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Background Patients with coronavirus disease 2019 (COVID-19) presenting for neurosurgery are not rare. Considering the lack of literature informing the outcomes in this subset, present study was conducted to compare perioperative management and postoperative outcomes between COVID-19 and non-COVID-19 neurosurgical patients. Methods After ethics committee approval, data of all patients with COVID-19 along with an equal number of age and diagnosis matched non-COVID-19 patients undergoing neurosurgery between April 2020 and January 2021 was analyzed retrospectively. Predictors of poor outcome were identified using multivariate logistic regression analysis. Results During the study period, 50 COVID-19 patients (28 laboratory confirmed (group-C) and 22 clinicoradiological diagnosed [group-CR]) underwent neurosurgery and were compared with 50 matched non-COVID-19 patients. Preoperatively, clinicoradiological diagnosed COVID-19 patients had higher American Society of Anesthesiologists (ASA) grade (p = 0.01), lower Glasgow Coma Scale (GCS) score (p Conclusions The concomitant presence of COVID-19 infection did not translate into poor outcome in patients undergoing neurosurgery. Preoperative motor-GCS predicted neurological outcome in both COVID-19 and non-COVID-19 neurosurgical patients.

Background Transcranial motor evoked potential (TcMEP) recording during spinal cord/spinal column surgery is a reliable and valid diagnostic adjunct to assess spinal cord integrity and is recommended if utilized for this purpose. Electrophysiologic monitoring in terms of TcMEP has been proven to be a useful tool in detecting spinal cord dysfunction at the earliest and allows corrective action to be taken before permanent neuronal dysfunction sets in. The quality of intraoperative neuromonitoring is influenced by various factors. Most anesthetics used in clinical practice suppress the evoked potentials. Thus, selecting an appropriate technique is always a challenging task. Materials and Methods Thirty ASA I and II patients scheduled for elective dorsolumbar spine surgery with TcMEP monitoring were recruited in the study. Patients were randomized into three groups: (1) Propofol (group P) 100 to 150 µg/kg/min with dexmedetomidine 0.6 µg/kg/hr and fentanyl 1 µg/kg/hr, (2) desflurane (group D) ( Results Three patients were excluded after allocation; 27 out of 30 patients were analyzed. The demographic and surgical characteristics of patients were comparable. The stimulation voltage needed to elicit the responses in all the three groups was comparable. No difference was observed in brachioradialis muscle amplitudes between the groups at different time points. However, in the right brachioradialis muscle, we found reduced amplitudes at baseline in group D and at 120 minutes in group P. We noticed reduced amplitudes of bilateral brachioradialis muscle in group P at 60 minutes and 90 minutes with respect to the baseline. For lower extremity, we measured amplitudes of TcMEP in tibialis anterior (TA) and did not find any difference in amplitudes between the groups at different time points. Conclusion We observed that the desflurane–dexmedetomidine combination did not hinder TcMEP as compared with both standard and propofol–dexmedetomidine groups. Thus, this combined regime could be used in surgeries requiring motor evoked potential monitoring.

Background There are insufficient data about clinical outcomes in critically ill neurological patients with concomitant coronavirus disease (COVID-19). This study describes the clinical characteristics, predictors of mortality, and clinical outcomes in COVID-19-positive neurological patients managed in a dedicated COVID-19 neurointensive care unit (CNICU). Methods This single-center, retrospective cohort study was conducted in critically ill neurological and neurosurgical patients with concomitant COVID-19 infection admitted to the CNICU at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, from July to November 2020. Patients’ demographic, clinical, laboratory, imaging, treatment, and outcome data were retrieved from the manual and electronic medical records. Predictors of mortality and neurological outcome were identified using logistic regression. Results During the study period, 50 COVID-19-positive neurological patients were admitted to the CNICU. Six patients were excluded from the analysis as they were managed in the CNICU for

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The primary aim was to identify the number of patients requiring vasopressors beyond the first week of cervical spinal cord injury (SCI). Secondary objectives were to note the type, duration and doses of vasopressors and any association between prolonged vasopressors use and outcome. SETTING: Neurosurgical intensive care of a tertiary trauma care centre. METHODS: After Ethical approval we retrospectively collected the data of patients of isolated cervical SCI admitted to neurosurgical intensive care from January to December 2017. Vasopressor requirement for sepsis or cardiac arrest was excluded. RESULTS: Out of 80 patients analysed, 54 (67.5%) received vasopressors. The prolonged requirement of vasopressors was observed in 77.7%. Our preferred agent was dopamine (64.8%). We found out that longer requirement (in days) of high dose of dopamine was associated with higher survival (p = 0.03). CONCLUSION: Our results describe a significant portion of cervical SCI patients need ongoing vasopressor to maintain a mean arterial pressure >65 mm of Hg beyond first week. We observed patients who required longer duration of high dose dopamine had a higher chance of survival suggesting some unknown mechanism of high dose of dopamine. This is first such observation, further studies are needed to substantiate.

