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CONFERENCE PROCEEDINGS
Cerebral oedema: Pathophysiological mechanisms and experimental therapies
Shalvi Mahajan, Hemant Bhagat
January 2016, 3(4):22-28
DOI:10.4103/2348-0548.174731  
  26,364 3,543 -
REVIEW ARTICLES
Anaesthetic considerations for evoked potentials monitoring
Parmod Kumar Bithal
January-April 2014, 1(1):2-12
DOI:10.4103/2348-0548.124832  
Intra-operative neurophysiologic monitoring (IONM) under anaesthesia has achieved popularity because it helps prevent/minimize neurologic morbidity from surgical manipulations of various neurologic structures. Neurologic functions in an anaesthetised patient can be monitored either by electroencephalography (EEG) or by evoked potentials. Whereas, EEG is difficult to analyse, evoked potentials, in contrast, are easy to interpret, they are either present or absent, delayed or not delayed, with normal or abnormal wave. The goal of IONM is to identify changes in nervous system function prior to irreversible damage. Many factors need consideration when selecting an anaesthetic regimen for intra-operative monitoring of evoked potentials. The very pathophysiological condition or the potential risks of the contemplated surgical procedure, which require evoked potentials monitoring, may place constraints on anaesthetic management as well. With the availability of numerous anaesthetic techniques, an appropriate plan for managing both anaesthesia and IONM in a patient should be organised. It is extremely essential not to alter the pharmacological state of the patient to avoid any changes in the recording of evoked responses. While an anaesthesiologist may alter plans for a patient in order to facilitate IONM, monitoring team too, sometimes may be required to modify plans for monitoring when a particular anaesthetic agent or technique is strongly indicated or contraindicated. At times, compromise may be required between an anaesthesia technique and a monitoring technique. To serve patients' best interest, it is critical to have a team approach and good communication among the neurophysiologist, anaesthesiologist and surgeon.
  14,872 2,589 4
REVIEW ARTICLES
Intracranial pressure monitoring
Mary Abraham, Vasudha Singhal
September-December 2015, 2(3):193-203
DOI:10.4103/2348-0548.165039  
Brain specific monitoring enables detection and prevention of secondary cerebral insults, especially in the injured brain, thereby preventing permanent neurological damage. Intracranial pressure (ICP) monitoring is widely used in various neurological, neurosurgical and even medical conditions, both intraoperatively and in critical care, to improve patient outcome. It is especially useful in patients with traumatic brain injury, as a robust predictor of cerebral perfusion, and can help to guide therapy and assess long-term prognosis. Intraventricular catheters remain the gold standard for ICP monitoring, as they are the most reliable, accurate and cost-effective, and allow therapeutic cerebrospinal fluid drainage. Newer fibreoptic catheter tip and microchip transducer techniques have revolutionised ICP monitoring, with their ease of insertion in patients with narrow ventricles, and reduced risk of infection and haemorrhage. Furthermore, non-invasive methods of ICP monitoring, such as transcranial Doppler, optic nerve sheath diameter, etc., have emerged as promising techniques for screening patients with raised ICP in settings where invasive techniques are either not feasible (patients with severe coagulopathy) or not available (setups without access to a neurosurgeon). Therefore, ICP monitoring, as a part of multi-modality neuromonitoring, is a useful tool in the armamentarium of the neuro-intensivist in decreasing morbidity and mortality of critically ill neurological patients.
  13,655 2,798 -
LETTERS TO EDITOR
Does bradycardia and hypertension always equal to Cushing's response during supratentorial craniotomy?
Ramamani Mariappan, Samuel D Chandran
May-August 2016, 3(2):155-156
DOI:10.4103/2348-0548.182339  
  15,219 253 -
REVIEW ARTICLES
Perioperative management of patients with pituitary tumours
Mary Abraham
September-December 2016, 3(3):211-218
DOI:10.4103/2348-0548.190066  
Management of pituitary tumours can be very challenging for the anaesthesiologist. These patients require a thorough pre-operative assessment in view of underlying endocrine disturbances, which could cause anatomic and physiological disturbances. This needs to be optimized prior to surgery and the anaesthetic technique planned accordingly. The main intraoperative problems that could be encountered by the anaesthesiologist are airway problems, haemodynamic disturbances and potential for bleeding during surgery. The postoperative concerns are related to the endocrine system and fluid and water balance and this needs to be monitored closely and managed appropriately. The advent of minimally invasive surgery along with neuroimaging has considerably decreased perioperative morbidity and mortality following pituitary surgery. A team approach and close coordination between the endocrinologist, neurosurgeon and anaesthesiologist is imperative for a favourable outcome in patients undergoing pituitary surgery.
