results CLG was significantly less in group G (group S, 137.12mL; group G, 65.52mL; 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.

Background: Surgeries in prone position expose a patient to multitude of complications including laryngeal edema which may be related to the volume of fluid administered. Administering larger volumes of fluid intraoperatively may contribute to significant tissue edema, leading many anesthesiologists to practice a restrictive fluid infusion strategy. Although previous studies have compared fluid infusion strategies, changes in airway dimensions leading to airway edema have not been extensively investigated. Here, we compared two fluid infusion regimens in patients undergoing spine surgery in the prone position, and assessed their association with airway edema by means of the cuff leak test (CLT). Aims: The aim of this study was to test the hypothesis whether a larger volume of crystalloid administration in spine surgeries performed in prone position would result in greater chances of airway edema, than would a restricted infusion policy, utilizing the CLT. Materials and Methods: After ethical committee approval, thirty patients, aged 21–60 years, American Society of Anesthesiologists Status I or II, scheduled for elective spine surgery in the prone position, were selected. Group 1 (restrictive group) received 3 mL.kg− 1.h− 1, whereas Group 2 (permissive group) received 5 mL.kg− 1.h− 1 of crystalloids plus urine output replacement. The airway edema was assessed by CLT which was performed soon after intubation (T1) and before extubation (T2). Cuff leak volume (CLV) was calculated from the difference in tidal volumes before (VTi) and after cuff deflation (VTe). Airway edema was evaluated by calculating the differences in the CLV at T1 and T2 (ΔCLV); the more the value of Δ CLV which means greater difference between these two points, the more the decrease in laryngeal lumen, signifying an increased risk of airway edema. Results: Decrease in laryngeal lumen was observed in patients who received permissive fluid regimen than that of the restrictive group, signifying more chances of airway edema in the former group. In addition, a poor correlation was found between the duration of anesthesia and development of airway edema in our study group. Conclusions: Because surgeries in the prone position are at risk of airway edema, restrictive fluid regimen strategy should be preferred over the liberal one as there are more chances of reduction in laryngeal lumen dimensions with permissive fluid infusions.

Maintenance of cerebral and spinal cord perfusion is the cornerstone for the safety of any neurosurgical procedure, and it depends upon stable hemodynamics.[ 1 ] Fluctuation in blood pressure (BP) in patients with impaired cerebral autoregulation may impact cerebral blood flow (CBF), and thus, perioperative morbidity and mortality.[ 2 ] Inadequate analgesia under general anesthesia (GA) is one major factor that causes episodic surges in BP. Anesthesiologists rely primarily on opioids for intraoperative analgesia during neurosurgery. Quick postoperative recovery after craniotomy is critically important and highly desirable. However, the opioids may delay recovery from anesthesia, thereby preventing immediate postoperative neurological assessment. Opioids may also cause respiratory depression with its attendant sequel, as well as postoperative nausea and vomiting (PONV).

Awake craniotomy (AC) is indicated to excise a lesion close to an eloquent area of the brain. Success of this procedure depends upon the patient's active participation during the awake phase of the surgery, especially for brain mapping. Occasionally, a patient may refuse to remain awake during the surgical procedure and demand general anesthesia (GA). A 27-year-old male with uncontrolled seizures from recurrent brain tumor near motor area refused to consent for AC citing his past unpleasant experience; so, the decision to administer GA was taken. To avoid straining/coughing on tracheal tube, his airway was anesthetized with transtracheal xylocaine, bilateral superior laryngeal nerve block, and inflation of tracheal tube cuff with xylocaine. GA was maintained with sevoflurane, infusion of fentanyl, and rocuronium. To awaken him, anesthetics were discontinued and rocuronium antagonized with sugammadex. Intravenous lignocaine and midazolam were administered to supress cough reflex and produce amnesia, respectively. He tolerated the entire duration of 30 minutes of brain mapping with electrocorticography and neurological testing comfortably. Upon completion of brain mapping, GA was reintroduced and the lesion excised. The surgical outcome was good with no neurological deficit. When interviewed postoperatively, the patient had no recall of the awake phase.

