Awake Craniotomy for Cerebral Abscess with Pulmonary Arteriovenous Malformation

A cerebral abscess can be a life-threatening complication of pulmonary arteriovenous malformations (PAVM), thus posing significant morbidity if left untreated. We report a case of an incidental finding of a PAVM in a patient diagnosed with cerebral abscess. A 22-year-old male presented to the emergency department with acute onset right-sided weakness in both upper and lower limbs for 1 week. Magnetic resonance imaging showed a ring-enhancing lesion within the left parasagittal frontoparietal region s/o intracerebral abscess. High-resolution computed tomography was done as a protocol in patients posted for surgery due to coronavirus disease 2019 and coincidentally, it showed a single well-defined parenchymal nodule, 4 x 3.4 cm in the lateral basal segment of the left lower lobe. The knowledge of the pathophysiology of PAVM and expected complications during general anesthesia (GA) and positive pressure mechanical ventilation is essential. In such conditions, awake craniotomy under conscious sedation and scalp block may be considered as an alternative to GA.

Awake Craniotomy in the MRI Suite - a review of local practice

Introduction: Modern awake craniotomy (AC) has been performed since the 1980s, initially for epilepsy surgery but expanding to surgery for intracranial tumours (1). Intra-operative magnetic resonance imaging (ioMRI) was first utilised in 1994 in Boston (2), to overcome the issue of intra-operative brain shift during craniotomy, and permit the surgical team to check the extent of resection before closing. The techniques have been more recently combined, aiming to remove as much tumour from eloquent areas as possible. The interventional MRI (iMRI) suite at the National Hospital for Neurology and Neurosurgery (NHNN) consists of a 1.5 Tesla MRI scanner with an MR-conditional anaesthetic machine and operating table just outside the 5 Gauss line. This can be rotated to connect to the MRI table, and the patient is transferred into the bore of the scanner. There have been very few studies looking at iMRI and awake craniotomies, however there has been a suggestion that the addition of the MRI scan to awake craniotomy may reduce the requirement for redo surgery (3), and that awake craniotomies in iMRI may reduce the incidence of neurological impairment compared to surgery under general anaesthesia in iMRI. As the number of iMRI theatre suites increases across the UK, increasingly AC is being performed in this environment. In our study, we looked at these patients and their various pathologies, undergoing awake tumour resections in our iMRI suite, and their clinical management. Method(s): The theatre log book in MRI was reviewed for all awake cases, a longer time window was selected due to the impact of covid. Records reviewed to exclude procedures other than awake tumour resections with intraoperative MRI scanning. Identified total of 43 cases, a number grossly affected by covid interruptions. Post operative notes and discharge letters were reviewed to ascertain Clavien-Dindo scoring for postop complications. Result(s): 43 cases, with an average patient age of 36 years (spanning 19 y to 72 y), gender ratio M:F=16:5. Mode ASA 2 (1-3), mean weight 78 kg (55-114 kg) and mean BMI 25.6 kg/m2 (20.2-35.6). * Most had a single ioMRI except three cases which had 2 scans, and 40% of cases had further resection after the ioMRI. * 44% noted complete resection on the post-operative MRI * Anaesthetic technique varied but asleep-awake-asleep/sedation comprised 88% of cases, with iGel used in 74% and classical LMA in 23%, and propofol/remifentanil used in 81%. * All patients had urinary catheters and arterial lines, no patients had central venous catheters. * Anaesthetic time (WHO sign-in to WHO time-out) ranged from 5 hours to 13 hours10 minutes with an average of 8 hours 54 minutes. * Postoperative destination was overnight recovery in 76%, HDU in 14%, and the remainder direct to the ward, where length of stay mean was 10.5 days (though mode was 4 d). * Clavien-Dindo score on discharge was 0 in 40%, 1 in 50%, 2 in 4.6% and 3b and 4 in 2.3%. * 44% were discharged with no new neurological deficit. Conclusion(s): We interpret the outcomes here as very positive, with a high proportion of patients leaving hospital with low Clavien-Dindo scores or with no new deficits identified post-operatively. It is clear that awake craniotomy is safely performed in the iMRI suite. As is often the case in anaesthesia, whilst we saw some absolute consistencies (such as 100% rate of urinary catheters and arterial lines), we saw here that the anaesthetic approaches were as varied as the anaesthetists themselves. Anaesthetists should be prepared for prolonged surgical time to ensure satisfactory surgical resection.

Experience in Neuroanesthesia Practice from Indonesia Tertiary Hospital during COVID-19 Pandemic Era: A Descriptive Study

