J Neurosurg Anesthesiol
Dube et al
FIGURE 1. Periodic lateralized epileptiform discharges-PLEDs (highlighted) in raw electroencephalogram (EEG) waveform with abnormally high bispectral index of 74.
isolation, this report illustrates the utility of the real-time raw EEG waveforms that can be obtained from the BIS monitor, and in this situation, prompting a formal EEG evaluation. Matthew Smith, FRCA Patrick Dobbs, FRCA George Eapen, FRCA, FFICM Sheffield Teaching Hospitals Sheffield, UK
REFERENCES 1. Hernandez-Fernandez F, Fernandez-Diaz E, Pardal-Fernandez J, et al. Periodic lateralized epileptiform discharges as manifestation of pneumococcal meningoencephalitis. Int Arch Med. 2011;4:23. 2. Pedersen G, Rasmussen S, Gyllenborg J, et al. Prognostic value of periodic electroencephalographic discharges for neurological patients with profound disturbances of consciousness. Clin Neurophysiol. 2013;124:44–51. 3. Fishman O, Legatt A. PLEDs following control of seizures and at the end of life. Clin EEG Neurosci. 2010;41:11.
left eye ball, and tinnitus in the left ear since the past 3 months. He had a history of road traffic accident for which he underwent repair of mandibular and maxillary fracture under anesthesia. The patient was diagnosed to have a left carotico-cavernous fistula (CCF) with venous drainage into ipsilateral cavernous sinus and inferior petrosal sinus and a significant steal in ipsilateral middle cerebral artery and anterior cerebral artery territories. He was scheduled for balloon occlusion of the CCF under monitored anesthesia care. In the neuroradiologic suite standard monitors were attached and femoral artery was cannulated for the procedure under local anesthetic infiltration. Two balloons were used for complete occlusion of the high-flow CCF (Fig. 1). The patient had stable hemodynamics throughout the procedure, which lasted
Volume 27, Number 1, January 2015
for 150 minutes and he received 8 mg of intravenous (IV) dexamethasone 30 minutes before completion of the procedure. The proptosis was visibly reduced after of the procedure. Ten minutes later, the patient complained of nausea and vomiting. The blood pressure, electrolytes, neurological status, and computed tomographic scan of the head were normal. Ondansetron (6 mg) was administered intravenously (IV) but without any relief to the episodes of nausea and vomiting. However, these episodes later responded to an injection of propofol 20 mg IV. The patient was then shifted to ICU for observation during which he remained asymptomatic for 4 to 5 hours. This was followed by recurrence of nausea and vomiting albeit with reduced severity. The patient received second dose of dexamethasone and ondansetron. Next morning, the computed tomography scan and fluoroscopic imaging confirmed correct position of the balloon. The patient continued to have nausea and vomiting but with each passing day, the severity and frequency was diminished and completely subsided on fifth postprocedural day. Balloon occlusion is one of the therapeutic options for CCF.1 This case is probably the first report of isolated episodes of nausea and vomiting following the procedure. Subanesthetic doses of propofol have been used to treat intractable nausea and vomiting, which was also used in our patient.2 Nakashima et al3 reported abducens nerve palsy, headache, vomiting, and convulsion in a patient with high-flow
Intractable Nausea and Vomiting Following Balloon Occlusion of Carotico-Cavernous Fistula To JNA Readers: A 19-year-old male patient weighing 60 kg presented with prominent veins on forehead, protrusion of The authors have no funding or conflicts of interest to disclose.
74 | www.jnsa.com
FIGURE 1. X-ray image showing balloon occlusion of carotico-cavernous fistula.
r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 27, Number 1, January 2015
posttraumatic CCF, which subsided gradually within a week following intervention. Hyperperfusion of cerebral circulation was thought to be responsible for these symptoms. Our patient had a high-flow CCF with significant steal in the middle cerebral artery and anterior cerebral artery territories. The most probable cause of nausea and vomiting was the increase in intracranial pressure following normal perfusion pressure breakthrough. This explanation is further supported by gradual reduction in symptoms over the period of 5 days, which correlates with the time when the cerebral vasculature adapts to the change in regional cerebral blood flow. With this report it has been emphasized that the episodes of nausea and vomiting could be a manifestation of normal perfusion pressure breakthrough. Hence, appropriate management with this regard should be initiated in patients presenting with persistent nausea and vomiting following balloon occlusion of CCF. Surya K. Dube, Arati Rai, Meyong P. Bhuttia, Girija P. Rath, MD,
MD MD MD DM
Department of Neuroanaesthesiology A.I.I.M.S., New Delhi, India
REFERENCES 1. Gemmete JJ, Chaudhary N, Pandey A, et al. Treatment of carotid cavernous fistulas. Curr Tr Options Neurol. 2010;12:43–53. 2. Gan TJ, Glass PS, Howell ST, et al. Determination of plasma concentrations of propofol associated with 50% reduction in postoperative nausea. Anesthesiology. 1997;87:779–784. 3. Nakashima H, Tomita T, Nakayama K, et al. A case of atypical course after balloon occlusion for high flow traumatic carotid-cavernous fistula. No to Shinkei. 1995;47:177–181.