  11,237 2,292 -
CONFERENCE PROCEEDINGS
Fluid management during neurosurgical procedures
Zulfiqar Ali, Hemanshu Prabhakar
January 2016, 3(4):35-40
DOI:10.4103/2348-0548.174733  
  10,784 1,855 -
ORIGINAL ARTICLES
Intensive care management of Guillain-Barre syndrome: A retrospective outcome study and review of literature
Hemant Bhagat, Hari Hara Dash, Rajendra S Chauhan, Puneet Khanna, Parmod Kumar Bithal
September-December 2014, 1(3):188-197
DOI:10.4103/2348-0548.139106  
Introduction: Guillain-Barre syndrome (GBS) is an immune mediated disorder which is associated with demyelination of peripheral nervous system and progressive muscle weakness. Severely affected patients have respiratory dysfunction and may need ventilatory support which can cause significant morbidity and mortality. There is limited Indian data with regards to the outcome of severely affected GBS patients. The present study reflects the intensive care management of severely affected GBS patients at neurological centre of a tertiary care institute of India. Materials and Methods: The study was designed to retrospectively review the patient records who were admitted to neurological intensive care unit (ICU) of AIIMS, New Delhi. The epidemiology, clinical features, course of management and outcome of GBS patients admitted between April 2000 to December 2005 were recorded and analysed. Results: The data of 59 patients were available for inclusion in the study. The mean age of patients admitted to neurological ICU was 35 years with male preponderance. Ventilatory failure was the most common indication for ICU admission. 95% patients required ventilatory support for a mean duration of 30 days. The mortality data included 60 patients and 13 patients died during the course of management. Conclusions: The present study indicates that severely affected GBS patients may need prolonged mechanical ventilation. Despite management in a specialized neurological ICU the mortality can be as high as 21%.
  9,953 1,600 -
REVIEW ARTICLES
Intensive care management of status epilepticus
Nidhi Gupta
May-August 2016, 3(2):83-95
DOI:10.4103/2348-0548.182344  
Status epilepticus (SE) is a life-threatening neurological emergency that requires prompt diagnosis and treatment. SE may be classified into convulsive and non-convulsive types, based on the presence of rhythmic jerking of the extremities. Clinically, tonic-clonic convulsive SE (CSE) is divided into four subsequent stages: Early, established, refractory and super-refractory. Initial elements of resuscitation include airway protection, haemodynamic resuscitation and seizure control. Further treatment should then be guided by the diagnostic workup. Rapid treatment of early SE is achieved with intravenous (IV) lorazepam or intramuscular midazolam. In established SE, IV antiepileptic drugs (AEDs) (phenytoin/fosphenytoin, valproate, levetiracetam, phenobarbital) are most commonly used, but there is no Class I evidence for choosing one over the other. Considered overall, cumulative data from the literature are consistent with valproate and levetiracetam, being a safe and effective therapeutic alternative to phenobarbital and phenytoin for treatment of established SE. Refractory SE (RSE) and super-RSE are treated with anaesthetic medications (propofol, midazolam, thiopental/pentobarbital, ketamine), non-anaesthetic drugs (lidocaine, magnesium, pyridoxine), AEDs (levetiracetam, lacosamide, topiramate, lacosamide, pregabalin, gabapentin) and other cause-directed treatments with low success rates. Potential non-pharmacologic interventions to be considered in super-RSE include hypothermia, electroconvulsive therapy, ketogenic diet, immunomodulatory treatments, emergency resective epilepsy surgery, cerebrospinal fluid drainage and vagal nerve or deep brain stimulation or transcranial magnetic stimulation. Diagnosis of non-CSE requires continuous electroencephalography and involves a high index of suspicion in all patients with an altered mental status of unclear cause or with a prolonged postictal state. Treatment options include addressing underlying causes and aggressive pharmacologic interventions with a benzodiazepine, phenytoin and valproate.
