Effect of administration of tranexamic acid on blood loss and transfusion requirements in children undergoing posterior fossa tumor excision: a retrospective cohort study.

BACKGROUND: Surgical resection of posterior fossa tumors (PFT) in the pediatric age group often results in significant intraoperative blood loss. The primary objective was to assess the effect of tranexamic acid (TXA) on blood loss and transfusion requirement in pediatric patients undergoing excision of PFT. METHODS: In this retrospective study, all pediatric patients ≤ 18 years, who underwent PFT resection over a period of 7 years, were included. The patient and surgical characteristics, estimated blood loss (EBL), the need for blood and blood product transfusion, use of crystalloids, vasopressors, and any adverse events like seizures and thromboembolic events were recorded and compared between Group A who received TXA and Group B who did not. RESULTS: The study included 50 patients, out of which 36 belonged to Group A and 14 to Group B. The median age was 8 years (IQR, 2-17) and the mean BMI was 16.46 ± 4.11 kg/m2. The mean EBL was 224.29 ± 110.36 ml in group A (n = 36) and 362 ± 180.11 ml in group B (n = 14) (p = 0.007). The intraoperative volume of crystalloid use was significantly higher in group B (p = 0.04). The requirement of blood and blood product transfusion was similar between the groups, but the volume of blood transfusion per kg body weight was higher in group B, 8.3 (IQR, 6.7-11.1) ml/kg in Group A versus 10.5 (IQR, 8.1-16.1) ml/kg in Group B (p-value 0.3). The rates of complications noted in the form of seizures and thromboembolic events were comparable. CONCLUSION: The use of TXA in the pediatric population undergoing PFT resection aids in reducing blood loss during the surgery without increasing complications.

A Rare Case of Rhinocerebral Mucormycosis Presenting as Garcin Syndrome and Acute Ischemic Stroke.

BACKGROUND: Mucormycosis is a rare fungal infection affecting immunocompromised patients, with the rhinocerebral variant as the most common presentation.1 Garcin syndrome is the progressive involvement of the cranial nerves resulting in total unilateral paralysis of cranial nerves, absence of sensory or motor deficits, and not associated with features of raised intracranial pressure.2 We report a case of invasive rhinocerebral mucormycosis presenting as Garcin syndrome and acute ischemic stroke. HOW TO CITE THIS ARTICLE: Nagendra V, Thakkar KD, Prasad Hrishi A, Prathapadas U. A Rare Case of Rhinocerebral Mucormycosis Presenting as Garcin Syndrome and Acute Ischemic Stroke. Indian J Crit Care Med 2020;24(11):1137-1138.

A Case of Transposition of Great Arteries with Ventricular Septal Defect and Mesocardia Presenting for Neurosurgery.

Congenitally corrected transposition of great arteries (CC-TGAs) associated with a ventricular septal defect (VSD) presents with cyanotic spells and systemic complications such as brain abscess. In mesocardia, the heart lies in the midline with no apex seen on the left side. We report the anesthetic management of a child with CC-TGA, VSD, and mesocardia presenting with parietal brain abscess for neurosurgery. The significant anesthetic challenges include maintenance of peripheral vascular resistance lower than systemic vascular resistance, prevention of air embolism and paradoxical embolism, avoidance of hyperviscosity in addition to avoiding any rise in intracranial pressure, and maintenance of cerebral perfusion pressure.

Novel application of near-infrared spectroscopy in detecting iatrogenic vasospasm during interventional neuroradiological procedures.

One of the complications of carotid artery stenting (CAS) is iatrogenic vasospasm caused by mechanical irritation of the blood vessel lumen by a guidewire, catheter, stent retriever, or distal protection devices. Although often self-limiting, the mechanical vasospasm can cause reduction in the cerebral blood flow and result in catastrophic ischemia, especially when undetected and persistent. Real-time cerebral oximetry with near-infrared spectroscopy (NIRS) could detect episodes of cerebral hypoxemia due to vasospasm and facilitate intervention for prevention of hypoxic brain injury during neuro-intervention procedures such as CAS. We present a case scenario where NIRS detected iatrogenic vasospasm even before the conventional tests could identify the event during CAS.

A Mysterious Case of Spontaneous Cervical Epidural Hematoma and Bilateral Primary Spontaneous Pneumothorax Caused by a Rare Etiology.