Artificial intelligence (AI) is the branch of computer science dealing with the simulation of intelligent behavior in computers.[1] Computers play a key role in almost every aspect of our daily life. In healthcare, computers are an excellent means of storage of patient-related data. The amount of data gleaned electronically from patients admitted in the intensive care units (ICUs) has been growing rapidly every day. Several equipment, such as pressure transducers, infusion pumps, electrocardiography (ECG), pulse oximeters, cardiac output monitors, fluids intake and output monitors, temperature, neurological examination, and mechanical ventilators, interface with computers and store electronic data. Similarly, a wealth of information is recorded from each patient in the ICU, including high-resolution physiological signals, various laboratory tests, and details of medical history in electronic health records (EHRs).[2] Computerized ICU systems interface, in turn, provide access to hospital database, including demographic, electronic patient records, order entry, laboratory, pharmacy, and radiological systems. To be of use, it is necessary that ICU bedside data must be extracted and organized to become information for clinical decisions.[3] AI can assist not only in administering repetitive patient assessment in real time, but also in integrating and interpreting these data source with EHR data, thus potentially enabling more timely and targeted interventions.[4] [5] Closed-loop AI systems can monitor parameters of patients; then, directly treat patients and induce changes in those very parameters that are undergoing monitoring. These systems can make direct real-time adjustments to patient care without any human input.[6] AI has proved effective in lowering cost, expanding access, and improving healthcare fields. The application of AI in medicine has been related to the development of AI programs, intended to help the clinician in the making of a diagnosis, adopting therapeutic decisions, and forecasting outcomes. It plays a pivotal role by forewarning impending complications, thereby resulting in a faster response by the clinician.[7] AI in an ICU setting could decrease clinicians’ as well as nurses’ workload, thereby allowing them to focus their attention on critical tasks. It could also augment human decision-making by offering low-cost, high-capacity intelligent data processing.

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.

The coronavirus (COVID-19) pandemic has ravaged India with more than 8.14 million patients having contracted it and nearly 122,000 fatalities being recorded at the time of penning this editorial. Although pandemics, by their very nature, have a global impact, the effects on population vary disproportionately, according to the prevailing socioeconomic conditions.[1] Countries that cannot guarantee social protection and equitable access to health care to their most vulnerable citizens run the risk of an extended and more severe pandemic.[2]

Fever is probably the most frequent symptom observed in neurointensive care by healthcare providers. It is seen in almost 70% of neurocritically ill patients. Fever of central origin was first described in the journal Brain by Erickson in 1939. A significant number of patients develop this fever due to a noninfectious cause, but are often treated as having an infectious fever. Unjustified use of antibiotics adds to the increased cost of treatment and the emergence of resistant strains, contributing to additional morbidity. Since fever has a detrimental impact on the recovery of the acutely injured brain and contributes to an increased stay in the neurointensive care unit (NICU), timely and accurate diagnosis of the cause of fever in the NICU is imperative. Here, we try to understand the underlying mechanism, risk factors, clinical characteristics, diagnosis and management options of the central fever. We also make an attempt to differentiate two noninfectious causes of fever in the NICU: paroxysmal sympathetic hyperactivity and central fever.

Acute postoperative sialadenitis, called “anesthesia mumps,” has been reported in different surgical procedures. It is usually benign in nature, and the swelling resolves spontaneously without any treatment in the majority of cases. The attending physician should be aware of this transient condition. Very rarely, serious complications can occur such as respiratory distress warranting urgent intervention. We report a case of acute transient sialadenitis in a 6-year-old child who underwent general anesthesia for upper gastrointestinal endoscopy, which resolved spontaneously without any treatment.

BACKGROUND:Spine surgery in prone position frequently results in pressure skin lesions (PSLs). No study from Arabic world has published their incidence in literature.METHODS:We retrospectively analyzed patients who underwent prone position spine surgery from December 1, 2017, to November 30, 2018. They received standardized anesthesia care and were made prone on Jackson table. The face was supported on a nonface contoured foam device, whereas the chest and pelvis were supported on soft cushions. Following completion of surgery, they were turned supine and their skin was inspected for any skin lesions. The lesions were categorized into five grades depending on severity.RESULTS:Data of 307 patients were analyzed. Their mean age and weight was 41.5 years and 71 kg, respectively. The mean duration of prone positioning was 470 min. One hundred and three PSLs were observed in 45 patients (14.7%), giving a PSL incidence of 43.7% in affected patients. Majority of patients (18, 40%) with lesions remained in prone position between 421 and 600 min. Multiple lesions were observed in 53.3% of the affected patients. The highest number of patients (21, 46.7%) had one lesion only and it was restricted to face. All lesions were of Grade I, II, or III. Body weight >71 kg was more prone to developing PSLs. Females were more prone to PSLs.CONCLUSION:PSLs in prone position spine surgery occur frequently, and their incidence is proportional to the duration of positioning and weight of the patients. Face is the most commonly affected area.