  9,298 2,105 -
'ROSE concept' of fluid management: Relevance in neuroanaesthesia and neurocritical care
Joseph N Monteiro, Shwetal U Goraksha
January-April 2017, 4(1):10-16
DOI:10.4103/2348-0548.197435  
Fluid therapy in neurosurgical patients aims to restore intravascular volume, optimise haemodynamic parameters and maintain tissue perfusion, integrity and function. The goal is to minimise the risk of inadequate cerebral perfusion pressure and to maintain good neurosurgical conditions. However, fluid management in brain-injured patients has several distinctive features compared with non-brain-injured critically ill patients. The ROSE concept advocates the restriction of fluids, which is consistent with the prevention of a 'tight brain' in neurosurgery. Whether this imbalance in fluid management studies between different types of brain injuries is a reflection of differences in clinical relevance of fluid management is not clear. Further randomised controlled trials in the future are essential in subarachnoid haemorrhage and traumatic brain injury patients who are critical and need long-term Intensive Care Unit stay to elucidate and define the role and relevance of the ROSE concept in neuroanaesthesia and neurocritical care.
  8,157 2,156 1
CONFERENCE PROCEEDING
Outcome and rehabilitation of patients following aneurysmal subarachnoid haemorrhage
Dhaval P Shukla
February 2017, 4(4):65-75
DOI:10.4103/2348-0548.199952  
Aneurysmal subarachnoid haemorrhage (SAH) is a dreaded neurosurgical disorder. Although the mortality has been declining in the past three decades, the disability after SAH is still significant. The main determinants of outcome are age, clinical grade, amount of SAH and size of aneurysm. Both neurophysical deficits and neuropsychological impairments are determinants of functional outcome after SAH. Patients should be assessed using outcome measures for both traumatic brain injury and stroke. Early rehabilitation after SAH improves not only physical outcome but also cognitive and functional outcome.
  7,751 701 -
REVIEW ARTICLES
Neurosurgery and pregnancy
Rajkumar Subramanian, Arijit Sardar, S Mohanaselvi, Puneet Khanna, Dalim K Baidya
September-December 2014, 1(3):166-172
DOI:10.4103/2348-0548.139095  
Pregnant patients rarely present with neurosurgical emergencies, but can cause significant morbidity and mortality to the mother and the foetus. Physiological changes of pregnancy in relevance to neurosurgery, effects of anaesthetic agents on the foetus, common neurosurgical emergencies, and anaesthetic implications both from obstetric and neurosurgical point of view are discussed in this review.
  6,285 2,017 -
REVIEW ARTICLES
Cerebral salt wasting syndrome
Harshal Dholke, Ann Campos, C Naresh K Reddy, Manas K Panigrahi
September-December 2016, 3(3):205-210
DOI:10.4103/2348-0548.190065  
Traumatic brain injury (TBI) is on the rise, especially in today's fast-paced world. TBI requires not only neurosurgical expertise but also neurointensivist involvement for a better outcome. Disturbances of sodium balance are common in patients with brain injury, as the central nervous system plays a major role in sodium regulation. Hyponatraemia, defined as serum sodium <135 meq/L is commonly seen and is especially deleterious as it can contribute to cerebral oedema in these patients. Syndrome of inappropriate antidiuretic hormone secretion (SIADH), is the most well-known cause of hyponatraemia in this subset of patients. Cerebral Salt Wasting Syndrome (CSWS), leading to renal sodium loss is an important cause of hyponatraemia in patients with TBI. Although incompletely studied, decreased renal sympathetic responses and cerebral natriuretic factors play a role in the pathogenesis of CSWS. Maintaining a positive sodium balance and adequate hydration can help in the treatment. It is important to differentiate between SIADH and CSWS when trying to ascertain a case for patients with acute brain injury, as the treatment of the two are diametrically opposite.