Spontaneous spinal epidural hematoma (SSEH) is a rare disorder that can present as an acute onset of pain and radicular symptoms that mimic disc herniation. Primary spontaneous pneumothorax (PSP) can be defined as the presence of air in the pleural space without apparent underlying lung disease or trauma. We describe a rare case of SSEH in the cervical spine (C5-7) presenting with a novel association, a bilateral PSP, which has never been documented before. Both SSEH and spontaneous pneumothorax, though rare, can be associated with vasculopathy and our patient had signs of vasculopathy of intracranial vessels and pulmonary vasculature. Vasculopathy also needs to be considered while evaluating a case of PSP without emphysema-like changes (ELC) and if diagnosed as the cause, pleurodesis could be considered as a part of the management to avoid the sequel of recurrent pneumothorax and prolonged ICU stay in this subset of patients. HOW TO CITE THIS ARTICLE: Thakkar K, Ajayan N, Unnikrishnan P, Sethuraman M, Hrishi AP. A Mysterious Case of Spontaneous Cervical Epidural Hematoma and Bilateral Primary Spontaneous Pneumothorax Caused by a Rare Etiology. Indian Journal of Critical Care Medicine, January 2019;23(1):51-53.

A Mysterious Case of Spontaneous Cervical Epidural Hematoma and Bilateral Primary Spontaneous Pneumothorax caused by a Rare Etiology.

Spontaneous spinal epidural hematoma (SSEH) is a rare disorder that can present as an acute onset of pain and radicular symptoms that mimic disk herniation. Primary spontaneous pneumothorax (PSP) can be defined as presence of air in the pleural space without apparent underlying lung disease or trauma. We describe a rare case of SSEH in cervical spine (C5-7) presenting with a novel association, a bilateral PSP, which has never been documented before. Both SSEH and spontaneous pneumothorax, though rare, can be associated with vasculopathy and our patient had signs of vasculopathy of intracranial vessels and pulmonary vasculature. Vasculopathy also needs to be considered while evaluating a case of PSP without emphysema-like changes (ELCs) and if diagnosed as the cause, pleurodesis could be considered as a part of the management to avoid the sequel of recurrent pneumothorax and prolonged ICU stay in this subset of patients. How to cite this article Thakkar K, Ajayan N, et al. A Mysterious Case of Spontaneous Cervical Epidural Hematoma and Bilateral Primary Spontaneous Pneumothorax caused by a Rare Etiology. Indian J Crit Care Med 2019;23(4):186-187.

Dexmedetomidine for Electrocorticography in Patients With Lennox-Gastaut Syndrome Presenting for Epilepsy Surgery: A Case Report.

We report the anesthetic management of 2 patients with Lennox-Gastaut syndrome presenting for respective epilepsy surgery with intraoperative electrocorticography. Electrocorticography is a useful tool to guide the localization of the epileptogenic focus for surgical resection in epilepsy surgery. Drug interactions, proconvulsant or anticonvulsant activity of the anesthetics, and anesthetic influence on intraoperative electrocorticography are the primary concerns to be addressed in these patients. We observed that dexmedetomidine-based anesthesia facilitates intraoperative electrocorticography monitoring. Dexmedetomidine, by decreasing the requirements of other anesthetic agents, offers better recovery profile and pain relief with minimal respiratory depression in patients undergoing disconnective epilepsy surgeries.

Limitations of near infrared spectroscopy (NIRS) in neurosurgical setting: our case experience.

One of the primary goals of anaesthesia in neurosurgical procedures is prevention of cerebral hypoxia leading to secondary neurological injury. Cerebral oximetry detects periods of cerebral hypoxemia and allows intervention for prevention of secondary brain injury and its sequelae. This can be achieved by the use of Near Infrared Spectroscopy (NIRS). In this regard, we present two cases where erroneous values of NIRS were shown which hindered monitoring of cerebral oxygenation in the intraoperative setting. In a neurosurgical setting, the erroneous values on the operative side could be attributed to altered tissue boundary conditions resulting in a changed optical path, which is normally held as a constant in NIRS measurements. The altered tissue boundary conditions could be due to the presence of air or blood between the myocutaneous flapskull, skull-dura, dura-brain interphases. It could also be that the sensors' penetrating depth was inadequate to compensate for the increased distance between sensor and brain tissue, thereby resulting in inaccurately higher values (> 80%).