Implementation of the American Society of Anesthesiologists 2022 paediatric guidelines in a child with mandibular metastasis.

The 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway differ significantly from prior guidelines, particularly regarding paediatric patients. These guidelines place new emphasis on establishing a multidisciplinary team led by an anaesthetist trained in paediatric anaesthesia. Here, we demonstrate the clinical application of the new guidelines by presenting the case of a 16-month-old girl with a rapidly growing mandibular mass. The new guidelines stipulated the need for multidisciplinary team assembly; planning with indirect laryngoscopy; the availability of surgical tracheostomy and extracorporeal membrane oxygenation; and multiple 'time out' stops to confirm team members and plans. The patient tolerated induction of general anaesthesia and mask-ventilation and tracheal intubation was achieved uneventfully on the first attempt. Her trachea was extubated uneventfully 5 days later. We emphasise the importance of paediatric anaesthesia training and videolaryngoscopy and discuss components of the 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway with reference to a successful outcome in a paediatric difficult airway scenario.

The long-term outcome of microvascular decompression for trigeminal neuralgia.

BACKGROUND: Several surgical procedures to treat trigeminal neuralgia (tic douloureux) are available, but most reports provide only short-term follow-up information. METHODS: We describe the long-term results of surgery in 1185 patients who underwent microvascular decompression of the trigeminal nerve for medically intractable trigeminal neuralgia. The outcome of the procedure was assessed prospectively with annual questionnaires. RESULTS: Of the 1185 patients who underwent microvascular decompression during the 20-year study period, 1155 were followed for 1 year or more after the operation. The median follow-up period was 6.2 years. Most postoperative recurrences of tic took place in the first two years after surgery. Thirty percent of the patients had recurrences of tic during the study period, and 11 percent underwent second operations for the recurrences. Ten years after surgery, 70 percent of the patients (as determined by Kaplan-Meier analysis) had excellent final results-that is, they were free of pain without medication for tic. An additional 4 percent had occasional pain that did not require long-term medication. Ten years after the procedure, the annual rate of the recurrence of tic was less than 1 percent. Female sex, symptoms lasting more than eight years, venous compression of the trigeminal-root entry zone, and the lack of immediate postoperative cessation of tic were significant predictors of eventual recurrence. Having undergone a previous ablative procedure did not lessen a patient's likelihood of having a cessation of tic after microvascular decompression, but the rates of burning and aching facial pain, as reported on the last follow-up questionnaire, were higher if a trigeminal-ganglion lesion had been created with radiofrequency current before microvascular decompression. Major complications included two deaths shortly after the operation (0.2 percent) and one brain-stem infarction (0.1 percent). Sixteen patients (1 percent) had ipsilateral hearing loss. CONCLUSIONS: Microvascular decompression is a safe and effective treatment for trigeminal neuralgia, with a high rate of long-term success.

Ossification of the anterior longitudinal ligament and Forestier's disease: an analysis of seven cases.

A retrospective review was conducted on the records and radiographs of six symptomatic patients and one asymptomatic patient with Forestier's disease. No other series of patients with this disease is found in the neurosurgical literature. Forestier's disease, also known as diffuse idiopathic skeletal hyperostosis (DISH), is an idiopathic rheumatological abnormality in which exuberant ossification occurs along ligaments throughout the body, but most notably the anterior longitudinal ligament of the spine. It affects older men predominantly; all of our patients were men older than 60 years of age. The disease is usually asymptomatic; however, dyspnea, dysphagia, spinal cord compression, and peripheral nerve entrapment have all been documented in association with the disorder. Five of the six symptomatic patients presented with dysphagia due to esophageal compression by calcified anterior longitudinal ligaments, and one patient developed recurrent spinal stenosis when scar tissue from a previous decompressive laminectomy became calcified. All patients responded well to surgery. Two of the four patients who underwent removal of cervical osteophytes required several months following surgery for the dysphagia to resolve. This would support the hypothesis that not all cases of dysphagia in Forestier's disease are due to mechanical compression. Dysphagia may result from inflammatory changes that accompany fibrosis in the wall of the esophagus or from esophageal denervation. Evaluation of dysphagia even in the presence of Forestier's disease must rule out occult malignancy. The authors' experience suggests that dysphagia in the setting of Forestier's disease is an underrecognized entity amenable to surgical intervention.

Microvascular decompression for hemifacial spasm.