Apnea During Awake Epilepsy Surgery: An Unusual Cause for a Rare Complication To JNA Readers: Awake craniotomy is occasionally used to safely excise seizure focus The authors have no funding or conflicts of interest to disclose r
2014 Lippincott Williams & Wilkins
with preservation of vital functions. However, intraoperative problems such as seizure, brain swelling, and cardiopulmonary changes during awake surgery can lead to adverse consequences.1 We describe a previously unreported complication of apnea during awake craniotomy for surgical treatment of refractory seizures. A 16-year-old boy, a musician by training, with a known diagnosis of medically refractory seizures was scheduled for awake surgical management. Preoperative evaluation included video electroencephalogram, magnetic resonance imaging (MRI), neuropsychiatric assessment, positron emission tomography, and functional MRI, apart from routine laboratory assessment. Awake surgery was planned to preserve his music function, which appeared to be located close to seizure focus on fMRI study. After instituting standard monitors, scalp block was performed with 30 mL of combined 1% lignocaine and 0.25% bupivacaine. Dexmedetomidine infusion was started at skin incision and maintained at 0.2 to 0.6 mg/kg/h during the procedure. Dexmedetomidine was temporarily stopped during intraoperative electrocorticography (ECOG) and to facilitate assessment of motor and musical function (both singing and listening to different tones [ragas] to evaluate discrimination/ interpretation ability to various previously familiar ragas). Restricted anterior temporal lobectomy was performed after ascertaining preservation of music functions. As seizure activity persisted during the depth electrode monitoring of ECOG, amygdalo-hippocampectomy was planned. Dexmedetomidine was restarted during resection of hippocampus at 0.25 mg/kg/h. Several minutes later, following uneventful amygdalectomy, there was a sudden apnea associated with bradycardia (heart rate decreased from 72 to 56 beats/min) during hippocampal resection (Fig. 1). There was no significant change in the spectral entropy values. Following cessation of surgical stimulus, spontaneous respiration resumed within 25 seconds. Suspecting ictal apnea, levetiracetam 1 g and phenytoin 200 mg were administered intravenously and the resection completed uneventfully.
Correspondence
The probable explanation for this previously unreported observation is seizure-associated apnea. Although ECOG was not being monitored at that time, there was no significant change in entropy waveform/values that was continuously monitored. Although it is possible that, frontal entropy did not record seizure activity, especially after anterior temporal lobectomy, electrical seizure during surgical stimulation of hippocampus might have resulted in apnea. Apnea during seizures is reported to be caused by functional disruption of hippocampus and/or mesial or basal temporal cortex. Excitation in these cortical areas following seizures descend through amygdalar or hippocampal connections to pontine respiratory centers and disturb normal breathing control.2 In our case, surgical stimulation and irritation of hippocampus during resection might have resulted in induction of seizure in a previously predisposed region, resulting in bradycardia and apnea. If unrecognized, apnea and bradycardia can result in sudden unexplained death in epilepsy.3 A recent study has shown that apnea and bradycardia occur more frequently during ictal seizures in children than in adults.4 This response is not appreciated when epilepsy surgery is performed under general anesthesia and controlled ventilation, although bradycardia is occasionally seen.5 To conclude, heightened vigilance should be maintained during awake epilepsy surgery. Administration of antiepileptic drugs and/or general anesthesia before resection of hippocampus might prevent occurrence of such episodes. Kamath Sriganesh, MD, DNB, DM Bhoil Sabina, MD Madhusudan Reddy, MD Department of Neuroanaesthesia NIMHANS Bangalore Karnataka, India
REFERENCES 1. Skucas AP, Artru AA. Anesthetic complications of awake craniotomies for epilepsy surgery. Anesth Analg. 2006;102:882–887. 2. Hoogstraate SR, Lequin MH, Huysman MA, et al. Apnoea in relation to neonatal temporal lobe haemorrhage. Eur J Paediatr Neurol. 2009;13:356–361.