Phenylketonuria (PKU) is an inborn error of metabolism caused by a deficiency of the enzyme phenylalanine hydroxylase which results in accumulation of phenylalanine. Patients of PKU presents with seizures, mental retardation, and organ damage and possess a unique challenge to the anesthesiologists when they need anesthetics for diagnostic or surgical procedures. There is limited literature regarding the safety of various anesthetic drugs in PKU patients. None of them reported the use of dexmedetomidine as safer sedative option for such patients. Therefore, we describe the management of such a case posted for magnetic resonance imaging under dexmedetomidine sedation.

Background and Aims: Full Outline of UnResponsiveness (FOUR) score is a more comprehensive score used to assess eye response, motor response, brainstem reflexes, and respiration that was introduced to overcome the drawbacks of Glasgow coma scale (GCS) score. Our aim was to assess which score best predicts mortality and poor outcome in aneurysmal subarachnoid haemorrhage (aSAH) patients. Methods: This cohort study, prospectively evaluated the use of FOUR score to assess the mortality and outcome in aSAH patients during the period from November 2015 to November 2016. For each patient of aSAH, GCS, FOUR score, Hunt and Hess (HH) score and World Federation of Neurological Surgeons (WFNS) score were determined at the time of admission to neurosurgical intensive care unit. All patients were followed till 28 days post-SAH and their outcome were assessed by Glasgow outcome scale (GOS). We calculated the sensitivity (Sn) and specificity (Sp) for each of these scores. We generated the receiver operating characteristic curve (ROC), quantified the accuracy by the area under curve (AUC), and also calculated their 95% confidence interval (95% CI). Results: A total of 75 aSAH patients were enrolled for the study. The mortality was 24/75 (32%) with 23 in-hospital deaths. FOUR score was highly specific (86.27%) and sensitive (75%) for the prediction of mortality. However, for predicting 28-day outcome, WFNS and HH grade were most specific (92.5%), whereas FOUR and HH score was moderately specific (68.57%). Conclusion: FOUR score is among the most specific and moderately sensitive tool for prediction of mortality. However, WFNS and HH grade are more specific in predicting the 28-day outcome.

Pediatric blood transfusion practices during neurosurgical procedures differ from those of adults with regard to physiologic and hematologic considerations. Such differences dictate different guidelines for blood transfusion practices. In addition, pediatric patients are more susceptible to certain transfusion-related complications as compared to their adult counterparts. The pediatric patients present with more incidence of allergic, febrile non-hemolytic, and hypotensive transfusion reactions. Oxygen consumption in children is higher as compared to adults. As the myocardium of a newborn operates to the full potential to meet the higher oxygen demand, it may not be able to compensate for diminished oxygen capacity by further increasing cardiac output and, thus, have a higher likelihood of cardiac decompensation and ischemia under stressful circumstances. Optimal hemoglobin concentrations are, thus, higher in newborns as compared to the adults. The term neonate has mean hemoglobin values of 16.5 gm/dL, and the hemoglobin concentrations vary in children and adolescents in an age-related manner. Fetal hemoglobin (HbF) in the full-term newborn is highest at birth, decreasing at 5% per week until 6 months. Children undergoing neurosurgery are vulnerable to intraoperative bleeding; some preocedures are prone to massive blood loss. A diverse physiology from adults precludes the pediatric patients from enduring even a small quantity of blood loss over a short duration. The management, in such scenario, requires throrough understanding of body physiology, usage of blood products, and appropriate monitoring methods.

Background Pregabalin is a gabapentinoid which has been shown to possess analgesic and anxiolytic properties. The present study aimed to assess the efficacy of a single dose of pregabalin on postoperative pain and preoperative anxiety in patients undergoing lumbar spine surgery. Materials and Methods Sixty adults posted for elective lumbar laminectomy and discectomy were randomly assigned to one of the three groups; Group C received placebo capsules, Group PI received pregabalin 150 mg, and Group P2 received pregabalin 300 mg capsules, 2 h prior to induction of anesthesia. The levels of anxiety and pain were assessed with respective 100 mm visual analog scale (VAS) score. Postoperative fentanyl consumption and occurrence of side effects were recorded. All patients were observed for 8 h, postoperatively. Results There was a significant reduction in preoperative anxiety in both pregabalin groups as compared to control group (p = 0.001). VAS score for pain (at rest and during movement) was significantly decreased at all time intervals in both PI and P2 groups as compared to control (p < 0.05). Fentanyl consumption in the postoperative period was significantly reduced in pregabalin groups as compared to control (p = 0.001). The level of sedation was higher in P2 group in the first 4 h (p < 0.05). The occurrence of postoperative nausea and vomiting was more in control group as compared to the pregabalin groups (p = 0.018). The incidence of dizziness and blurring of vision was significantly more in P2 group. Conclusion Single preoperative dose of pregabalin 150 or 300 mg was effective in reducing preoperative anxiety, postoperative pain and total fentanyl consumption in patients undergoing lumbar laminectomy and discectomy. However, the incidence of postoperative side effects such as sedation, dizziness and visual blurring was more in patients who received pregabalin 300 mg.

