Thoracic aortic aneurysms larger than 5 cm are associated with a fatal risk of rupture, and their... more Thoracic aortic aneurysms larger than 5 cm are associated with a fatal risk of rupture, and their diagnosis is usually followed by urgent surgical repair. Other complications associated with this condition include heart failure, myocardial infarction, and stroke. Literature regarding management of these patients for emergency noncardiac surgeries is scarce, with anecdotal reports advising both surgeries in the same sitting. However, neurosurgical procedures present a unique challenge in this situation, since systemic anticoagulation may be associated with a rebleed within the cranial vault. In this case report, we present an extremely rare and challenging scenario, wherein a patient with a 6.2-cm thoracic aortic aneurysm underwent subdural hematoma evacuation prior to aneurysmal repair.
The Bombay blood group is an extremely rare entity within the conventional ABO blood grouping sys... more The Bombay blood group is an extremely rare entity within the conventional ABO blood grouping system. End-stage liver disease also presents with myriad disorders of coagulation due to impaired synthesis and dysfunction of clotting factors, which predisposes patients to spontaneous and life-threatening episodes of bleeding. We report a patient with Bombay blood group and end-stage liver disease who presented to our hospital with a spontaneous subdural hematoma. Although conventional parameters of coagulation in this patient were abnormal, we were able to safely defer product transfusion because his thromboelastography (TEG) report was within acceptable ranges. In this article, we discuss our strategy for optimization of extremely limited blood resources in this scenario and perioperative strategies for the management of coagulation anomalies in patients with liver dysfunction.
Entrapment of the auriculotemporal nerve (ATN) could possibly be the most frequent of all the tri... more Entrapment of the auriculotemporal nerve (ATN) could possibly be the most frequent of all the trigeminal headaches. Classically, the patient presents with complaints of headache in the area of temple. There are two main presentations when the ATN is involved: auriculotemporal neuralgia and auriculotemporal syndrome.
Formal brainstem reflex testing remains one of the most important procedures in identification an... more Formal brainstem reflex testing remains one of the most important procedures in identification and evaluation of patients who meet clinical criteria for brainstem death. Early identification of such patients is critical since willing donors may contribute to the organ donation process. During the first two waves of the coronavirus disease of 2019 (COVID-19) pandemic, organ transplantation from brainstem dead donors has declined significantly due to several reasons, including perceived increased risk of virus transmission to both physicians as well as patients as well as lack of awareness regarding donor workup in the context of the COVID-19 pandemic.
Journal of Anaesthesiology, Clinical Pharmacology, 2018
1. Pancholy SB, Sanghvi KA, Patel TM. Radial artery access technique evaluation trial: Randomized... more 1. Pancholy SB, Sanghvi KA, Patel TM. Radial artery access technique evaluation trial: Randomized comparison of Seldinger versus modified Seldinger technique for arterial access for transradial catheterization. Catheter Cardiovasc Interv 2012;80:288‐91. 2. Seto AH, Roberts JS, Abu‐Fadel MS, Czak SJ, Latif F, Jain SP, et al. Real‐time ultrasound guidance facilitates transradial access. Cardiovasc Interv 2015;8:283‐91. 3. Berk D, Gurkan Y, Kus A, Ulugol H, Solak M, Toker K. Ultrasound‐guided radial arterial cannulation: Long axis/in‐plane versus short axis/out‐of‐plane approaches? J Clin Monit Comput 2013;27:319‐24. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Background: Neuroanesthesiology and neurocritical care are constantly evolving branches of clinic... more Background: Neuroanesthesiology and neurocritical care are constantly evolving branches of clinical neuroscience, and patient management is often influenced by literature such as randomized controlled trials, systematic reviews, and meta-analyses. Many controversies still exist in the management of neurologically injured patients, and most research in this field does not translate into significant changes in clinical practice. Objective: This review aims to discuss studies of clinical importance published in preeminent journals over the time period 2017–2020, which may have the potential to influence our current management protocols. Methods: In this review, key articles have been selected to represent neuroemergencies where recent evidence may prompt changes in practice. In preparing this article, contents of prominent journals between 2017 and 2020 were reviewed, and relevant articles were also identified from abstraction services. Areas chosen for consideration are high-quality t...