www.jnsa.com |
75
Dube et al
FIGURE 1. Periodic lateralized epileptiform discharges-PLEDs (highlighted) in raw electroencephalogram (EEG) waveform with abnormally high bispectral index of 74.
isolation, this report illustrates the utility of the real-time raw EEG waveforms that can be obtained from the BIS monitor, and in this situation, prompting a formal EEG evaluation. Matthew Smith, FRCA Patrick Dobbs, FRCA George Eapen, FRCA, FFICM Sheffield Teaching Hospitals Sheffield, UK
REFERENCES 1. Hernandez-Fernandez F, Fernandez-Diaz E, Pardal-Fernandez J, et al. Periodic lateralized epileptiform discharges as manifestation of pneumococcal meningoencephalitis. Int Arch Med. 2011;4:23. 2. Pedersen G, Rasmussen S, Gyllenborg J, et al. Prognostic value of periodic electroencephalographic discharges for neurological patients with profound disturbances of consciousness. Clin Neurophysiol. 2013;124:44–51. 3. Fishman O, Legatt A. PLEDs following control of seizures and at the end of life. Clin EEG Neurosci. 2010;41:11.
left eye ball, and tinnitus in the left ear since the past 3 months. He had a history of road traffic accident for which he underwent repair of mandibular and maxillary fracture under anesthesia. The patient was diagnosed to have a left carotico-cavernous fistula (CCF) with venous drainage into ipsilateral cavernous sinus and inferior petrosal sinus and a significant steal in ipsilateral middle cerebral artery and anterior cerebral artery territories. He was scheduled for balloon occlusion of the CCF under monitored anesthesia care. In the neuroradiologic suite standard monitors were attached and femoral artery was cannulated for the procedure under local anesthetic infiltration. Two balloons were used for complete occlusion of the high-flow CCF (Fig. 1). The patient had stable hemodynamics throughout the procedure, which lasted
Volume 27, Number 1, January 2015
for 150 minutes and he received 8 mg of intravenous (IV) dexamethasone 30 minutes before completion of the procedure. The proptosis was visibly reduced after of the procedure. Ten minutes later, the patient complained of nausea and vomiting. The blood pressure, electrolytes, neurological status, and computed tomographic scan of the head were normal. Ondansetron (6 mg) was administered intravenously (IV) but without any relief to the episodes of nausea and vomiting. However, these episodes later responded to an injection of propofol 20 mg IV. The patient was then shifted to ICU for observation during which he remained asymptomatic for 4 to 5 hours. This was followed by recurrence of nausea and vomiting albeit with reduced severity. The patient received second dose of dexamethasone and ondansetron. Next morning, the computed tomography scan and fluoroscopic imaging confirmed correct position of the balloon. The patient continued to have nausea and vomiting but with each passing day, the severity and frequency was diminished and completely subsided on fifth postprocedural day. Balloon occlusion is one of the therapeutic options for CCF.1 This case is probably the first report of isolated episodes of nausea and vomiting following the procedure. Subanesthetic doses of propofol have been used to treat intractable nausea and vomiting, which was also used in our patient.2 Nakashima et al3 reported abducens nerve palsy, headache, vomiting, and convulsion in a patient with high-flow
Intractable Nausea and Vomiting Following Balloon Occlusion of Carotico-Cavernous Fistula To JNA Readers: A 19-year-old male patient weighing 60 kg presented with prominent veins on forehead, protrusion of The authors have no funding or conflicts of interest to disclose.
74 | www.jnsa.com
FIGURE 1. X-ray image showing balloon occlusion of carotico-cavernous fistula.
r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 27, Number 1, January 2015
posttraumatic CCF, which subsided gradually within a week following intervention. Hyperperfusion of cerebral circulation was thought to be responsible for these symptoms. Our patient had a high-flow CCF with significant steal in the middle cerebral artery and anterior cerebral artery territories. The most probable cause of nausea and vomiting was the increase in intracranial pressure following normal perfusion pressure breakthrough. This explanation is further supported by gradual reduction in symptoms over the period of 5 days, which correlates with the time when the cerebral vasculature adapts to the change in regional cerebral blood flow. With this report it has been emphasized that the episodes of nausea and vomiting could be a manifestation of normal perfusion pressure breakthrough. Hence, appropriate management with this regard should be initiated in patients presenting with persistent nausea and vomiting following balloon occlusion of CCF. Surya K. Dube, Arati Rai, Meyong P. Bhuttia, Girija P. Rath, MD,
MD MD MD DM
Department of Neuroanaesthesiology A.I.I.M.S., New Delhi, India
REFERENCES 1. Gemmete JJ, Chaudhary N, Pandey A, et al. Treatment of carotid cavernous fistulas. Curr Tr Options Neurol. 2010;12:43–53. 2. Gan TJ, Glass PS, Howell ST, et al. Determination of plasma concentrations of propofol associated with 50% reduction in postoperative nausea. Anesthesiology. 1997;87:779–784. 3. Nakashima H, Tomita T, Nakayama K, et al. A case of atypical course after balloon occlusion for high flow traumatic carotid-cavernous fistula. No to Shinkei. 1995;47:177–181.
