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Background: Renal autotransplantation is a complex procedure performed for various indications such as treatment of renal vascular and urologic lesions and loin pain hematuria syndrome (LPHS). Because of the rarity of the procedure, few reports have been published, and little is known about anesthetic management and postoperative outcomes of patients with LPHS. The goal of this study was to review and describe all cases of renal autotransplantation performed at Cleveland Clinic during a specified period, focusing on anesthetic management and postoperative 30-day outcomes. Methods:We performed a retrospective review of the records of all patients who underwent renal autotransplantation from2005 to 2014 at the Cleveland Clinic and collected demographic, anesthetic, surgical, and postoperative data. Results: A total of 64 patients underwent renal autotransplantation from 2005 to 2014. The most frequent indications were nephrolithiasis and LPHS. General endotracheal anesthesia with epidural for pain control was used in 47% of cases. Median duration of anesthesia was 528 minutes.Most patientswere sent to a regular nursing floor postoperatively, but 28% of patients required intensive care unit admission. Two patients developed graft ischemia, and 1 patient developed graft failure requiring nephrectomy. No anesthetic-related complications and no mortality were associated with this procedure during the study. Conclusion: Renal autotransplantation is a safe option for patients with LPHS. Additional studies are needed to assess the effect of intraoperative anesthetic management on outcomes in this patient population. [ABSTRACT FROM AUTHOR]

The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns. [ABSTRACT FROM AUTHOR]

A 68-year-old woman with acute ischemic stroke presented for mechanical thrombectomy, after failed thrombolysis with intravenous recombinant tissue plasminogen activator. The procedure was completed successfully with dexmedetomidine infusion. However, she developed acute angioedema toward the end of the procedure requiring emergent fiberoptic-guided endotracheal intubation. Angioedema has been reported to occur after administering intravenous recombinant tissue plasminogen activator with an incidence of 1.3%-5.1% in patients with acute stroke. [ABSTRACT FROM AUTHOR]

Background: Cushing's disease is a condition rarely encountered during pregnancy. It is known that hypercortisolism is associated with increased maternal and fetal morbidity and mortality. When hypercortisolism from Cushing's disease does occur in pregnancy, the impact of achieving biochemical remission on fetal outcomes is unknown. We sought to clarify the impact of successful surgical treatment by presenting such a case report. Case Description: A 38-year-old pregnant woman with recurrent Cushing's disease after 8 years of remission. The patient had endoscopic transsphenoidal of her pituitary adenoma in her 18th week of pregnancy. The patient had postoperative biochemical remission and normal fetal outcome with no maternal complications. Conclusion: Transsphenoidal surgery for Cushing's disease can be performed safely during the second trimester of pregnancy. [ABSTRACT FROM AUTHOR]

Abstract: The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n=101) to patients undergoing craniotomy under general anesthesia (group AS: n=77). Episodes of desaturation (AW=31% versus AS=1%, p <0.0001), although temporary, and hypercarbia (AW=43.75mmHg versus AS=32.75mmHg, p <0.001) were more common in the AW group. The mean arterial pressure during application of head clamp pins and emergence was significantly lower in AW patients compared to AS patients (pinning 91.47mmHg versus 102.9mmHg, p <0.05 and emergence 84.85mmHg versus 105mmHg, p <0.05). Patients in the AW group required less vasopressors intraoperatively (AW=43% versus AS=69%, p <0.01). Intraoperative fluids were comparable between the two groups. The post anesthesia care unit (PACU) administered significantly fewer intravenous opioids in the AW group. The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen. [Copyright &y& Elsevier]

Abstract: Antiepileptic drugs (AED) are known to cause coagulation disturbances. We retrospectively analyzed the effect of AED on coagulation parameters in children who underwent craniotomy for epilepsy surgery. A total of 84 children were included. Perioperative coagulation parameters, the number and type of AED, estimated blood loss and the amount of blood products transfused were recorded. The most commonly used AED was lamotrigine. Of all patients, 7.1% were taking valproate. None of the patients showed significantly abnormal prothrombin time, activated partial thromboplastin time, or platelet count preoperatively. Thirty-eight percent of patients were transfused with allogeneic red blood cells and 4.7% of all patients showed significant coagulopathy intraoperatively and postoperatively. We concluded that the number of AED does not appear to be associated with preoperative coagulation disorders or blood transfusion requirements. However, caution should be taken in patients taking AED who undergo complex brain epilepsy surgery due to the potential for significant blood loss. [Copyright &y& Elsevier]

Deep brain stimulation (DBS) of the subthalamic nucleus and globus pallidus is used to improve Parkinsonian symptoms and reduce levodopa-induced motor complications in Parkinson’s disease (PD). This procedure is usually performed with minimal or no sedation to allow accurate feedback from patients during surgery. Venous air embolism (VAE) has been previously reported in patients undergoing awake neurosurgical procedures for brain tumors or pallidotomy for PD. We describe a case of intraoperative VAE in an awake, supine patient while undergoing DBS surgery for PD who presented with coughing, tachypnea and hypoxemia. The difference in clinical presentation between VAE in awake vs. anesthetized patients is discussed as are intraoperative monitoring techniques and management options. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Unintentional intraoperative tracheal extubation can be potentially catastrophic, especially in patients with difficult airways. We describe a case in which extubation occurred during cervical spine decompression. Reintubation was facilitated with a Laryngeal Mask Airway and an Aintree intubation catheter. [Copyright &y& Elsevier]

