Correspondence
Priscilla Nelson, MD* W. Andrew Kofke, MD, MBAw *Lankenau Medical Center wUniversity of Pennsylvania Philadelphia, PA
REFERENCES 1. Nelson P, Nelson JA, Chen AJ, et al. An alternative position for the BIS-Vista montage in frontal approach neurosurgical cases. J Neurosurg Anesthesiol. 2013;25:135–142. 2. Dahaba AA, Xue JX, Zhao GG, et al. BISvista occipital montage in patients undergoing neurosurgical procedures during propofol-remifentanil anesthesia. Anesthesiology. 2010;112:645–651. 3. Hall JD, Lockwood GG. Bispectral index: comparison of two montages. Br J Anaesth. 1998;80:342–344.
Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache
J Neurosurg Anesthesiol
origin, which was thought to be connected only to the upper cervical nerve roots. This was also shown in the study by Persson et al2 who reported that the vast majority of patients with headache had lower cervical root pathology. Shay Shabat, MD Spinal Care Unit Sapir Medical Center St. Kfar-Saba, Israel
REFERENCES 1. Shabat S, Leitner J, Folman Y. Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache. J Neurosurg Anesthesiol. 2013;25:340–343. 2. Persson LC, Carlsson JY, Anderberg L. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J. 2007;16:953–959.
The Need for Development of Protocol for Managing Refractory Cerebral Vasospasm
In Reply: I read with great interest the letter to the editor regarding our manuscript.1 In their correspondence, Dr. Chatterjee and Dr. Roy state that a detailed clinical examination of the shoulder region along with cervical spine could have given a valuable insight to the diagnosis (shoulder pathology vs. radiculopathy). Indeed, such a detailed examination was performed but was not reported as it was not the focus of the study. The radiofrequency procedure was applied to the patients only after a shoulder pathology was ruled out, and a cervical pathology was confirmed by a combination of physical examination and imaging studies. Of course, most patients with distal cervical root pathology have “classical” radiculopathy along the hand distribution, and these patients were treated with nerve root blocks or pulsed radiofrequency procedures of the affected nerve roots. In our study, the main essence was to demonstrate that the lower cervical nerve roots are sometimes responsible for headache from cervical spine
To the Editor: We highly appreciate Anand et al1 for their interesting report on management of refractory cerebral vasospasm with high doses of nimodipine and milrinone (both intravenous and intra-arterial route) in postcoiling patient. However, we have few issues to be addressed in this context. First, it is important to know about the mean arterial pressure (MAP) of this patient, as induced hypertension may be the best possible option among triple H (hypertension, hypervolemia, and hemodilution) therapy for the treatment and prevention of the vasospasm.2 Second, there also exist other potential pharmaceutical agents such as nicardipine, verapamil (intra-arterial), and magnesium (intravenous), which can be used in such situation.3,4 Especially combination of these agents may reduce the dose of each agent and thereby may reduce the chances of side effects such as arterial hypotension. Third, the
The author has no funding or conflicts of interest to disclose.
The authors have no funding or conflicts of interest to disclose.
264 | www.jnsa.com
Volume 26, Number 3, July 2014
stellate ganglion block has been described in refractory cases and can be given as twice/thrice daily on alternate site.5 Such a therapy can be used directly in the angiography suite under fluoroscopic guidance so that preinjection and postinjection effects can be seen. Endovascular therapies (with intra-arterial medications) are currently recommended as optional rescue strategies for patients that do not adequately respond to medical therapy.3,4 There are some noteworthy issues regarding the management of cerebral vasospasm. There should be some defined criteria to start enthusiastic management of vasospasm. Generally, it is the development of focal neurological symptoms or deterioration of consciousness, which governs this specific treatment option.2,3 Whether the presence of vasospasm diagnosed with angiography or transcranial Doppler should be treated aggressively or not, is still a matter of debate. Oral and intravenous nimodipine is a standard of care; however, if this therapy does not work alone, one should consider other alternatives.2–4 In addition, patients who remain refractory to combined therapies may be developing or experiencing infarct-associated changes with other sequelae of subarachnoid hemorrhage, such as early brain injury or delayed ischemia.2,3 Neurological monitoring is of great importance in these cases and should include speech testing, motor power, etc. at frequent intervals (1 to 2 hourly in first 24 h postoperatively). If there is intraoperative rupture or evidence of vasospasm, these patients are likely to develop vasospasm postoperatively; hence, such patients will require more vigilance and monitoring. In general, we recommend a protocol comprised of the following steps: (1) induced hypertension (MAP = 20% to 30% above baseline), avoidance of hypotension, nimodipine (oral or intravenous), correction of electrolytes; (2) secondline drugs: diltiazem, verapamil, nicardipine, milrinone, and magnesium; (3) combination of above drugs; and (4) refractory cases or frequent failures—stellate ganglion block (2 or 3 times a day at alternate site). r
2014 Lippincott Williams & Wilkins
Priscilla Nelson, MD* W. Andrew Kofke, MD, MBAw *Lankenau Medical Center wUniversity of Pennsylvania Philadelphia, PA
REFERENCES 1. Nelson P, Nelson JA, Chen AJ, et al. An alternative position for the BIS-Vista montage in frontal approach neurosurgical cases. J Neurosurg Anesthesiol. 2013;25:135–142. 2. Dahaba AA, Xue JX, Zhao GG, et al. BISvista occipital montage in patients undergoing neurosurgical procedures during propofol-remifentanil anesthesia. Anesthesiology. 2010;112:645–651. 3. Hall JD, Lockwood GG. Bispectral index: comparison of two montages. Br J Anaesth. 1998;80:342–344.
Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache
J Neurosurg Anesthesiol
origin, which was thought to be connected only to the upper cervical nerve roots. This was also shown in the study by Persson et al2 who reported that the vast majority of patients with headache had lower cervical root pathology. Shay Shabat, MD Spinal Care Unit Sapir Medical Center St. Kfar-Saba, Israel
REFERENCES 1. Shabat S, Leitner J, Folman Y. Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache. J Neurosurg Anesthesiol. 2013;25:340–343. 2. Persson LC, Carlsson JY, Anderberg L. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J. 2007;16:953–959.
The Need for Development of Protocol for Managing Refractory Cerebral Vasospasm
In Reply: I read with great interest the letter to the editor regarding our manuscript.1 In their correspondence, Dr. Chatterjee and Dr. Roy state that a detailed clinical examination of the shoulder region along with cervical spine could have given a valuable insight to the diagnosis (shoulder pathology vs. radiculopathy). Indeed, such a detailed examination was performed but was not reported as it was not the focus of the study. The radiofrequency procedure was applied to the patients only after a shoulder pathology was ruled out, and a cervical pathology was confirmed by a combination of physical examination and imaging studies. Of course, most patients with distal cervical root pathology have “classical” radiculopathy along the hand distribution, and these patients were treated with nerve root blocks or pulsed radiofrequency procedures of the affected nerve roots. In our study, the main essence was to demonstrate that the lower cervical nerve roots are sometimes responsible for headache from cervical spine
To the Editor: We highly appreciate Anand et al1 for their interesting report on management of refractory cerebral vasospasm with high doses of nimodipine and milrinone (both intravenous and intra-arterial route) in postcoiling patient. However, we have few issues to be addressed in this context. First, it is important to know about the mean arterial pressure (MAP) of this patient, as induced hypertension may be the best possible option among triple H (hypertension, hypervolemia, and hemodilution) therapy for the treatment and prevention of the vasospasm.2 Second, there also exist other potential pharmaceutical agents such as nicardipine, verapamil (intra-arterial), and magnesium (intravenous), which can be used in such situation.3,4 Especially combination of these agents may reduce the dose of each agent and thereby may reduce the chances of side effects such as arterial hypotension. Third, the
The author has no funding or conflicts of interest to disclose.
The authors have no funding or conflicts of interest to disclose.
264 | www.jnsa.com
Volume 26, Number 3, July 2014
stellate ganglion block has been described in refractory cases and can be given as twice/thrice daily on alternate site.5 Such a therapy can be used directly in the angiography suite under fluoroscopic guidance so that preinjection and postinjection effects can be seen. Endovascular therapies (with intra-arterial medications) are currently recommended as optional rescue strategies for patients that do not adequately respond to medical therapy.3,4 There are some noteworthy issues regarding the management of cerebral vasospasm. There should be some defined criteria to start enthusiastic management of vasospasm. Generally, it is the development of focal neurological symptoms or deterioration of consciousness, which governs this specific treatment option.2,3 Whether the presence of vasospasm diagnosed with angiography or transcranial Doppler should be treated aggressively or not, is still a matter of debate. Oral and intravenous nimodipine is a standard of care; however, if this therapy does not work alone, one should consider other alternatives.2–4 In addition, patients who remain refractory to combined therapies may be developing or experiencing infarct-associated changes with other sequelae of subarachnoid hemorrhage, such as early brain injury or delayed ischemia.2,3 Neurological monitoring is of great importance in these cases and should include speech testing, motor power, etc. at frequent intervals (1 to 2 hourly in first 24 h postoperatively). If there is intraoperative rupture or evidence of vasospasm, these patients are likely to develop vasospasm postoperatively; hence, such patients will require more vigilance and monitoring. In general, we recommend a protocol comprised of the following steps: (1) induced hypertension (MAP = 20% to 30% above baseline), avoidance of hypotension, nimodipine (oral or intravenous), correction of electrolytes; (2) secondline drugs: diltiazem, verapamil, nicardipine, milrinone, and magnesium; (3) combination of above drugs; and (4) refractory cases or frequent failures—stellate ganglion block (2 or 3 times a day at alternate site). r
2014 Lippincott Williams & Wilkins
