Analysis on Short-Term Outcomes for Cerebral Protection Treatment in Post Severe Traumatic Brain Injury Patients: A Single Neurosurgical Centre Study.

Background: Severe traumatic brain injury (TBI) is a leading cause of disability worldwide and cerebral protection (CP) management might determine the outcome of the patient. CP in severe TBI is to protect the brain from further insults, optimise cerebral metabolism and prevent secondary brain injury. This study aimed to analyse the short-term Glasgow Outcome Scale (GOS) at the intensive care unit (ICU) discharge and a month after ICU discharge of patients post CP and factors associated with the favourable outcome. Methods: This is a prospective cohort study from January 2021 to January 2022. The short-term outcomes of patients were evaluated upon ICU discharge and 1 month after ICU discharge using GOS. Favourable outcome was defined as GOS 4 and 5. Generalised Estimation Equation (GEE) was adopted to conduct bivariate GEE and subsequently multivariate GEE to evaluate the factors associated with favourable outcome at ICU discharge and 1 month after discharge. Results: A total of 92 patients with severe TBI with GOS of 8 and below admitted to ICU received CP management. Proportion of death is 17% at ICU discharge and 0% after 1 month of ICU discharge. Proportion of favourable outcome is 26.1% at ICU discharge and 61.1% after 1 month of ICU discharge. Among factors evaluated, age (odds ratio [OR] = 0.96; 95% CI: 0.94, 0.99; P = 0.004), duration of CP (OR = 0.41; 95% CI: 0.20, 0.84; P = 0.014) and hyperosmolar therapy (OR = 0.41; CI 95%: 0.21, 0.83; P = 0.013) had significant association. Conclusion: CP in younger age, longer duration of CP and patient not receiving hyperosmolar therapy are associated with favourable outcomes. We recommend further clinical trial to assess long term outcome of CP.

Perianaesthetic management on a child with Lennox-Gastaut Syndrome for vagus nerve stimulation (VNS) placement.

Vagus nerve stimulation (VNS) is a neurostimulatory modality in treating patients with medically resistant epilepsy (MRE). It was introduced in 1997 and has been proven to reduce patients' dependency on antiepileptic drugs and seizure frequency. However, the usage of VNS in children with MRE has been limited, especially those with Lennox Gastaut Syndrome (LGS). Our teenage boy with this syndrome developed MRE and successfully underwent VNS placement. We discuss the perianaesthetic challenges, a brief description of VNS and the reported successes in patients with LGS.

Clinical outcomes and thermodynamics aspect of direct brain cooling in severe head injury.

Background: Brain cooling therapy is one of the subjects of interest, and currently, data on direct brain cooling are lacking. Hence, the objective is to investigate the clinical outcomes and discuss the thermodynamics aspect of direct brain cooling on severely injured brain patients. Methods: This pilot study recruited the severely injured brain patients who were then randomized to either a direct brain cooling therapy group using a constant cooling temperature system or a control group. All studied patients must be subjected to an emergency neurosurgical procedure of decompressive craniectomy and were monitored with intracranial pressure, brain oxygenation, and temperature. Further, comparison was made with our historical group of patients who had direct brain cooling therapy through the old technique. Results: The results disclosed the direct brain cooling treated patients through a newer technique obtained a better Extended Glasgow Outcome Score than a control group (P < 001). In addition, there is a significant outcome difference between the combined cooling treated patients (new and old technique) with the control group (P < 0.001). Focal brain oxygenation and temperature are likely factors that correlate with better outcomes. Conclusion: Direct brain cooling is feasible, safe, and affects the clinical outcomes of the severely traumatized brain, and physics of thermodynamics may play a role in its pathophysiology.

Neuroanaesthetic challenges in a pregnant patient with a huge cerebellopontine angle meningioma.

Intracranial malignancy among pregnant women is extremely rare. Neuroanaesthesia for such high-risk patients demands extreme precautions. Our patient presented with a huge right cerebellopontine angle meningioma during the first trimester of her pregnancy. We share our valuable perianaesthetic challenges in managing her tumour-debulking surgery and a brief review of intracranial neoplasm during pregnancy.