Background Parkinson disease (PD), a neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra of the midbrain, is commonly thought of as a motion disorder, but it can have significant effect on the respiratory system. Respiratory failure is the most common cause of death in these patients, but it can also affect laryngeal function causing dysphonia, dysphagia, and dysarthric speech. Acute upper airway obstruction is a rare finding in PD, especially in the perioperative settings. In this article we report a PD patient who developed upper respiratory obstruction postoperatively. We also review the literature and highlight the importance of preoperative evaluation to identify patients who may be at risk of this complication. Case Description We describe a PD patient presenting for brain stimulation electrode implantation under general anesthesia, who postoperatively developed stridor and near complete upper airway obstruction despite maintenance of oral anti-Parkinson medication regimen intraoperatively. The patient was reintubated in post-anesthesia-care unit, and tracheostomy was performed after 1 week due to persistent vocal cord dysfunction. Conclusions Baseline vocal cord impairment in PD patients can be acutely aggravated perioperatively. Symptoms such as dysphagia and dysarthria, which can indicate susceptibility to postoperative upper airway obstruction, may not be well recognized by the patient and family. Surgical candidates should be carefully interviewed preoperatively, and watchful monitoring of respiratory function intraoperatively and postoperatively is of paramount importance. Neurosurgical and neuroanesthesia team should be aware of, and prepared to manage, this potentially life-threatening airway obstruction in PD patients. [ABSTRACT FROM AUTHOR]

Background Lumbar spinal surgery may be associated with electrophysiologic and hemodynamic abnormalities during the procedure. Case Description A 58-year-old man with grade II L4-5 spondylolisthesis and degenerative changes underwent single-level transforaminal lumbar interbody fusion. During decompression of the L4 foramina, distraction of the disc space, and placement of the interbody cage and pedicle screws, episodes of extreme bradycardia with up to 5 seconds of asystole were detected on electrocardiogram and invasive hemodynamic monitoring. The events correlated with and possibly could have been a result of traction on the dura mater. Conclusions Anesthesia providers should be aware of electrophysiologic and hemodynamic abnormalities during lumbar spinal surgery and the need to respond appropriately with sympathomimetic or vagolytic interventions. [ABSTRACT FROM AUTHOR]

Study Objective: Simulation-based learning is emerging as an alternative educational tool in this era of a relative shortfall of teaching anesthesiologists. The objective of the study is to assess whether screen-based (interactive computer simulated) case scenarios are more effective than problem-based learning discussions (PBLDs) in improving test scores 4 and 8 weeks after these interventions in anesthesia residents during their first neuroanesthesia rotation.Design: Prospective, nonblinded quasi-crossover study.Setting: Cleveland Clinic.Patients: Anesthesiology residents.Interventions: Two case scenarios were delivered from the Anesoft software as screen-based sessions, and parallel scripts were developed for 2 PBLDs. Each resident underwent both types of training sessions, starting with the PBLD session, and the 2 cases were alternated each month (ie, in 1 month, the screen-based intervention used case 1 and the PBLD used case 2, and vice versa for the next month).Measurements: Test scores before the rotation (baseline), immediately after the rotation (4 weeks after the start of the rotation), and 8 weeks after the start of rotation were collected on each topic from each resident. The effect of training method on improvement in test scores was assessed using a linear mixed-effects model.Main Results: Compared to the departmental standard of PBLD, the simulation method did not improve either the 4- or 8-week mean test scores (P = .41 and P = .40 for training method effect on 4- and 8-week scores, respectively). Resident satisfaction with the simulation module on a 5-point Likert scale showed subjective evidence of a positive impact on resident education.Conclusions: Screen-based simulators were not more effective than PBLD for education during the neuroanesthesia rotation in anesthesia residency. [ABSTRACT FROM AUTHOR]