Proximal balloon occlusion prior to carotid artery stenting is considered a relatively safe practice during endovascular treatment of carotid artery stenosis. Transient neurological deterioration affecting the ipsilateral hemisphere is seen soon after balloon inflation, when placed proximal to the stenotic segment. This occurs in cases of bilateral carotid disease due to insufficient collateral blood flow from the contralateral side. Near infrared spectroscopy cerebral oximetry (NIRS) is a valuable tool in detecting hypoperfusion- induced cerebral tissue desaturation (rSO2) during these procedures. This helps the interventional radiologist to deflate the balloon at the earliest to re-establish the cerebral blood flow. The non-invasive nature and continuous real-time interpretation make NIRS an attractive adjunct in the neuroanesthesiolgist's armamentarium for monitoring cerebral ischemia. However, significant contribution from chromophores in the extra-cerebral tissues and external carotid artery circulation can limit its sensitivity during occlusion of the internal carotid artery. In our case, it did not reflect brain ischemia during hypotension and when the neurologic symptoms were obvious. Commonly available cerebral oximetry sensors placed over the frontal region do not cover the parietal lobe where ischemia is likely to occur during occlusion of the carotid artery. In such scenarios, it has been shown that multi-channel NIRS has a better sensitivity in detecting cerebral ischemia. This case report highlights the importance of frequent neurological examination during carotid stenting as rSO2 values might not always suggest cerebral ischemia.

Enhanced recovery after surgery (ERAS) is a systematic multimodal perioperative care aimed at reducing the immense surgical stress of the patient and thereby facilitating early recovery. This is basically a multidiscipline, multimodal integrated approach in patient care and it integrates the basic knowledge in a more streamlined fashion, which ultimately improves the outcome of surgery. This article reviews the various aspects of ERAS, and its implementation in neurosurgical practice as some concepts of ERAS may not be applicable in the setting of neurosurgery.

Pneumocephalus is an unusual presentation after lumbar spine surgery. We report the case of a young healthy patient, who had delayed emergence from anesthesia after undergoing an uncomplicated lumbar spine surgery. After shifting to the Intensive Care Unit, the patient had an episode of generalized tonic—clonic seizure. Computed tomography scan revealed the presence of pneumocephalus. The patient was managed conservatively, extubated the following day and discharged with no neurological deficits.

Background Placement of flow diverter (FD) is an endovascular technique where the flow to the aneurysm is directed away from the aneurysmal sac using a stent in the parent vessel. In this clinical report, the authors share their institutional experience pertaining to clinical course of patients with intracranial aneurysm requiring placement of FD. Materials and Methods After approval from institute ethics committee (IEC), the authors retrospectively studied all patients who underwent placement of FD for intracranial aneurysms from January 2014 to December 2017. Data regarding patient demographics, presenting complaints, aneurysm details, anesthesia technique, and intra- and postprocedural complications were noted. Duration of hospital stay, neurological outcome as measured by Glasgow outcome scale (GOS) at discharge and at 6 months was noted. Data are presented as median (range) or number (%). Results Over a period of 3 years, 22 patients underwent FD placement. Two patients had subarachnoid hemorrhage (SAH) at the time of presentation, and the rest had unruptured aneurysms. All patients received general anesthesia (GA) for the procedure, and intravenous propofol was used for induction of anesthesia. Majority of the patients received sevoflurane and nitrous oxide combination for maintenance of anesthesia (20/22 [91%]). Five patients were not extubated at the end of the procedure. The most common indication for mechanical ventilation was delayed reversal because of hypothermia. At 6 months of follow-up, GOS was 5 in 18 patients. None of the patients developed any delayed complications related to FD and were neurologically intact. Conclusions The use of FD for the treatment of aneurysms is a safe option. GA was used for carrying out procedure in all patients. The neurological outcome was good in all patients who were followed at 6 months.