The authors report the results of 782 microvascular decompression procedures for hemifacial spasm in 703 patients (705 sides), with follow-up study from 1 to 20 years (mean 8 years). Of 648 patients who had not undergone prior intracranial procedures for hemifacial spasm, 65% were women; their mean age was 52 years, and the mean preoperative duration of symptoms was 7 years. The onset of symptoms was typical in 92% and atypical in 8%. An additional 57 patients who had undergone prior microvascular decompression elsewhere were analyzed as a separate group. Patients were followed prospectively with annual questionnaires. Kaplan-Meier methods showed that among patients without prior microvascular decompression elsewhere, 84% had excellent results and 7% had partial success 10 years postoperatively. Subgroup analyses (Cox proportional hazards model) showed that men had better results than women, and patients with typical onset of symptoms had better results than those with atypical onset. Nearly all failures occurred within 24 months of operation; 9% of patients underwent reoperation for recurrent symptoms. Second microvascular decompression procedures were less successful, whether the first procedure was performed at Presbyterian-University Hospital or elsewhere, unless the procedure was performed within 30 days after the first microvascular decompression. Patient age, side and preoperative duration of symptoms, history of Bell's palsy, preoperative presence of facial weakness or synkinesis, and implant material used had no influence on postoperative results. Complications after the first microvascular decompression for hemifacial spasm included ipsilateral deaf ear in 2.6% and ipsilateral permanent, severe facial weakness in 0.9% of patients. Complications were more frequent in reoperated patients. In all, one operative death (0.1%) and two brainstem infarctions (0.3%) occurred. Microvascular decompression is a safe and definitive treatment for hemifacial spasm with proven long-term efficacy.

Tortuous peripheral arteries: a cause of focal neuropathy. Case report.

Segmental ulnar neuropathy has been reported as a result of ulnar nerve compression due to posttraumatic false aneurysms of the ulnar artery and, more infrequently, due to thrombosis or true aneurysms of the same vessel. The authors present a case of segmental sensory ulnar neuropathy in the wrist which intraoperatively demonstrated impingement on the ulnar nerve by a tortuous ulnar artery. The symptomatic relief and electrophysiological improvement that occurred immediately following neurovascular decompression confirm that the vascular anomaly was the cause of neuropathy. Pulsatile pressure applied to the nerve trunk may have triggered ectopic stimulation of sensory fibers manifested by a tingling and burning sensation. There was immediate resolution of paresthesia following mobilization of the impinging vessel from the nerve. Subsequent rapid electrophysiological recovery may be explained by improvement in focal nerve microcirculation following vascular decompression. Tortuosity (megadolichoectatic anomaly) of intracranial arteries has been related to cranial nerve or brain-stem dysfunction; however, this appears to be the first report in the literature of a case in which such association has been found to occur extracranially, involving a peripheral nerve.

Experimental limbic epilepsy: models, pathophysiologic concepts, and clinical relevance.

Complex partial seizures originating in the temporal lobe are one of the most common types of seizures in patients with epilepsy. They are frequently intractable to medical treatment and are increasingly considered for surgical therapy. These seizures are often associated with focal epileptogenicity in limbic structures (amygdala and hippocampus) or with rapid spread of seizure activity to these areas. Much research is being undertaken to better understand this disorder and to develop more effective approaches to diagnosis and treatment. Experimental work in animals has contributed to the understanding of epileptogenesis, the interictal state, and the homeostatic mechanisms that limit seizure activity.

Cranial postoperative site: MR imaging appearance.

The ability to diagnose adverse postcraniotomy or postcraniectomy events is essential for proper postoperative care. The importance of identifying postoperative changes on CT has previously been shown. The purpose of this study is to assess the normal and abnormal MR changes that may be seen in the postcraniotomy/postcraniectomy period. The postoperative MR, CT, and medical records of 41 postcraniotomy patients and 26 postcraniectomy patients were reviewed. Reasons for choosing craniectomy over craniotomy included decompression, infected flap, bony involvement by tumor, and posttraumatic skull. In general, the postoperative normal anatomy was better seen with MR. Postoperative events included hemorrhage (two), infection (five), cyst formation (10), and recurrent tumor (five). In general, MR was found to be more useful than CT for the detection of hemorrhage and infection after craniotomy or craniectomy and for the proper localization of postoperative cysts. MR proved to be a useful method for following postoperative sites in the skull.

Fusiform basilar artery aneurysm in a 33-month-old child.

A 33-month-old girl presented with acute subarachnoid hemorrhage from a ruptured multilobulated fusiform aneurysm of the midbasilar artery. This rare lesion was treated surgically by occluding the basilar artery. Intraoperative brain stem auditory evoked potential and somatosensory evoked potential monitoring results did not change with basilar artery occlusion, suggesting that the occlusion would be tolerated. However, the amplitudes of brain stem auditory evoked potential Waves III-V to right ear stimulation were transiently reduced during left pontine retraction during the aneurysm exposure. The patient made a complete clinical recovery.