  6,798 1,433 -
Jugular venous oximetry
Avanish Bhardwaj, Hemant Bhagat, Vinod K Grover
September-December 2015, 2(3):225-231
DOI:10.4103/2348-0548.165046  
The measurement of saturation of venous blood as it drains out of brain by sampling it from the jugular bulb provides us with an estimate of cerebral oxygenation, cerebral blood flow and cerebral metabolic requirement. Arterio-jugular venous difference of the oxygen content (AVDO 2 ) and jugular venous oxygen saturation (SjVO 2 ) values per se helps clinicians in identifying the impairment of cerebral oxygenation due to various factors thereby prompting implementation of corrective measures and the prevention of secondary injury to the brain due to ischaemia. SjVO 2 values are also used for prognostication of patients after traumatic brain injury and in other clinical situations. Sampling and measuring SjVO 2 intermittently or continuously using fibreoptic oximetry requires the tip of the catheter to be placed in the jugular bulb, which is a relatively simple bedside procedure. In the review below we have discussed the relevant anatomy, physiology, techniques, clinical applications and pitfalls of performing jugular venous oximetry as a tool for measurement of cerebral oxygenation.
  6,679 1,492 -
BRIEF REPORTS
Post-operative complications in patients undergoing anterior cervical discectomy and fusion: A retrospective review
Rahul Yadav, Siddharth Chavali, Arvind Chaturvedi, Girija P Rath
September-December 2017, 4(3):170-174
DOI:10.4103/jnacc.jnacc_18_17  
Background: Anterior cervical discectomy and fusion (ACDF) is a surgical procedure used to manage various cervical spine disorders including spondylosis, prolapsed intervertebral disc, trauma and degenerative disc disease. However, this procedure may be associated with significant post-operative complications. In this study, we aimed to analyse the prevalence of post-operative complications following ACDF. Methods: Perioperative data of 128 patients who underwent ACDF surgery at our institute over a 3-year period was analysed. Patients who underwent previous neck surgeries were excluded. Results: Single level ACDF without cervical plating was observed to be the most commonly performed surgical procedure (53%). Dysphagia was the most common (16.4%) post-operative complaint, followed by neurological deterioration (7.9%). One patient suffered pharyngeal perforation and presented postoperatively with subcutaneous emphysema and haemoptysis. Conclusions: Post-operative dyphagia and worsening of pre-existing myelopathy were the most common complications following ACDF, and multilevel surgery was identified as the most significant risk factor. The early detection and prompt management may help reduce mortality and morbidity in such patients.
  7,448 541 -
CONFERENCE PROCEEDING
Optic nerve sheath diameter: A novel way to monitor the brain
Seelora Sahu, Amlan Swain
February 2017, 4(4):13-18
DOI:10.4103/jnacc.jnacc_73_16  
Measurement and monitoring of intracranial pressure is pivotal in management of brain injured patients. As a rapid and easily done bed side measurement, ultrasonography of the optic nerve sheath diameter presents itself as a possible replacement of the conventional invasive methods of intracranial pressure management. In this review we go through the evolution of optic nerve sheath diameter measurement as a novel marker of predicting raised intracranial pressure, the modalities by which it can be measured as well as its correlation with the invasive methods of intracranial pressure monitoring.
  6,606 1,097 -
REVIEW ARTICLE
Understanding the physiological changes induced by mannitol: From the theory to the clinical practice in neuroanaesthesia
Wilson Fandino
September-December 2017, 4(3):138-146
DOI:10.4103/jnacc.jnacc_31_17  
In this narrative review, the current evidence for the use of mannitol in neuroanaesthesia is presented, with focus on its pharmacokinetics and its main physiologic effects. Mannitol is a naturally occurring polyol that undergoes no biotransformation and is freely filtered in the kidney. Due to its strong osmotic effects, it induces key physiological changes, mainly in the cardiovascular system, the kidney and the brain. While it is clear that hypertonic solutions are effective in the treatment of intracranial hypertension in patients with acute brain injury, the role of mannitol in the context of intracranial haemorrhage, acute stroke and brain relaxation remains controversial. Furthermore, it possesses important side effects including acute kidney injury and electrolyte imbalances, particularly related to high doses in predisposing patients. Other aspects including the capability to modify neurological outcomes, the impact on mortality, the utility in patients with disrupted blood–brain barrier and the alternative use of hypertonic saline are also discussed. Further research is needed to make clear recommendations on these aspects.
