Comparison of propofol and desflurane for postoperative neurocognitive function in patients with aneurysmal subarachnoid hemorrhage: A prospective randomized trial.

Background: Following aneurysmal subarachnoid hemorrhage, 40-50% of survivors experience cognitive dysfunction, which affects their quality of life. Anesthetic agents play a pivotal role in aneurysm surgeries. However, substantial evidence regarding their effects on neurocognitive function is lacking. This study evaluated the effects of propofol and desflurane on postoperative neurocognitive function and serum S-100B levels. Methods: One hundred patients were equally randomized to receive either propofol (Group P) or desflurane (Group D). Cognitive function was assessed using the Montreal Cognitive Assessment scale at three different time points: Preoperatively, at the time of discharge, and one month after surgery. Perioperative serum levels of S-100B were also measured. Results: The preoperative mean cognitive score in Group P was 21.64 + 4.46 and in Group D was 21.66 + 4.07 (P = 0.79). At discharge, a significant decrease in cognitive scores was observed compared to preoperative scores (Group P- 20.91 + 3.94, P = 0.03 and Group D-19.28 + 4.22, P = 0.00); however, scores were comparable between the two groups (P = 0.09). One month following surgery, mean cognitive scores were 22.63 + 3.57 in Group P and 20.74 + 3.89 in Group D, and the difference was significant (P = 0.04). Higher memory and orientation scores were observed in Group P than in Group D at one month (P < 0.05) in the subgroup analysis. Both groups had similar serum S-100B levels. Conclusion: The mean cognitive scores one month after surgery improved significantly with propofol compared with desflurane, but without clinical significance. Individual domain analysis demonstrated that orientation and memory scores were better preserved with propofol.

Effect of Peri-operative Blood Transfusion on Neurological Outcome Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Study.

BACKGROUND: Anemia is a common complication of aneurysmal subarachnoid hemorrhage and is associated with unfavorable outcomes. Whether the physiological benefits of transfusion for anemia surpass the risk of blood transfusion remains to be determined. OBJECTIVES: The primary outcome was to evaluate the impact of peri-operative blood transfusion on the long-term neurological outcome, assessed by Glasgow Outcome Scale Extended at 3 months. The secondary outcomes included the impact of transfusion on the short-term neurological outcome, assessed by Modified Rankin Score at discharge/7 days, and on the incidence of vasospasm, infarction, re-exploration, tracheostomy, and length of hospital stay. MATERIAL AND METHODS: This prospective observational study was conducted on 185 patients with aneurysmal subarachnoid hemorrhage undergoing clipping of the aneurysmal neck. In our study, blood transfusion was administered to keep the target Hb around 10 g/dL. RESULTS: Unfavorable long-term outcome was found in 27/97 (28%) of patients who received a blood transfusion as compared to 13/74 (18%) of patients who did not receive a transfusion (P = 0.116). Patients receiving transfusion had more chances of an unfavorable outcome at discharge/7 days as compared to those not transfused [44/103 (43%) versus 22/80 (27%)], P = 0.025. There were increased chances of vasospasm, infarction, re-exploration, tracheostomy, and increased length of hospital stay in patients receiving transfusion (P < 0.05). CONCLUSIONS: The use of blood transfusion in patients with aneurysmal subarachnoid hemorrhage was associated with increased neurological complications and hence an unfavorable short-term outcome. However, when used judiciously as per the clinical requirements, blood transfusion did not have a significant effect on long-term neurological outcome.

Comparison of Effects of Propofol and Sevoflurane on the Cerebral Vasculature Assessed by Digital Subtraction Angiographic Parameters in Patients Treated for Ruptured Cerebral Aneurysm: A Preliminary Study.

BACKGROUND: Studies have evaluated the effects of volatile and intravenous anesthetic agents on the cerebral vasculature with inconsistent results. We used digital subtraction angiography to compare the effects of propofol and sevoflurane on the luminal diameter of cerebral vessels and on cerebral transit time in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: This prospective preliminary study included adult patients with good-grade aSAH scheduled for endovascular coil embolization; patients were randomized to receive propofol or sevoflurane anesthesia during endovascular coiling. The primary outcome was the luminal diameter of 7 cerebral vessel segments measured on the diseased and nondiseased sides of the brain at 3 time points: awake, postinduction of anesthesia, and postcoiling. Cerebral transit time was also measured as a surrogate for cerebral blood flow. RESULTS: Eighteen patients were included in the analysis (9 per group). Baseline and intraoperative parameters were similar between the groups. Propofol increased the diameter of 1 vessel segment at postinduction and postcoiling on the diseased side and in 1 segment at postcoiling on the nondiseased side of the brain ( P <0.05). Sevoflurane increased vessel diameter in 3 segments at postinduction and in 2 segments at postcoiling on the diseased side, and in 4 segments at postcoiling on the nondiseased side ( P <0.05). Cerebral transit time did not change compared with baseline awake state in either group and was not different between the groups. CONCLUSIONS: Sevoflurane has cerebral vasodilating properties compared with propofol in patients with good-grade aSAH. However, sevoflurane affects cerebral transit time comparably to propofol.

Systemic Air Embolism in a Patient With Lung Lesion Undergoing Neurosurgery in Sitting Position: A Case Report.

Systemic air embolism secondary to venous air embolism is a known complication of sitting position surgery. However, the possibility of an isolated systemic air embolism must be considered, especially in patients with preexisting lung disease receiving positive pressure ventilation. These patients may benefit from a comprehensive preoperative evaluation and advanced intraoperative monitoring. We report a case of a 53-year-old woman with chronic obstructive airway disease and a preexisting fibrocavitary lung lesion, who developed isolated air entrainment into the left heart during sitting position surgery.

Abrupt Cessation of Atrial Fibrillation in a Neurosurgical Patient: Does Positioning Matter?

Atrial fibrillation (AF) has been associated with cancer. However, the literature regarding the occurrence of AF in patients with brain tumors is limited. Neuroanatomic connections between the brain and the heart may affect heart rate and rhythm. We discuss a case of transient AF in a 64-year-old female who was operated for a right-sided sphenoid wing meningioma. The AF might have been related to the positioning of the head and neck of the patient, in whom the intracranial compliance was reduced due to the brain tumor.

Comparison of postoperative delirium in patients anesthetized with isoflurane versus desflurane during spinal surgery: A prospective randomized controlled trial.

BACKGROUND: Following spine surgery, different types of inhalational anesthetic agents can result in postoperative delirium (POD) that can increase perioperative/postoperative morbidity. Here, we compared the incidence of POD in adults undergoing spine surgery anesthetized with isoflurane versus desflurane. METHODS: A prospective randomized double-blind clinical trial for patients undergoing spinal surgery was performed in 60 adults (aged 18-65 years); they were randomized to receive isoflurane or desflurane. On postoperative days 1 and 3, the diagnosis and severity of POD utilized 3D-Confusion Assessment Method (CAM) and CAM-severity delirium severity scores to assess patients' status. Multiple other variables which may have influenced the frequency/severity of POD were also studied. RESULTS: For the two groups, the incidence of POD utilizing isoflurane and desflurane was similar on postoperative days 1 (10% vs. 13.3%, P > 0.05) and 3 (6.6% vs. 0%, P > 0.05). The severity scores of POD for both anesthetic agents were also similar on postoperative days 1 (1.5 vs. 1) and 3 (0.5 vs. 0.5). In addition, there was no significant association of POD with other perioperative factors. CONCLUSION: A significant number of patients undergoing spine surgery experience POD. However, the incidence and severity of POD remained similar when utilizing either isoflurane or desflurane.