Supraorbital neuralgia is an uncommon pain syndrome which may present with a typical history of s... more Supraorbital neuralgia is an uncommon pain syndrome which may present with a typical history of shock-like pain restricted to the area just above the eyebrow. It is also known as Goggle headache [1] or Swimmer’s headache [2]. It is associated with a characteristic triad of symptoms, namely: (1) Pain limited to the area innervated by the supraorbital nerve; (2) Tenderness on supraorbital notch or area distributed by the nerve; and (3) Symptomatic relief following nerve blockade. The pain presents with an intermittent or chronic pattern. The pain presents with an intermittent or chronic pattern with periods of varied severity. The hallmark of supraorbital neuralgia is localized pain in or above the eyebrow (sometimes extending into the scalp region) [3]. There may be symptoms of altered sensation and typical features of neuralgia, such as pain triggered by relatively innocuous mechanisms.
The infraorbital nerve is the terminal branch of the maxillary nerve. It may become entrapped at ... more The infraorbital nerve is the terminal branch of the maxillary nerve. It may become entrapped at any point along the length of its course, usually as it exits the skull via the infraorbital foramen causing shock-like unilateral pain its distribution known as infraorbital neuralgia. The classical findings of infraorbital neuralgia include (1) Pain over upper cheek radiating to upper teeth, nose and upper eyelid usually described as sharp, tingling or electric-like; (2) Tenderness to pressure over infraorbital foramen with possible radiation of pain along the nerve distribution on the affected side; and (3) Symptoms may be exacerbated by smiling, laughing or excessive tension on the zygomatic muscles, possibly due to further compression of the infraorbital nerve.
There has always been confusion regarding whether the symptoms of supraorbital neuralgia are caus... more There has always been confusion regarding whether the symptoms of supraorbital neuralgia are caused by compressive lesions of the supraorbital nerve in isolation, or due to compression of the supraorbital and supratrochlear nerves in combination. Although these two nerves share the sensory innervation of the forehead, the supraorbital nerve is typically held accountable for neuralgic pain in this region. In a prospective study by Pareja and colleagues [1], pain was observed to be limited to the area supplied by the supratrochlear nerve. It offers insights on the best way to distinguish between supraorbital and supratrochlear neuralgia (Table 1).
ventilation. A discrete plan for ventilation at each surgical step is needed. Considering the ext... more ventilation. A discrete plan for ventilation at each surgical step is needed. Considering the extent of tracheal pathology, preparations for alternative modes of ventilation are employed in coordination with the surgeon. In the face of an open airway, ventilation can be managed by manual oxygen through a small bore anode tube placed through the upper tracheal lesion combined with a distal endotracheal or bronchial tube inserted distal to the stenosis.[1] Earlier belief was that maximum length of the trachea that can be resected is 2 cm.[2] Lesions requiring resection of more than 6 cm or more than 50% of total length of trachea in adults or more than 30% trachea in children are considered inoperable. Longer segment involvement after previous surgery needs patch augmentation or slide trachaeoplasty.[3] Tissue engineering advances have successfully used cadaveric allografts and autologous tissue.[4]
Neurology India | Volume 67 | Issue 3 | May‐June 2019 889 A game‐changer? Expert Rev Neurother 20... more Neurology India | Volume 67 | Issue 3 | May‐June 2019 889 A game‐changer? Expert Rev Neurother 2016;16:849‐59. 5. Pruss H, Finke C, Holtje M, Hofmann J, Klingbeil C, ProbstC, et al. N‐methyl‐D‐aspartate receptor antibodies in herpes simplex encephalitis. Ann Neurol 2012;72:902‐11. 6. Ti t u l a e r M J , L e y p o l d t F, D a l m a u J . A n t i b o d i e s to N‐methyl‐D‐aspartate and other synaptic receptors in choreoathetosis and relapsing symptoms post‐herpes virus encephalitis. Mov Disord 2014;29:3‐6. 7. De Tiège X, De Laet C, Mazoin N, Christophe C, Mewasingh LD, Wetzburger C, et al. Postinfectious immune mediated encephalitis after pediatric herpes simplex encephalitis. Brain Dev 2005;27:304‐7. 8. Patel R, Jha S, Yadav RK. Pleomorphism of the clinical manifestations of neurocysticercosis.Trans R Soc Trop Med Hyg 2006;100:134‐41. 9. Dale RC, Irani SR, Brilot F, Pillai S, Webster R, Gill D, et al. N‐methyl‐D aspartate receptor antibodies in pediatric dyskinetic encephalitisleth...