Perianaesthetic challenges in patients undergoing vagus nerve stimulation (VNS) placement.

Patients with medically refractory epilepsy (MRE) are indicated for vagus nerve stimulation (VNS) placement. Anaesthesia for VNS placement is extremely challenging and requires several considerations. We present a man in his 20s with MRE who successfully underwent VNS placement. We review the mechanism of action of VNS, anaesthetic challenges and measures to prevent seizures.

The Effectiveness of Dedicated Trauma Operation Theatre and Trauma Intensive Care Unit on the Outcomes of Patients with Traumatic Brain Injury after Emergency Neurosurgery.

Background: A dedicated trauma operation theatre (TOT) and a trauma intensive care unit (TICU) within the same block as the emergency department (ED) can facilitate immediate management and surgery of patients suffering from traumatic brain injury (TBI). The present study compared the effectiveness and outcomes of TBI management between the TOT-TICU and general OT (GOT) and neuro-ICU (NICU) setups. Methods: This was a retrospective cohort study involving 120 patients with TBI who were divided into the GOT-NICU (n = 63) and TOT-TICU (n = 57) groups. Data were obtained from patients' admission and medical records. Demographic data, durations of specific management phases and outcomes of patients were documented. Results: In the TOT-TICU group, the duration of transportation from ED to OT [15 (standard deviation [SD] = 15) min versus 45 (SD = 15) min; P < 0.001], duration of arrival in OT to incision [50 (SD = 30) versus 70 (SD = 23) min; P = 0.005] and duration of transportation from OT to ICU [40 (SD = 17) versus 48 (SD = 30); P = 0.005] were significantly shorter than those in the GOT-NICU group. However, the duration of mechanical ventilation, duration of ICU stays, Glasgow Outcome Scale (GOS) upon discharge and GOS at 3-month post-discharge were comparable between both groups. Conclusion: The TOT-TICU setup shortened the duration of transportation from ED to OT, duration of arrival in OT to incision and duration of transportation from OT to ICU compared with the GOT-NICU setup. Hence, the availability of OT and ICU within the trauma block managed to provide immediate management to TBI patients.

Nosocomial Elizabethkingia meningoseptica meningitis and bacteremia in a post transsphenoidal hypophysectomy complicated with sagittal sinus thrombosis: A case report.

Background: Elizabethkingia meningoseptica meningitis is rare and challenging to manage infection. As this infection is always associated with superimposed multidrug-resistant organisms, a combination and prolonged antibiotic treatment are necessary to ensure the complete eradication of infections. Case Description: We report successful antibiotic therapies in a patient with E. meningoseptica bacteremia and meningitis complicated with superimposed extreme-drug-resistant Acinetobacter baumannii infection in a patient post transsphenoidal hypophysectomy complicated with central venous thrombosis. Conclusion: Antibiotic combination therapy with prolonged duration in those with E. meningoseptica with concomitant multi-resistant organisms is needed. Diagnosing associated prothrombotic risk with the infection and prompt treatment would also be essential.

Role of high-flow nasal oxygen therapy in COVID-19 pneumonia with Eisenmenger syndrome: A case report.

Since the coronavirus disease 2019 (COVID-19) pandemic emerged in November 2019, various international guidelines and local protocols have been published to assist clinicians face the pandemic effectively. Medical and ventilatory strategies have evolved and researchers have come out with multiple studies and solutions within a short period of time. The patient's best interest is always the goal of the management. We present a case report of COVID-19 pneumonia in a patient with underlying Eisenmenger syndrome and the potential benefits of high-flow nasal oxygen therapy in this patient.

Comparison of the Baska mask and the i-gel supraglottic airway devices in patients undergoing elective surgery.

