One-year journey in Kauvery!
Challenges in Neuroanaesthesia and Neurointensive care
KV. Bhagyashree*
Department of Neurosciences, Kauvery Hospital, Bengaluru, India
*Correspondence: bhags74@gmail.com
It's been a year since we started the Department of Neurosciences at Kauvery Hospital
Bangalore and Hosur. It has been a learning experience with some unique challenges
but overall a very satisfying one so far. We present here some of the interesting patients
we came across through the year, and their management.
Some illustrative cases are below.
Emergency Cases
(1) A 50-year-old man with Severe Traumatic brain injury came with a GCS of
E2V2M5 with CT showing an Acute Subdural Haematoma with significant
midline shift. His past history was significant for coronary angioplasty done one
month back following which he was on Aspirin and Ticagrelor. A Right FTP
craniotomy was done and clot evacuated undercover of platelet transfusion. The
challenge here was to balance between the risk of stent thrombosis and recurrent
intracranial bleeding. Postoperatively the patient was neurologically intact but
after 48 h when LMWH was started, he bled again and had to be reexplored twice.
When LMWH was stopped for 36 h in view of rebleeding, he developed a stroke.
So, the rehabilitation was longer requiring a balance between his cardiac and
neurologic status. He was discharged home in a stable condition, having been
decannulated and neurologically obeying commands.
(2) A 50-year-old lady, a known case of chronic Atrial Fibrillation on Acitrom
presented to the ER with Acute Middle Cerebral Artery Infarct. A Mechanical
Thrombectomy was done and she recovered well post-intervention and was
discharged home with mild speech difficulty and hemiparesis. Challenges faced
with her were Intraoperative Atrial Fibrillation with fast ventricular Rate and
readmission with Ischemic limb requiring Embolectomy twice. We expected her
to end up with amputation but the limb survived.
(3) We treated a number of High cervical spine injuries requiring C1–C2 cervical
spine fixation. The challenge in these cases was airway management
intraoperatively and post-extubation respiratory management in view of
compromised respiratory muscle function.
(4) A young patient presented with stroke with no pre-existing co-morbidities and
echocardiogram revealed a big Left Ventricular clot.
(5) An elderly man presented with stroke, on evaluation with carotid ultrasound was
found to have a dissection and floating thrombus in the carotid artery. A CT
angiogram showed a Type A Aortic dissection extending from the Aortic Root to
Descending thoracic aorta and involving the carotids.
Elective Cases
(1). Paediatric cases: We treated a variety of spine and cranial cases
(a). A 7-day-old Neonate with Myelomeningocele.
(b). A 4-month-old infant with thoracic spinal cord lesion with intrathoracic
extension - Issues faced - blood loss post-operatively, flail chest in view of rib
excision. Histopathology revealed a Rhabdomyosarcoma.
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(c). A 2-year-old child, post excision of Tumour developed severe pulmonary
oedema in the immediate post-operative period, managed with diuretics,
elective ventilation with sedation and relaxant, the child recovered well and
went on to receive radiotherapy and is doing well.
(d). A 2-month-old premature infant with postnatal ICH with ventriculosubgaleal
shunt was planned for double barrel VP shunt. The challenges faced-securing
an IV line (no lines as a result of being in the NICU for one month). We wanted
to induce after securing an IV line since the baby was underweight (weighing 2
kg at 2 months). Due to inability to secure an IV-line, Intraosseous line was
inserted for induction and then the central line was secured. Post-operatively the
infant had an episode of status epilepticus due to which she was electively
ventilated, kept on multiple IV antiepileptics and the seizures were controlled
after a week. The baby recovered well.
(e). A 3-year-old presented with a Temporal lobe lesion with epilepsy, not
responding to antiepileptics. The child underwent a temporal lobectomy,
amygdala hippocampectomy under Neuromonitoring. The child is seizure-free
post-operatively.
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Awake Craniotomies in Special Circumstances
(1) A 50-year-old man presented with sudden onset weakness, imaging showing lesion
involving motor area on the left side due to which awake craniotomy was planned.
Pre-operative
evaluation
revealed
chronic
alcoholic
liver
disease,
Thromboelastogram showed deficiency of all factors. He was transfused with
platelets, cryoprecipitate, FFP and then taken up for awake craniotomy.