Clinicians have been searching for means to alleviate incapacitating pain for a long time. Perine... more Clinicians have been searching for means to alleviate incapacitating pain for a long time. Perineural injection of various substances found to reduce pain, by interrupting neural conduction, chemical neurolysis, or other mechanisms of action. The medications most commonly administered during interventional procedures for pain management include local anaesthetics, corticosteroids, and neurolytic agents. This chapter contains a brief review of the most commonly used agents in interventional procedures for trigeminal neuralgia (TGN).
The management of drug-resistant trigeminal neuralgia (TGN) includes peripheral injections of dif... more The management of drug-resistant trigeminal neuralgia (TGN) includes peripheral injections of different chemical agents into the affected nerve. Historically, chloroform was the first substance used for this purpose. Later on, substances like glycerol, phenol, boiling water, high concentrations of tetracaine [1], and streptomycin [2, 3] were also used. Alcohol injections [4] are preferred at the initial presentation of TGN or in elderly patients with similar problem [5]. Patients with significant medical co-morbidities who are not fit to undergo invasive surgeries safely, may also benefit from alcohol injection [5]. Peripheral alcohol nerve block is associated with a variable duration of pain relief ranging from 6 to 16 months [6]. There are two distinct techniques described for peripheral nerve blocks for TGN: (a) extra-oral or percutaneous nerve blocks and (b) intraoral nerve block; this chapter will focus on intraoral nerve block techniques involving mandibular and maxillary nerves, and their branches (Table 1). The preferred local anesthetic (LA) agents include lignocaine (1–2%) and bupivacaine (0.5%) with or without adrenaline (1:2,00,000). Currently, the use of ropivacaine (0.5%) has also been increased as it has minimal cardiovascular risks with a prolonged duration of action.
Mental nerve neuralgia is a painful disorder in the distribution of the mental nerve. The first d... more Mental nerve neuralgia is a painful disorder in the distribution of the mental nerve. The first description of mental nerve neuropathy was given by Charles Bell in 1830, who reported the phenomenon in a patient with advanced breast cancer due to a bony metastasis in her left mandible [1]. Mental nerve neuropathy, which has also been called Numb Chin Syndrome is a purely sensory neuropathy identified by paraesthesia or numbness in the lower lip and chin. The clinical presentations are paraesthesia (tingling/burning/pins and needles) localised to a discrete area of the lower maxillary/mandibular region of the face, patients experiences a numb/swollen lower lip, loss of sensitivity may lead to inadvertent biting, or injury to the lower lip, symptoms are predominantly unilateral; however bilateral symptoms may also be present [2].
Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteris... more Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteristics that differ from adults. These can be attributed to age-related anatomical and physiological differences and distinct patterns of injuries seen in children. Our aim was to identify the patient characteristics, clinical variables during intensive care and intraoperative management associated with poor functional outcome in a cohort of pediatric TBI patients. Methods Retrospective chart review of pediatric TBI patients admitted to neurotrauma intensive care unit (NICU) over a period of 1 year. Results A total of 105 children (< 12 years) with head injury were admitted in the NICU during the study period. The most common mechanism of injury was fall in 78% cases. Fifty-four patients (51.4%) presented with a severe head injury (Glasgow coma scale [GCS] ≤ 8), while 31 (29.5%) and 20 (19.1%) had a mild and moderate head injury. The most common finding was skull fractures (59%), contusi...