  5,867 1,608 -
REVIEW ARTICLES
Anaesthesia for awake craniotomy
Girija Prasad Rath, Charu Mahajan, Parmod Kumar Bithal
September-December 2014, 1(3):173-177
DOI:10.4103/2348-0548.139098  
Awake craniotomy is a neurosurgical procedure during which the patient remains awake as a whole or during some part of the surgery. Although not a new procedure, it has regained its importance since last two decades following the advent of newer drugs along with improvised techniques. The role of anesthesiologist during this procedure is of paramount importance. In this review, we discussed the anesthetic management during awake craniotomy and re-emphasized on the avoidance of intraoperative untoward events with appropriate patient selection.
  6,023 1,444 1
BRIEF REPORT
Vasoplegic syndrome: A challenge to anaesthetic management
Amarjyoti Hazarika, Gyaninder P Singh, Vishwas Malik, Parmod K Bithal
May-August 2015, 2(2):139-141
DOI:10.4103/2348-0548.155467  
Perioperative hypotension is a well-recognized and relatively common problem during surgery. Vasoplegic syndrome is one such condition which is characterized by severe persistent hypotension with normal to high cardiac output and low systemic resistance. It is commonly seen in patients undergoing cardiac surgery on cardiopulmonary bypass. However, this syndrome has also been reported in off pump surgeries. Management of intraoperative hypotension may be challenging for an anaesthesiologist, if it does not respond or poorly respond to conventional therapy. We report the management of a hypertensive patient posted for spine surgery in prone position, who developed severe hypotension under anaesthesia refractory to treatment.
  6,589 863 -
CASE REPORTS
Wolff-Parkinson-White syndrome: Implications for an anaesthesiologist
Vinaya Udaybhaskar, C Sreemayee, Prasad Ingley
January-April 2017, 4(1):49-52
DOI:10.4103/2348-0548.197447  
Wolff-Parkinson-White (WPW) syndrome is an electrical conduction abnormality of the heart that can induce potentially fatal arrhythmias at intermittent intervals. The induction and maintenance of general anaesthesia for a patient with WPW syndrome are risky due to the triggering capability of arrhythmias by various drugs and instrumentation. We hereby present the case of a 28-year-old male with previous cardiac illness, admitted for neurosurgical procedure, with drug-controlled WPW syndrome. The pre-operative optimisation, intraoperative scrutiny and vigil, along with readiness of standby medications and defibrillator made the ingress and egress from general anaesthesia uneventful. Thus, the potential dangers of WPW syndrome can be circumvented with watchful preparedness and meticulous monitoring.
  6,820 619 -
REVIEW ARTICLES
What is optimal in patients with myasthenic crisis: Invasive or non-invasive ventilation?
Hemant Bhagat, Vinod K Grover, Kiran Jangra
May-August 2014, 1(2):116-120
DOI:10.4103/2348-0548.130388  
Myasthenia gravis is an immune disorder involving the neuromuscular junction. The consequent weakness of respiratory muscles leads to variable disorders of ventilation in patients with myasthenia gravis. This article reviews the options of invasive and non-invasive ventilation in patients with advanced form of the disease.
  6,324 965 -
CONFERENCE PROCEEDING
Critical care of subarachnoid haemorrhage
Michael J Souter
February 2017, 4(4):49-55
DOI:10.4103/jnacc.jnacc_75_16  
Subarachnoid haemorrhage (SAH) is a consistent presentation of haemorrhagic stroke of significance to clinicians in neurocritical care, inducing consequent effects on non-neurological systems, while at the same time, rendering the brain vulnerable to secondary physiological insult modifying neurological outcome, despite control of the original point of haemorrhage. Coordinated treatment depends on comprehensive evaluation of both cerebral and systemic physiology, identifying and treating impaired function. The presence of a dedicated neurocritical care team can benefit outcome. Protocols of care have evolved to meet evidence-based challenges, discarding potentially deleterious components of hypervolaemia and haemodilution, while maintaining pressure-guided perfusion. Treatment targets have also evolved with a shift in focus away from SAH-associated vasospasm, towards actual ischaemic outcome - illustrated by lack of effectiveness of pharmaceutical treatments of vasospasm. Clinicians must consequently review pathophysiological mechanisms of injury and devise new treatment opportunities.