Background: Severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) or COVID-19 pandemic was a highly contagious virus that was first reported in the city of Wuhan, China in December 2019. COVID-19 pandemic has been a challenge to the global healthcare system and healthcare professionals including Indonesia. The first case found in Indonesia was in March 2020 and there were three peaks of the case, which were in January 2021, July 2021, and February 2022. Cipto Mangunkusumo Hospital, as a tertiary level and national referral hospital, was assigned as one of the biggest COVID-19 center hospitals in Indonesia. Throughout the pandemic, several policies regarding anesthesia practice were made, including the COVID-19 screening system and surgical patient pathway. Thus, there were two exclusive negative pressure operating rooms located in a centralized COVID-19 building and an emergency unit. Many surgical procedures were performed during the pandemic, including neurosurgical cases which involved neuro anesthesia practices that needed some adjustment due to the pandemic. There are two main questions that will be addressed in this research. First, Of all patients that undergo neurosurgery procedures how many have COVID-19. Second, Of all COVID- 19 patients that undergo surgery how many of them are neurosurgery. Method(s): This study was descriptive and involved a retrospective review of data collected from patients who underwent neurosurgeries between March 2020 and March 2022. Analyzes were performed according to COVID-19 status, age, classification case, type of surgery, and type of anesthesia. Result(s): A total of 933 neurosurgery cases and 488 COVID-19 surgery cases were identified. There were 26 neurosurgery cases with COVID 19. It was about 2.7% relative to all neurosurgery cases and about 5.3% relative to all COVID 19 surgery cases. General anesthesia was conducted in all of the cases. Fifty percent of the surgery was performed in centralized COVID-19 building operating room with elective setting, following 46% of cases was performed in emergency unit. There was one case was performed in catheterization lab. The population of cases was 65.3% in adult patients and 34.7% in pediatric population, consisted of eight vascular cases, seven oncology cases, seven infection cases, three trauma cases, and one congenital case. The procedure performed were 57.6% cerebrospinal fluid diversion, 34.6% craniotomy and 7,6% debridement.We followed our hospital established local COVID-19 guideline for surgical procedures, international guidelines, and recommendations, such as SNACC, to help deciding the risk stratification and time to perform the procedures. However, we have not performed transnasal procedure, awake craniotomy, and intraoperative neuromonitoring. All safety measures and infection control protocols were implemented. Conclusion(s): Neurosurgical procedures for patient with COVID-19 are considered uncommon with respect to all COVID-19 surgery cases and all neurosurgery cases. This information can be taken into consideration when making guidelines in the pandemic era. Further research are needed to explore impact of COVID-19 to neurosurgery patients.

Awake craniotomy for glioblastoma in COVID-19-positive patients and delivering the standard of care: illustrative case.

BACKGROUND: Providing the standard of care to patients with glioblastoma (GBM) during the novel coronavirus of 2019 (COVID-19) pandemic is a challenge, particularly if a patient tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Further difficulties occur in eloquent cortex tumors because awake speech mapping can theoretically aerosolize viral particles and expose staff. Moreover, microscopic neurosurgery has become difficult because the use of airborne-level personal protective equipment (PPE) crowds the space between the surgeon and the eyepiece. However, delivering substandard care will inevitably lead to disease progression and poor outcomes. OBSERVATIONS: A 60-year-old man with a left insular and frontal operculum GBM was found to be COVID-19 positive. Treatment was postponed pending a negative SARS-CoV-2 result, but in the interim, he developed intratumoral hemorrhage with progressive expressive aphasia. Because the tumor was causing dominant hemisphere language symptomatology, an awake craniotomy was the recommended surgical approach. With the use of airborne-level PPE and a surgical drape to protect the surgeon from the direction of potential aerosolization, near-total gross resection was achieved. LESSONS: Delaying the treatment of patients with GBM who test positive for COVID-19 will lead to further neurological deterioration. Optimal and timely treatment such as awake speech mapping for COVID-19-positive patients with GBM can be provided safely.

One day at a time.

In this issue of Biomedical Journal we get to know measures to prevent a nosocomial COVID-19 outbreak, a compound that is able to stall SARS-CoV-2 replication, and the connection between air pollution and COVID-19 cases. Another article allows an insight into the potential of treating HIV combining a conventional drug and low level laser therapy. Furthermore, the advantages of awake craniotomy are presented, the efficacy of IRES is examined, and plant extracts are on the one hand explored as a nociceptive agent and on the other hand as therapeutic approach against breast cancer. We learn about drug resistance in liver cancer, a mutation involved in a rare inflammatory disorder, and lung surgery related unilateral vocal fold paralysis. Finally, the success of emergency endotracheal intubations across different hospital units is compared, the importance of monitoring cerebral blood flow in asphyxiated neonates is elucidated, and resistance variants in hepatitis C virus are examined. A study about the necessity to perform quantitative cardiac MRI in Asian population is presented, and an approach is shown on how to augment the effect of platelet-rich plasma injections in chronic knee osteoarthritis.

Awake craniotomy in a Covid-19 positive patient: The challenges and outcome.

BACKGROUND: The SARS-COV-2 is a novel coronavirus which is the etiological agent of the COVID-19 infection. The neurosurgical practice is not exempted from the impact of the COVID-19 pandemic. Awake craniotomy in a COVID-19 positive patient pose a significant risk for theatre staff but intubation of a COVID-19 positive patient for surgery under general anesthesia also pose similar risk. METHOD: Federal Teaching Hospital Ido Ekiti is a tertiary hospital in suburban community in Southwest Nigeria with 300-bed capacity. The hospital is a designated COVID-19 treatment centre. A 69-year-old female patient was referred from a nearby COVID-19 treatment hospital on account of left parieto-occipital high grade glioma. She had awake craniotomy and gross total tumor excision. RESULT: There was no need to convert to general anesthesia and she had immediate post-operative neurological improvement. Repeat COVID-19 test on post-operative day 4 was negative and she was discharged home. Thirty-day post-operative review confirmed progressive motor gain. CONCLUSION: Awake craniotomy in COVID-19 positive patient with appropriate use of necessary PPEs is achievable.