Thoracic aortic aneurysms larger than 5 cm are associated with a fatal risk of rupture, and their... more Thoracic aortic aneurysms larger than 5 cm are associated with a fatal risk of rupture, and their diagnosis is usually followed by urgent surgical repair. Other complications associated with this condition include heart failure, myocardial infarction, and stroke. Literature regarding management of these patients for emergency noncardiac surgeries is scarce, with anecdotal reports advising both surgeries in the same sitting. However, neurosurgical procedures present a unique challenge in this situation, since systemic anticoagulation may be associated with a rebleed within the cranial vault. In this case report, we present an extremely rare and challenging scenario, wherein a patient with a 6.2-cm thoracic aortic aneurysm underwent subdural hematoma evacuation prior to aneurysmal repair.
The Bombay blood group is an extremely rare entity within the conventional ABO blood grouping sys... more The Bombay blood group is an extremely rare entity within the conventional ABO blood grouping system. End-stage liver disease also presents with myriad disorders of coagulation due to impaired synthesis and dysfunction of clotting factors, which predisposes patients to spontaneous and life-threatening episodes of bleeding. We report a patient with Bombay blood group and end-stage liver disease who presented to our hospital with a spontaneous subdural hematoma. Although conventional parameters of coagulation in this patient were abnormal, we were able to safely defer product transfusion because his thromboelastography (TEG) report was within acceptable ranges. In this article, we discuss our strategy for optimization of extremely limited blood resources in this scenario and perioperative strategies for the management of coagulation anomalies in patients with liver dysfunction.
Entrapment of the auriculotemporal nerve (ATN) could possibly be the most frequent of all the tri... more Entrapment of the auriculotemporal nerve (ATN) could possibly be the most frequent of all the trigeminal headaches. Classically, the patient presents with complaints of headache in the area of temple. There are two main presentations when the ATN is involved: auriculotemporal neuralgia and auriculotemporal syndrome.
Formal brainstem reflex testing remains one of the most important procedures in identification an... more Formal brainstem reflex testing remains one of the most important procedures in identification and evaluation of patients who meet clinical criteria for brainstem death. Early identification of such patients is critical since willing donors may contribute to the organ donation process. During the first two waves of the coronavirus disease of 2019 (COVID-19) pandemic, organ transplantation from brainstem dead donors has declined significantly due to several reasons, including perceived increased risk of virus transmission to both physicians as well as patients as well as lack of awareness regarding donor workup in the context of the COVID-19 pandemic.
Journal of Anaesthesiology, Clinical Pharmacology, 2018
1. Pancholy SB, Sanghvi KA, Patel TM. Radial artery access technique evaluation trial: Randomized... more 1. Pancholy SB, Sanghvi KA, Patel TM. Radial artery access technique evaluation trial: Randomized comparison of Seldinger versus modified Seldinger technique for arterial access for transradial catheterization. Catheter Cardiovasc Interv 2012;80:288‐91. 2. Seto AH, Roberts JS, Abu‐Fadel MS, Czak SJ, Latif F, Jain SP, et al. Real‐time ultrasound guidance facilitates transradial access. Cardiovasc Interv 2015;8:283‐91. 3. Berk D, Gurkan Y, Kus A, Ulugol H, Solak M, Toker K. Ultrasound‐guided radial arterial cannulation: Long axis/in‐plane versus short axis/out‐of‐plane approaches? J Clin Monit Comput 2013;27:319‐24. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Background: Neuroanesthesiology and neurocritical care are constantly evolving branches of clinic... more Background: Neuroanesthesiology and neurocritical care are constantly evolving branches of clinical neuroscience, and patient management is often influenced by literature such as randomized controlled trials, systematic reviews, and meta-analyses. Many controversies still exist in the management of neurologically injured patients, and most research in this field does not translate into significant changes in clinical practice. Objective: This review aims to discuss studies of clinical importance published in preeminent journals over the time period 2017–2020, which may have the potential to influence our current management protocols. Methods: In this review, key articles have been selected to represent neuroemergencies where recent evidence may prompt changes in practice. In preparing this article, contents of prominent journals between 2017 and 2020 were reviewed, and relevant articles were also identified from abstraction services. Areas chosen for consideration are high-quality t...