  5,514 1,551 -
REVIEW ARTICLES
Protecting the anaesthetised brain
Mary Abraham
January-April 2014, 1(1):20-39
DOI:10.4103/2348-0548.124841  
The anaesthetized brain is vulnerable to ischaemic insults, which could result in neurological deficits ranging from neuropsychological disturbances to stroke and even death. The risk of perioperative brain injury is relatively high in cardiac, neurosurgical and major vascular surgery, although it has also rarely been reported in noncardiac nonneurosurgical operations. Besides underlying risk factors such as cerebrovascular disease, advanced age, and cardiovascular disease, anaesthesia and surgery per se could also be a contributory factor. The anaesthesiologist plays a pivotal role in protecting the anaesthetized brain, both by taking preventive measures and instituting brain protection strategies. Despite advances and breakthroughs in pharmacological neuroprotection in the laboratory, currently there is no drug, anaesthetic or non-anaesthetic, which is available for clinical use. The anaesthesiologist has to rely on non-pharmacological modalities and neuromonitoring to prevent intraoperative brain injury
  5,638 1,200 -
EDITORIAL
Dexmedetomidine: Its fascination, fad, and facts in neuroanaesthesia practice!
Sethuraman Manikandan
September-December 2014, 1(3):163-165
DOI:10.4103/2348-0548.139091  
  3,385 3,415 1
REVIEW ARTICLES
Current neuromonitoring techniques in critical care
Anette Ristic, Raoul Sutter, Luzius A Steiner
May-August 2015, 2(2):97-103
DOI:10.4103/2348-0548.154234  
Early detection of secondary events is a major target of neuromonitoring in critically ill patients. Intracranial pressure (ICP) and cerebral perfusion pressure are the most widely accepted neuromonitoring parameters. Many studies have shown both to be related to mortality after traumatic brain injury. However, the benefit of ICP monitoring has not been established by a randomized controlled trial, and the efficacy of ICP-guided management has indeed been challenged. This review considers current neuromonitoring techniques in critical care medicine.
  5,340 1,362 -
ORIGINAL ARTICLES
Anaesthetic management of patients undergoing surgery for Moyamoya disease - our institutional experience
Vivek B Sharma, Hemanshu Prabhakar, Girija Prasad Rath, Parmod K Bithal
May-August 2014, 1(2):131-136
DOI:10.4103/2348-0548.130399  
Background: Moyamoya disease (MMD) is a chronic cerebrovascular disorder, defined as the progressive stenosis or occlusion of the intracranial vessels. Because of the insecure cerebral circulation, these patients represent an anaesthetic challenge. Literature is scarce on the anaesthetic management of MMD, especially from the Indian subcontinent. The main objective of our study was to evaluate the peri-operative course and outcome of patients undergoing surgery for MMD. Materials and Methods: We analysed available medical records of all patients who underwent revascularisation surgeries for MMD over a period of 10 years (January 2002 to June 2012). Various intra- and post-operative data related to anaesthesia were recorded. The patients for the analysis were divided into two groups: Group 1, paediatrics (<18 years) and group 2, adults (≥18 years). Data are presented as number (%) or mean ± SD or median (range). Results: There were 36 patients (12 adults and 24 children). Normotension, normovolaemia, normo- or mild-hypercapnia and normothermia were maintained in all patients. No patient developed complications or new neurological deficit in the post-operative period. All patients were discharged with a full Glasgow coma scale (GCS) and no new neurologic deficit. Conclusion: Although the incidence of MMD is not high in India, it is an important cause of cerebral stroke in children and adults. Proper pre-operative evaluation is the most effective method to achieve good results. Anaesthetic management of MMD should focus on the maintenance of adequate cerebral blood flow and cerebral perfusion pressure ensuring adequate cerebral oxygenation to avoid ischaemic complications.
  5,454 824 1
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