Severe brain swelling during routine neurosurgery can herald serious consequences. Failure to control brain swelling despite adequate measures warns of a surgical cause and should be dealt efficiently. We report a case of an adult female who developed intraoperative acute subdural haematoma (SDH) and consequent intractable brain swelling during surgery of supratentorial arteriovenous malformation (AVM). Such a manifestation of contralateral acute SDH during supratentorial AVM surgery has not been reported earlier.

Trigeminal neuralgia (TGN) is a chronic debilitating condition characterized by recurrent attacks of lancinating pain in the distribution of the trigeminal nerve. Carbamazepine is the initial drug of choice for treating TGN [1]; however, several other drugs, including antidepressants may provide pain relief in some cases. Neurosurgical treatment may be helpful in treating drug-refractory cases. Apart from pharmacotherapy and surgical interventions, several complementary therapies provide additional benefit.

Postoperative visual loss (POVL) is a rare but grave postoperative complication. It has been mainly reported in patients undergoing cardiac and spinal surgeries. Dorsal root entry zone (DREZ) is pain relieving procedure performed in patients with refractory neuropathic pain with minimal complication rate. We present a case of unilateral POVL following DREZ rhizotomy in prone position in a patient having brachial plexus neuropathy. Exact etiology of vision loss was though not clear; hypotension, use of vasopressors and hemodilution may have led to vision loss in this patient. This case report highlights the associated risk factors for development of this hazardous complication.

Background: Lignocaine and Magnesium have an analgesic action and reduce perioperative opioid requirements. We carried out this study to evaluate the effect of magnesium and lignocaine on postoperative pain as assessed using the visual analog scale (VAS) and fentanyl consumption. We also measured S-100 B levels and noted the side effect of drugs if any. Materials and Methods: In this prospective preliminary study, 45 patients undergoing supratentorial craniotomy for tumor surgery were randomized to receive either lignocaine (group I-1.5 mg/kg bolus followed by 2 mg/kg/h infusion), saline (Group II) or magnesium (group III: bolus of 50 mg/kg followed by 25 mg/kg/hr) intraoperatively. The amount of fentanyl required, VAS over first 24 hours and any side effects were noted. S100 B levels were also measured to assess brain protective effect of these drugs, if any. Appropriate statistical tests were applied for analysis of data and a P value < 0.05 was considered statistically significant. Results: None of the patient experienced any adverse hemodynamic effect intraoperatively secondary to the study drugs. The amount of intraoperative fentanyl consumption was comparable among the three groups. The mean VAS score was significantly less in group I and III [Group I (15.3 ± 6.0), Group II (24.8 ± 6.7), Group III (17.9 ± 7.6); (P < 0.01)]. The fentanyl consumed in first 24 hours was significantly less in those patients who received lignocaine and magnesium [Group I (204.4 ± 136.4), Group II (383 ± 168.2), Group III (194 ± 148.9); (P = 0.01)]. S100 value did not differ in the lignocaine and the saline group during the perioperative period. However, a significant decline was noted in the levels of S100 B in the magnesium group. Conclusion: Intraoperative infusion of lignocaine and magnesium results in lower VAS score and decreases the postoperative opioid requirement in patients undergoing craniotomy for excision of supratentorial tumors.

Despite the advent of short and ultra-short acting drugs, an in-depth knowledge of the reversal agents used is a necessity for any anaesthesiologist. Reversal agents are defined as any drug used to reverse the effects of anaesthetics, narcotics or potentially toxic agents. The controversy on the routine reversal of neuromuscular blockade still exists. The advent of newer reversal agents like sugammadex have made the use of steroidal neuromuscular blockers like rocuronium feasible in rapid sequence induction situations. We made a review of the older reversal agents and those still under investigation for drugs that are regularly used in our anaesthesia practice.

• Near Infrared Spectroscopy (NIRS) monitors continuous non-invasive regional oxygen balance within the frontal cerebral cortex.

Background and Aims: Bispectral index (BIS) values may be anaesthetic agent-specific, depending on their ability to suppress the electroencephalogram (EEG) signals. We carried out a prospective, randomised clinical trial to study the effect of nitrous oxide (N2O) on the BIS values at an equi-minimum alveolar concentration (MAC) of sevoflurane and desflurane. Methods: Sixty adult patients undergoing spine surgery were randomised into two groups; Group S (sevoflurane; n = 30) and Group D (desflurane; n = 30) for the maintenance of anaesthesia in oxygen and air or oxygen and N2O mixture (FiO2-0.4) (Stage 1). BIS and fraction of inspired and end-tidal concentration of agents were noted at 1.0 MAC. In Stage 2, air or N2O was discontinued and the other carrier gas was introduced. At steady state of this carrier gas, values were again noted as in Stage 1. Statistical analysis was performed using two-way analysis of variance followed by Bonferroni correction, and Student's t-test for paired data. P