Supraorbital neuralgia is an uncommon pain syndrome which may present with a typical history of s... more Supraorbital neuralgia is an uncommon pain syndrome which may present with a typical history of shock-like pain restricted to the area just above the eyebrow. It is also known as Goggle headache [1] or Swimmer’s headache [2]. It is associated with a characteristic triad of symptoms, namely: (1) Pain limited to the area innervated by the supraorbital nerve; (2) Tenderness on supraorbital notch or area distributed by the nerve; and (3) Symptomatic relief following nerve blockade. The pain presents with an intermittent or chronic pattern. The pain presents with an intermittent or chronic pattern with periods of varied severity. The hallmark of supraorbital neuralgia is localized pain in or above the eyebrow (sometimes extending into the scalp region) [3]. There may be symptoms of altered sensation and typical features of neuralgia, such as pain triggered by relatively innocuous mechanisms.
The infraorbital nerve is the terminal branch of the maxillary nerve. It may become entrapped at ... more The infraorbital nerve is the terminal branch of the maxillary nerve. It may become entrapped at any point along the length of its course, usually as it exits the skull via the infraorbital foramen causing shock-like unilateral pain its distribution known as infraorbital neuralgia. The classical findings of infraorbital neuralgia include (1) Pain over upper cheek radiating to upper teeth, nose and upper eyelid usually described as sharp, tingling or electric-like; (2) Tenderness to pressure over infraorbital foramen with possible radiation of pain along the nerve distribution on the affected side; and (3) Symptoms may be exacerbated by smiling, laughing or excessive tension on the zygomatic muscles, possibly due to further compression of the infraorbital nerve.
There has always been confusion regarding whether the symptoms of supraorbital neuralgia are caus... more There has always been confusion regarding whether the symptoms of supraorbital neuralgia are caused by compressive lesions of the supraorbital nerve in isolation, or due to compression of the supraorbital and supratrochlear nerves in combination. Although these two nerves share the sensory innervation of the forehead, the supraorbital nerve is typically held accountable for neuralgic pain in this region. In a prospective study by Pareja and colleagues [1], pain was observed to be limited to the area supplied by the supratrochlear nerve. It offers insights on the best way to distinguish between supraorbital and supratrochlear neuralgia (Table 1).
ventilation. A discrete plan for ventilation at each surgical step is needed. Considering the ext... more ventilation. A discrete plan for ventilation at each surgical step is needed. Considering the extent of tracheal pathology, preparations for alternative modes of ventilation are employed in coordination with the surgeon. In the face of an open airway, ventilation can be managed by manual oxygen through a small bore anode tube placed through the upper tracheal lesion combined with a distal endotracheal or bronchial tube inserted distal to the stenosis.[1] Earlier belief was that maximum length of the trachea that can be resected is 2 cm.[2] Lesions requiring resection of more than 6 cm or more than 50% of total length of trachea in adults or more than 30% trachea in children are considered inoperable. Longer segment involvement after previous surgery needs patch augmentation or slide trachaeoplasty.[3] Tissue engineering advances have successfully used cadaveric allografts and autologous tissue.[4]
Neurology India | Volume 67 | Issue 3 | May‐June 2019 889 A game‐changer? Expert Rev Neurother 20... more Neurology India | Volume 67 | Issue 3 | May‐June 2019 889 A game‐changer? Expert Rev Neurother 2016;16:849‐59. 5. Pruss H, Finke C, Holtje M, Hofmann J, Klingbeil C, ProbstC, et al. N‐methyl‐D‐aspartate receptor antibodies in herpes simplex encephalitis. Ann Neurol 2012;72:902‐11. 6. Ti t u l a e r M J , L e y p o l d t F, D a l m a u J . A n t i b o d i e s to N‐methyl‐D‐aspartate and other synaptic receptors in choreoathetosis and relapsing symptoms post‐herpes virus encephalitis. Mov Disord 2014;29:3‐6. 7. De Tiège X, De Laet C, Mazoin N, Christophe C, Mewasingh LD, Wetzburger C, et al. Postinfectious immune mediated encephalitis after pediatric herpes simplex encephalitis. Brain Dev 2005;27:304‐7. 8. Patel R, Jha S, Yadav RK. Pleomorphism of the clinical manifestations of neurocysticercosis.Trans R Soc Trop Med Hyg 2006;100:134‐41. 9. Dale RC, Irani SR, Brilot F, Pillai S, Webster R, Gill D, et al. N‐methyl‐D aspartate receptor antibodies in pediatric dyskinetic encephalitisleth...
