Reversible Cerebral Vasoconstriction Syndrome with Intracranial Hypertension: Should Decompressive Craniectomy Be Considered?

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is a rare cause of intracerebral hemorrhage (ICH) causing intracranial hypertension. METHODS: Case report. RESULTS: We report a case of RCVS-related ICH leading to refractory intracranial hypertension. A decompressive craniectomy was performed to control intracranial pressure. We discuss here the management of RCVS with intracranial hypertension. Decompressive craniectomy was preformed to avoid the risky option of high cerebral perfusion pressure management with the risk of bleeding, hemorrhagic complications, and high doses of norepinephrine. Neurological outcome was good. CONCLUSION: RCVS has a complex pathophysiology and can be very difficult to manage in cases of intracranial hypertension. Decompressive craniectomy should probably be considered.

Postoperative complications after craniotomy for brain tumor surgery.

INTRODUCTION: After elective craniotomy for brain tumour surgery, patients are usually admitted to an intensive care unit (ICU) for monitoring. Our goal was to evaluate the incidence and timing of neurologic and non-neurologic postoperative complications after brain tumour surgery, to determine factors associated with neurologic events and to evaluate the timing and causes of ICU readmission. PATIENTS AND METHODS: This prospective, observational and analytic study enrolled 188 patients admitted to the ICU after brain tumour surgery. All postoperative clinical events during the first 24hours were noted and classified. Readmission causes and timing were also analysed. RESULTS: Twenty-one (11%) of the patients were kept sedated after surgery; the remaining 167 patients were studied. Thirty one percent of the patients presented at least one complication (25% with postoperative nausea and vomiting (PONV), 16% with neurologic complications). The occurrence of neurological complications was significantly associated with the absence of preoperative motor deficit and the presence of higher intraoperative bleeding. Seven patients (4%) were readmitted to the ICU after discharge; 43% (n=3) of them had a posterior fossa surgery. CONCLUSION: Postoperative complications, especially PONV, are frequent after brain tumour surgery. Moreover, 16% of patients presented a neurological complication, probably justifying the ICU postoperative stay for early detection. The absence of preoperative motor deficit and intraoperative bleeding seems to predict postoperative neurologic complications. Finally, patients may present complications after ICU discharge, especially patients with fossa posterior surgery, suggesting that ICU hospitalization may be longer in this type of surgery.

The optimal time between clinical brain death diagnosis and confirmation using CT angiography: a retrospective study.

BACKGROUND: In several countries, a computed tomography angiography (CTA) is used to confirm brain death (BD). A six­hour interval is recommended between clinical diagnosis and CTA acquisition despite the lack of strong evidence to support this interval. The aim of this study was to determine the optimal timing for CTA in the confirmation of BD. METHODS: This retrospective observational study enrolled all adult patients admitted between January 2009 and December 2013 to the intensive care units of a French university hospital with clinically diagnosed BD and at least one CTA performed as a confirmatory test. The CTAs were identified as conclusive (e.g. yielding confirmation of BD) or inconclusive (e.g. showing persistent brain circulation). RESULTS: One hundred and four patients (sex ratio M/F 1.8; age 55 years [41­64]) underwent 117 CTAs. CTAs confirmed cerebral circulatory arrest in 94 cases yielding a sensitivity of 80%. Inconclusive CTAs were performed earlier than conclusive ones (2 hours [1­3] vs. 4 hours [2­9], P=0.03) and were associated with decompressive craniectomy (5 cases [23%] vs. 6 cases [7%], P=0.05) and the failure to complete full neurological examination (5 cases [23%] vs. 4 cases [5%], P=0.02). Six hours after BD clinical diagnosis, the proportion of conclusive CTA was only 51%, with progressive increase overtime with more than 80% of conclusive CTA after 12 hours. CONCLUSIONS: A 12­hour interval might be appropriate in order to limit the risk of inconclusive CTAs.

Optimal perioperative management of arterial blood pressure.