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The frequency of duplex ultrasound screening (DUS) for deep vein thrombosis (DVT) in patients with brain tumors undergoing craniotomy is center-specific. We evaluated clinical conditions that increase the tendency to perform DUS, focusing on tumor type., Methods: This is a single-center retrospective analysis to assess the association of intracranial tumor type with DVT as a major decision-making indicator for DUS. A primary analysis investigated the association between tumor pathology and preoperative DVT, and a secondary analysis investigated the development of DVT postoperatively. Confounding factors were defined and included in both analyses., Results: Among 1478 patients, 751 had preoperative DUS and 35 (5%) had DVT. No significant difference in the odds of preoperative DVT was observed between patients having malignant glioma versus benign tumors (odds ratio [OR; 95% CI]: 1.68 [0.65, 4.35], P = 0.29), or metastatic tumors versus benign tumors (OR: 2.10; 95% CI: 0.75-5.89; P = 0.16). Among patients with negative preoperative DUS, 93 underwent postoperative evaluation and 20 (22%) were diagnosed with postoperative DVT. Malignant glioma or (OR: 1.69; 95% CI: 0.36-7.84; P = 0.50) metastatic tumors (OR: 1.84; 95% CI: 0.29-11.5; P = 0.52) were not associated with postoperative DVT versus benign tumors., Conclusion: Brain tumor pathology may not increase the risk for DVT and may not be a good indicator for the selection of patients for DVT screening with DUS. The incidence of DVT in selective preoperative DUS was similar to studies that performed DUS on all patients. Further studies across multiple institutions are needed to develop criteria for DUS in brain tumor surgery., Competing Interests: R.A. is a member of the editorial board of the Journal of Neurosurgical Anesthesiology. He has received invited speaker honoraria, a SPARK Catalyst Grant for medical device Innovation and other patents with potential royalties, none of which are relevant to this study. The remaining authors have no conflicts of interest to declare., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Current management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts., Methods: The authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed., Results: A total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months., Conclusions: In this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.

Patients with medically intractable epilepsy often undergo invasive evaluation and surgery, with a 50% success rate. The low success rate is likely due to poor identification of the epileptogenic zone (EZ), the brain area causing seizures. This work introduces a new method using functional magnetic resonance imaging (fMRI) with simultaneous direct electrical stimulation of the brain that could help localize the EZ, performed in five patients with medically intractable epilepsy undergoing invasive evaluation with intracranial depth electrodes. Stimulation occurred in a location near the hypothesized EZ and a location away. Electrical recordings in response to stimulation were recorded and compared to fMRI. Multiple stimulation parameters were varied, like current and frequency. The brain areas showing fMRI response were compared with the areas resected and the success of surgery. Robust fMRI maps of activation networks were easily produced, which also showed a significant but weak positive correlation between quantitative measures of blood-oxygen-level-dependent (BOLD) activity and measures of electrical activity in response to direct electrical stimulation (mean correlation coefficient of 0.38 for all acquisitions that produced a strong BOLD response). For four patients with outcome data at 6 months, successful surgical outcome is consistent with the resection of brain areas containing high local fMRI activity. In conclusion, this method demonstrates the feasibility of simultaneous direct electrical stimulation and fMRI in humans, which allows the study of brain connectivity with high resolution and full spatial coverage. This innovative technique could be used to better define the localization and extension of the EZ in intractable epilepsies, as well as for other functional neurosurgical procedures.

Pregnancy may aggravate the natural history of an intracranial tumour, and may even unmask a previously unknown diagnosis. Here we present a series of seven patients who had brain tumours during pregnancy. The aim of this case series is to characterize the current perioperative management and to suggest evidence based guidelines for the anaesthetic management of pregnant females with brain tumours. This is a retrospective study. Information on pregnant patients diagnosed with brain tumours that underwent caesarean section (CS) and/or brain tumour resection from May 2003 through June 2008 was obtained from the Department of General Anaesthesia and the Rose Ella Burkhardt Brain Tumour & Neuro-Oncology Centre (BBTC) at the Cleveland Clinic, OH, USA. The mean age was 34.5 years (range 29-40 years old). Six patients had glioma, two of whom had concomitant craniotomy and CS. Six cases had the tumour in the frontal lobe. Four cases were operated on under general anaesthesia and three underwent awake craniotomy. The neonatal outcomes of the six patients with elective or emergent delivery were six viable infants with normal Apgar scores. Pregnancy was terminated in the 7th patient. In conclusion, good knowledge of the variable anesthetic agents and their effects on the fetus is very important in managing those patients.

Standardization and accreditation of fellowship training have been considered in the field of neuroanesthesiology. A prior survey of members of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) suggested strong support for accreditation and standardization. In response, SNACC created a Task Force that developed curricular guidelines for neuroanesthesiology fellowship training programs. These guidelines represent a first step toward standards for neuroanesthesiology training and will be useful if accreditation is pursued in the future.

Technological advances have made it possible to seamlessly integrate modern neuroimaging into the neurosurgical operative environment. This integration has introduced many new applications improving surgical treatments. One major addition to the neurosurgical armamentarium is intraoperative navigation and MRI, enabling real-time use during surgery. In the 1970s, the American College of Radiology issued safety guidelines for diagnostic MRI facilities. Until now, however, no such guidelines existed for the MRI-integrated operating room, which is a high-risk zone requiring standardized protocols to ensure the safety of both the patient and the operating room staff. The forces associated with the strong 1.5- and 3.0-T magnets used for MRI are potent and hazardous, creating distinct concerns regarding safety, infection control, and image interpretation. Authors of this paper provide an overview of the intraoperative MRI operating room, safety considerations, and a series of checklists and protocols for maintaining safety in this zero tolerance environment.