Clinicians have been searching for means to alleviate incapacitating pain for a long time. Perine... more Clinicians have been searching for means to alleviate incapacitating pain for a long time. Perineural injection of various substances found to reduce pain, by interrupting neural conduction, chemical neurolysis, or other mechanisms of action. The medications most commonly administered during interventional procedures for pain management include local anaesthetics, corticosteroids, and neurolytic agents. This chapter contains a brief review of the most commonly used agents in interventional procedures for trigeminal neuralgia (TGN).
The management of drug-resistant trigeminal neuralgia (TGN) includes peripheral injections of dif... more The management of drug-resistant trigeminal neuralgia (TGN) includes peripheral injections of different chemical agents into the affected nerve. Historically, chloroform was the first substance used for this purpose. Later on, substances like glycerol, phenol, boiling water, high concentrations of tetracaine [1], and streptomycin [2, 3] were also used. Alcohol injections [4] are preferred at the initial presentation of TGN or in elderly patients with similar problem [5]. Patients with significant medical co-morbidities who are not fit to undergo invasive surgeries safely, may also benefit from alcohol injection [5]. Peripheral alcohol nerve block is associated with a variable duration of pain relief ranging from 6 to 16 months [6]. There are two distinct techniques described for peripheral nerve blocks for TGN: (a) extra-oral or percutaneous nerve blocks and (b) intraoral nerve block; this chapter will focus on intraoral nerve block techniques involving mandibular and maxillary nerves, and their branches (Table 1). The preferred local anesthetic (LA) agents include lignocaine (1–2%) and bupivacaine (0.5%) with or without adrenaline (1:2,00,000). Currently, the use of ropivacaine (0.5%) has also been increased as it has minimal cardiovascular risks with a prolonged duration of action.
Mental nerve neuralgia is a painful disorder in the distribution of the mental nerve. The first d... more Mental nerve neuralgia is a painful disorder in the distribution of the mental nerve. The first description of mental nerve neuropathy was given by Charles Bell in 1830, who reported the phenomenon in a patient with advanced breast cancer due to a bony metastasis in her left mandible [1]. Mental nerve neuropathy, which has also been called Numb Chin Syndrome is a purely sensory neuropathy identified by paraesthesia or numbness in the lower lip and chin. The clinical presentations are paraesthesia (tingling/burning/pins and needles) localised to a discrete area of the lower maxillary/mandibular region of the face, patients experiences a numb/swollen lower lip, loss of sensitivity may lead to inadvertent biting, or injury to the lower lip, symptoms are predominantly unilateral; however bilateral symptoms may also be present [2].
Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteris... more Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteristics that differ from adults. These can be attributed to age-related anatomical and physiological differences and distinct patterns of injuries seen in children. Our aim was to identify the patient characteristics, clinical variables during intensive care and intraoperative management associated with poor functional outcome in a cohort of pediatric TBI patients. Methods Retrospective chart review of pediatric TBI patients admitted to neurotrauma intensive care unit (NICU) over a period of 1 year. Results A total of 105 children (< 12 years) with head injury were admitted in the NICU during the study period. The most common mechanism of injury was fall in 78% cases. Fifty-four patients (51.4%) presented with a severe head injury (Glasgow coma scale [GCS] ≤ 8), while 31 (29.5%) and 20 (19.1%) had a mild and moderate head injury. The most common finding was skull fractures (59%), contusi...
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