INTRODUCTION: The Baska mask and i-gel are two new types of second-generation supraglottic airway devices. The aim of this study was to compare these two devices in terms of quality of insertion, quality of ventilation and post-insertion complications. MATERIAL AND METHODS: A total of 80 adult patients who were scheduled for elective surgery under general anaesthesia were randomised to two groups: Group BM: Baska mask (n = 40) and Group IG: i-gel (n = 40). The assessment focused on ease of insertion, number of attempts, insertion time, number of corrective manoeuvres, oropharyngeal leak pressure, tidal volume, peak airway pressure (PAP) and post-insertion complications. RESULTS: Group IG showed a significantly shorter median insertion time (13.3 [interquartile range, IQR 7.8] vs. 17.0 [IQR 9.6] s; P < 0.001), a higher percentage in the 'very easy' ease of insertion category (62.5% vs. 10.0%; P < 0.001), a higher percentage in the no corrective manoeuvre category (92.5% vs. 72.5%; P = 0.003) and a higher percentage in the no post-operative throat pain category (67.5% vs. 32.5%; P = 0.011) than Group BM. However, Group BM showed a significantly higher generated PAP than Group IG (12.7 [1.8] and 11.5 [2.2] cm H2O, respectively; P = 0.010). There were no significant differences in other parameters. CONCLUSIONS: The i-gel was better than the Baska mask in terms of ease of insertion, speed of insertion, fewer corrective manoeuvres and less post-operative throat pain. However, the Baska mask had a better cuff seal, as shown by a higher generated PAP.

Language Mapping in Awake Surgery: Report of Two Cases with Review of Language Networks.

The role of language in communication plays a crucial role in human development and function. In patients who have a surgical lesion at the functional language areas, surgery should be intricately planned to avoid incurring further morbidity. This normally requires extensive functional and anatomical mappings of the brain to identify regions that are involved in language processing and production. In our case report, regions of the brain that are important for language functions were studied before surgery by employing (a) extraoperative methods such as functional magnetic resonance imaging, transmagnetic stimulation, and magnetoencephalography; (b) during the surgery by utilizing intraoperative awake surgical methods such as an intraoperative electrical stimulation; and (c) a two-stage surgery, in which electrical stimulation and first mapping are made thoroughly in the ward before second remapping during surgery. The extraoperative methods before surgery can guide the neurosurgeon to localize the functional language regions and tracts preoperatively. This will be confirmed using single-stage intraoperative electrical brain stimulation during surgery or a two-stage electrical brain stimulation before and during surgery. Here, we describe two cases in whom one has a superficial lesion and another a deep-seated lesion at language-related regions, in which language mapping was done to preserve its function. Additional review on the neuroanatomy of language regions, language network, and its impairment was also described.

Non-invasive ventilation in a pregnancy with severe pneumonia.

INTRODUCTION: Non-invasive ventilation (NIV) is not proven to be effective in treating respiratory failure in severe pneumonia. However, some clinicians nevertheless attempt NIV to indirectly deliver adequate oxygenation and avoid unnecessary endotracheal intubation. CASE PRESENTATION: In this article, we report the case of a 24-year-old woman at 32 weeks' gestation who presented with hypoxemic respiratory failure requiring mechanical ventilation. She was successfully managed by NIV. DISCUSSION: However, NIV must be managed by providers who are trained in mechanical ventilation. This is of the utmost importance in avoiding any delay should the patient's condition worsen and require endotracheal intubation. Moreover, in pregnant women, the severity of illness may progress quickly due to the immunosuppression inherent in these patients. CONCLUSION: Special attention should be given to the choices of invasive ventilation and NIV to manage community acquired pneumonia patients in third trimester.

Epilepsy Surgery in Hospital Universiti Sains Malaysia: Our Experiences since 2004.

Epilepsy surgery has been performed by a few centres in Malaysia, including Hospital Universiti Sains Malaysia (HUSM). To date, a total of 15 patients have undergone epilepsy surgery in HUSM. The epilepsy surgery included anterior temporal lobectomy (ATL) with amygdalohippocampectomy (AH) and Vagal nerve stimulation (VNS). The surgical outcomes of the patients were assessed using the International League Against Epilepsy (ILAE) outcome scale. The ILAE scores for patients who underwent ATL with AH were comparatively better than those who underwent VNS. One of the patient who underwent ATL with AH and frontal lesionectomy was found to have psychosis during follow up. Epilepsy surgery has proven to be an important treatment for medically resistant epilepsy. Thus it is important to raise public awareness regarding epilepsy and its treatment.