Perioperative blood pressure management is a key factor of patient care for anesthetists, as perioperative hemodynamic instability is associated with cardiovascular complications. Hypertension is an independent predictive factor of cardiac adverse events in noncardiac surgery. Intraoperative hypotension is one of the most encountered factors associated with death related to anesthesia. In the preoperative setting, the majority of antihypertensive medications should be continued until surgery. Only renin-angiotensin system antagonists may be stopped. Hypertension, especially in the case of mild to moderate hypertension, is not a cause for delaying surgery. During the intraoperative period, anesthesia leads to hypotension. Hypotension episodes should be promptly treated by intravenous vasopressors, and according to their etiology. In the postoperative setting, hypertension predominates. Continuation of antihypertensive medications and postoperative care may be insufficient. In these cases, intravenous antihypertensive treatments are used to control blood pressure elevation.

Anesthetic regimen for cardiac function evaluation by echocardiography in mice: comparison between ketamine, etomidate and isoflurane versus conscious state.

Mice with genetic alterations are used in heart research for the extrapolation of human diseases. Echocardiography is an essential tool for evaluating cardiac and hemodynamic functions in small animals. The purpose of this study was to compare the effect of different anesthetic regimens and the conscious state on the evaluation of cardiac function by echocardiography. Mice were examined in the conscious state after three days of training, and then for a 7 min period after a single intraperitoneal injection of ketamine at 100 mg/kg, etomidate at 10, 20 or 30 mg/kg, or after inhalation of isoflurane at 1.5% with or without a short period of induction with isoflurane 3%. Intra- and inter-observer variabilities were assessed. The operator's comfort was also assessed. Heart rate, left ventricular end diastolic diameter, fraction shortening and cardiac output were measured using echocardiography. Ketamine at 5 and 7 min after induction and isoflurane at 3, 5 and 7 min after induction provided good anesthetic conditions and a quick awakening time, and did not influence cardiac performance, whereas the conscious state was associated with a non-physiological sympathetic activation and other anesthetic drugs induced a significant decrease in heart rate. Etomidate 10 mg/kg and 20 mg/kg were not enough to provide adequate anesthesia. Etomidate 30 mg/kg induced a good anesthetic condition but influenced cardiac performance and had a long awakening time. Our results indicate that ketamine and isoflurane with a short induction period are better anesthetic drugs than isoflurane without induction or etomidate for evaluating cardiac function in healthy mice.

Apnea test for brain death determination in a patient on extracorporeal membrane oxygenation.

BACKGROUND: Apnea test is a key component to confirm brain death. For patients receiving extracorporeal membrane oxygenation (ECMO), apnea test remains challenging. Brain death (BD) diagnosis is often made without apnea test. CASE: We report the case of a 29-year-old man presenting clinical signs of BD while treated with ECMO therapy for refractory cardiogenic shock. Decreasing the ECMO sweep gas flow from 3 to 1 L/min and increasing oxygen delivery to 100% on ECMO during the apnea test have allowed increasing the PaCO2 of more than 20 mmHg without decreasing PaO2. DISCUSSION: In order to diagnose BD, neurological examination should be complete, including apnea testing, which can be not possible in patients receiving ECMO due to CO2 removal from the membrane. Decreasing sweep gas rate allows reduction in CO2 diffusion through the membrane. However, decreasing the ECMO gas flow to zero could be insufficient to maintain normoxemia. Decreasing (but not stopping) the sweep gas flow to 1 L/min and increasing the oxygen delivery through the ECMO have allowed performing the apnea test safely. CONCLUSION: To assess brain death in patients on ECMO, apnea test can be performed without compromising oxygenation by decreasing (but not stopping) the sweep gas flow and increasing oxygen delivery through the membrane.

Brainstem hemorrhage following decompressive craniectomy.

Decompressive craniectomy (DC) is used for the management of refractory raised intracranial pressure, but the impact of DC on surgical outcome is still controversial. We report a 21-year-old man admitted to our hospital after a road traffic accident. The brain CT scan revealed a left hemispheric acute subdural hematoma. After DC, he developed a brainstem hemorrhage. Recovery was, however, good.

Continuous spinal anaesthesia for a total hip arthroplasty in a patient with an atrial septal defect.

Atrial septal defect (ASD) is often diagnosed and repaired during childhood. Nevertheless, it is the most common congenital cardiac defect seen in adults. ASD is characterized by a left-to-right intracardiac shunt and pulmonary hypertension. Pulmonary hypertension increases perioperative risks of morbidity and mortality. We report the anaesthetic management of a 68-year-old woman with an unrepaired ASD, who underwent a total hip arthroplasty under continuous spinal anaesthesia.