(2) A 60-year-old presented with altered sensorium, hemiparesis and speech difficulty.
During evaluation, a screening CT scan of the thorax showed lung lesions
suggestive of carcinoma lung. An Awake craniotomy was done in view of a SpaceOccupying-Lesion in the motor area involving the speech area and being a poor
candidate for general anaesthesia in view of poor respiratory reserve associated
with carcinoma lung.
(3) A few patients presented with medically intractable seizures on two to three
antiepileptics. Awake craniotomy with neuromonitoring was done. We had
challenges with Intraoperative seizures in these patients.
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(4) Recurrent sphenoid wing meningioma presented with medically intractable
seizures. Craniotomy and excision of tumour and epileptic foci which involved
amygdala and hippocampus was done in an awake patient with neuromonitoring.
The duration of surgery was 8 h which was a challenge in an awake patient. We
also had difficulties with identification of the epileptic foci and intraoperative
seizures.
(5) Cavernoma near the speech area. Awake craniotomy was done with good results.
ACom Aneurysm Clipping
The patient presented with GCS of E2V3M5 Fisher grade 4 vasospasm, clipping of the
aneurysm was done, intraoperative period was uneventful. Post-operatively the patient
was ventilated in view of subarachnoid haemorrhage and vasospasm. DSA was done in
view of poor neurological recovery. The DSA did not show Aneurysmal filing. There
was no vasospasm seen, so intraarterial Nimodipine was deferred. After three weeks,
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the patient was weaned off the ventilator. His neurological recovery was good with M5
response. The patient later developed abdominal distension and anasarca. CT abdomen
showed ascites, but no intestinal obstruction. Liver function tests were deranged and
Meropenem induced liver injury was diagnosed and he was managed with Ascitic
tapping and hepatoprotective drugs. He made a full recovery after one month in
rehabilitation with a total hospital stay of three months.
09/05/21
11/05/21
18/05/21
22/05/21
05/06/21
21/07/21
T.BIL
1.5
1.8
1.5
1.0
1.7
0.5
D.BIL
0.9
1.1
0.5
0.1
0.2
0.1
PROTEINS
5.6
5.7
5.1
5.3
8.5
6.8
Albumin
3.2
3.5
2.1
2.3
4.5
3.0
SGOT
135
218
85
49
43
25
SGPT
68
113
152
97
30
16
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ALK PHOS
140
124
87
60
111
85
GGT
526
753
319
196
104
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Skull Base Surgery
A 72-year-old obese lady presented with clival tumour extending into Brain stem
invaginating the basilar and vertebral artery with Hydrocephalus. On admission, the
patient was breathless and not able to walk due to imbalance. Pre-operative evaluation
revealed saturation of 85% on room air with CT chest changes suggestive of COVID
pneumonia. RT–PCR was positive. So, only VP shunt was done and the patient was
discharged home and elective skull base surgery was performed after six weeks.
Endonasal endoscopic navigation-guided tumour excision was done under
Neuromonitoring and TIVA.
Patient was ventilated post-operatively in view of post-COVID status, long duration
surgery and obesity.
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Patient is doing well at six months follow up.
Bilateral ST-MCA BYPASS for Moyamoya Disease
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(1). A 28-year-old patient presented with Right-sided Hemiparesis, left-sided numbness
and visual defects with colour blindness. Left-sided ST-MCA bypass was performed in
Aug 2020 and the patient recovered from right-sided weakness and vision improved
significantly, but there was no change in colour blindness. Right sided ST-MCA bypass
was considered after six months in view of her left-sided numbness and to prevent
further ischemic changes. The patient was discharged in a stable condition. At followup her colour blindness is improving. Hemiparesis improved to Normal power.
(2). A 40-year-old guy with a Jugular Foramen tumour with all lower cranial nerves
involved. Provisional diagnoses of schwannoma or paraganglioma were considered.
There was no hypertension and no signs of any sympathetic overactivity
preoperatively. The tumour was very vascular with a resultant intraoperative blood loss
of 2.5 L. He recovered well postoperatively and was discharged on nasogastric tube
feeding in view of lower cranial nerve involvement. Histopathology has been reported
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as Plasmoacytoma or paraganglioma. IHC is awaited. This was unique since
plasmacytoma is a very rare entity in jugular foramen tumours
Dr. KV. Bhagyashree
Senior Consultant
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