One-year journey in Kauvery!
Challenges in Neuroanaesthesia and Neurointensive care

KV. Bhagyashree*

Department of Neurosciences, Kauvery Hospital, Bengaluru, India

*Correspondence: [email protected]

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.
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Elective Cases

Paediatric cases:

We treated a variety of spine and cranial cases

  • A 7-day-old Neonate with Myelomeningocele.
  • 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.
  • 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.
  • 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.
  • 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

  • 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.
  • 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 Space-Occupying-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.
  • 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.
  • 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.
  • Cavernoma near the speech area. Awake craniotomy was done with good results.
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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, 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.

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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
ALK PHOS 140 124 87 60 111 85
GGT 526 753 319 196 104 47

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.

Patient is doing well at six months follow up.

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Bilateral ST-MCA BYPASS for Moyamoya Disease

(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 follow-up her colour blindness is improving. Hemiparesis improved to Normal power.

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(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 as Plasmoacytoma or paraganglioma. IHC is awaited. This was unique since plasmacytoma is a very rare entity in jugular foramen tumours

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dr.kv.bhagyashree

Dr. KV. Bhagyashree
Senior Consultant

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