Apnea During Awake Epilepsy Surgery: An Unusual Cause for a Rare Complication To JNA Readers: Awake craniotomy is occasionally used to safely excise seizure focus The authors have no funding or conflicts of interest to disclose r
2014 Lippincott Williams & Wilkins
with preservation of vital functions. However, intraoperative problems such as seizure, brain swelling, and cardiopulmonary changes during awake surgery can lead to adverse consequences.1 We describe a previously unreported complication of apnea during awake craniotomy for surgical treatment of refractory seizures. A 16-year-old boy, a musician by training, with a known diagnosis of medically refractory seizures was scheduled for awake surgical management. Preoperative evaluation included video electroencephalogram, magnetic resonance imaging (MRI), neuropsychiatric assessment, positron emission tomography, and functional MRI, apart from routine laboratory assessment. Awake surgery was planned to preserve his music function, which appeared to be located close to seizure focus on fMRI study. After instituting standard monitors, scalp block was performed with 30 mL of combined 1% lignocaine and 0.25% bupivacaine. Dexmedetomidine infusion was started at skin incision and maintained at 0.2 to 0.6 mg/kg/h during the procedure. Dexmedetomidine was temporarily stopped during intraoperative electrocorticography (ECOG) and to facilitate assessment of motor and musical function (both singing and listening to different tones [ragas] to evaluate discrimination/ interpretation ability to various previously familiar ragas). Restricted anterior temporal lobectomy was performed after ascertaining preservation of music functions. As seizure activity persisted during the depth electrode monitoring of ECOG, amygdalo-hippocampectomy was planned. Dexmedetomidine was restarted during resection of hippocampus at 0.25 mg/kg/h. Several minutes later, following uneventful amygdalectomy, there was a sudden apnea associated with bradycardia (heart rate decreased from 72 to 56 beats/min) during hippocampal resection (Fig. 1). There was no significant change in the spectral entropy values. Following cessation of surgical stimulus, spontaneous respiration resumed within 25 seconds. Suspecting ictal apnea, levetiracetam 1 g and phenytoin 200 mg were administered intravenously and the resection completed uneventfully.
Correspondence
The probable explanation for this previously unreported observation is seizure-associated apnea. Although ECOG was not being monitored at that time, there was no significant change in entropy waveform/values that was continuously monitored. Although it is possible that, frontal entropy did not record seizure activity, especially after anterior temporal lobectomy, electrical seizure during surgical stimulation of hippocampus might have resulted in apnea. Apnea during seizures is reported to be caused by functional disruption of hippocampus and/or mesial or basal temporal cortex. Excitation in these cortical areas following seizures descend through amygdalar or hippocampal connections to pontine respiratory centers and disturb normal breathing control.2 In our case, surgical stimulation and irritation of hippocampus during resection might have resulted in induction of seizure in a previously predisposed region, resulting in bradycardia and apnea. If unrecognized, apnea and bradycardia can result in sudden unexplained death in epilepsy.3 A recent study has shown that apnea and bradycardia occur more frequently during ictal seizures in children than in adults.4 This response is not appreciated when epilepsy surgery is performed under general anesthesia and controlled ventilation, although bradycardia is occasionally seen.5 To conclude, heightened vigilance should be maintained during awake epilepsy surgery. Administration of antiepileptic drugs and/or general anesthesia before resection of hippocampus might prevent occurrence of such episodes. Kamath Sriganesh, MD, DNB, DM Bhoil Sabina, MD Madhusudan Reddy, MD Department of Neuroanaesthesia NIMHANS Bangalore Karnataka, India
REFERENCES 1. Skucas AP, Artru AA. Anesthetic complications of awake craniotomies for epilepsy surgery. Anesth Analg. 2006;102:882–887. 2. Hoogstraate SR, Lequin MH, Huysman MA, et al. Apnoea in relation to neonatal temporal lobe haemorrhage. Eur J Paediatr Neurol. 2009;13:356–361.
www.jnsa.com |
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