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Coagulation Profile in Patients With Traumatic Brain Injury.

Article  in  Journal of Neurosurgical Anesthesiology · April 2016

DOI: 10.1097/ANA.0000000000000287

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9th International Update on
Neuroanesthesia and Neurointensive
Care
EURONEURO 2016: Barcelona, Spain,
April 14–16, 2016
Abstracts
S1 EN16-NA01 Trends in Perioperative Treatment in Neurosurgery in Spain. A National Survey
N. Saiz-Sapena, R. Valero, E. Carrero, and F. Iturri

S1 EN16-NA02 A Comparison of Various Doses of Hypertonic Saline on Brain Relaxation

During Supratentorial Brain Tumor Craniotomy
P. Dome´nech-Asensi, D. Fuentes-Garcı´a, C. Piqueras-Pe´rez, S. Burguillos-López,
J. Garcı´a-Ferreira, and J. Hernández-Palazón

S1 EN16-NA03 Comparison of 0.9% Saline Versus ‘‘Plasma-Lyte A’’ For Brain Relaxation in
Patients Undergoing Supratentorial Tumor Resection
S. Shiv, VK. Grover, H. Bhagat, N. Panda, K. Jandra, SK. Gupta, and P. Dutta

S2 EN16-NA04 Corticosteroid Therapy and Surgery Trauma Impact on Blood Glucose

Variability for Patients Undergoing Brain Tumor Surgery
G. Banevicius, M. Kazlauskas, A. Vilke, D. Bilskiene, and A. Macas

S2 EN16-NA05 Anesthesia Technique for Surgical Treatment of Insular Gliomas, Choices,

and Effects
B.Y. Gravesteijn, M. Keizer, J.W. Schouten, and M. Klimek

S2 EN16-NA06 Management Strategy for Left Frontal Low-grade Glioma Diagnosed During
Pregnancy
K. Kamata, R. Fukushima, Y. Shimokado, A. Ijuin, N. Komayama, N. Morioka,
and M. Ozaki

S3 EN16-NA07 Dexmedetomidine an Alternative Medication for Awake Fiberoptic Intubation in

a Patient With C2 Axis Fracture
L.M. Martı´nez Parra, C.J. Salazar Bonilla, M.A. De Juan Jime´nez, M.C. Martı´n Lorenzo,
N. Montón Gime´nez, and V. González Fariña

S3 EN16-NA08 Laryngeal Mask Ventilation During Lumbar Spine Neurosurgery in Knee-Chest

Position is Feasible
P. Hurtado, M. Lopez, J. Tercero, A. Lopez, N. Fábregas, and R. Valero

S3 EN16-NA09 Relevance of Automatic Cuff Pressure Controller for Assessment of

Endotracheal Tube Cuff Pressure in Neurosurgeries
M. Jain Kumar, and C.B. Tripathi

S4 EN16-NA10 Reduction in End-Tidal Carbon Dioxide as an Indicator for Venous Air

Embolism in Sitting Neurosurgical Procedures
C. Harper, A. Abcejo, and J. Pasternak
S4 EN16-NA11 Detection of Venous Air Embolism With TEE in Posterior Fossa Surgery in the
Sitting Position: A 4-Year Analysis of our Institutional Practice
S. Goraksha, B. Thakore, R. Chelani, B. Misra, and J. Monteiro

S4 EN16-NA12 Adenosine Flow Arrest to Facilitate Cerebral Aneurysm Clipping: 2-Year

Institutional Experience
S. Goraksha, R. Chelani, B. Thakore, B. Misra, and J. Monteiro

S5 EN16-NA13 Opthlamic Aneurism: A Case Report

E. Guerra Hernández, Z. Hussein Dib González, M. Mourad, A. Rodrı´guez Pe´rezar,
T. Sarmiento, A.L. Cervantes, and L. Grosso

S5 EN16-NA14 Noncardiogenic Electrocardiographic Abnormalities In Cervicomedullary

Junction Tumor
C.H. Goh, Y. Kenny, T. Peter, and A. Wong

S5 EN16-NA15 Rapid Ventricular Pacing For Neurovascular Surgery: A Safety Study For
Brain And Heart
V. Saldien, K. Van Loock, T. Schepens, and T. Menovsky

S6 EN16-NA16 ST-Segment ‘‘Hump Sign’’ in Resting Electrocardiogram. Is it a New

Independent Predictor of the Risk of Acute Diastolic Heart Failure in Neurosurgical Patients?
P. Kumari

S6 EN16-NA17 Different Subtypes of Trigeminocardiac Reflex in the Same Patient

During Craniotomy
P. Tan, I. Kong, A. Ng, and N. Eza

S6 EN16-NA18 Diaphragmatic Pacing Stimulation: Anesthetic Management at Institut

Guttmann
N. Alegret Monroig, P. Serra, and J. Pere Pessas

S7 EN16-NA19 Management of Cardiac Arrest During Neurosurgery: Survey of Anesthetists in

a Neurosurgical Unit in the UK
G. Bose, S. Salib, A. Sztucki, and R. Mittal

S7 EN16-NA20 Use of Cerebral Oximetry in Patients With Cerebral Vasospasm After

Spontaneous Subarachnoid Hemorrhage (SAH)
B. Lim, J. Rao, S.Y. Chong, C.G. Gu, V. Ng, and J. Tan

S7 EN16-NA21 Immediate Increase in Cerebral Oxygenation Induced by Successful Electrical

Cardioversion of Atrial Fibrillation is Not Maintained at Long-Time Follow-Up
S. Louage, E. Jorissen, C. Genbrugge, F. Jans, J. Dens, and C. De Deyne

S7 EN16-NA22 Effects Of Subanesthetic Doses of Ketamine on Bilateral Bispectral Index

During Stable Target Controlled Infusion (TCI) General Anesthesia
A.M. Araujo, C.S. Nunes, and M. Campos

S8 EN16-NA23 Individual Effect-Site Concentrations of Propofol at Return and Loss of

Consciousness are Correlated
A.L. Ferreira, C.S. Nunes, A.C. Ferreira, S. Vide, R. Correia, and P. Amorim

S8 EN16-NA24 Comparison of the Effect of Intravenous Dexmedetomidine and Lignocaine

Spray Instilled Into the Endotracheal Tube on Extubation Response in Patients Undergoing
Spine Surgery
D. Dutta, S. Purohit, M. Khandelwal, and R. Meena
S9 EN16-NA25 Assessment of Dexmedetomidine Versus Esmolol in Preventing Emergence
Agitation After Neurosurgical Procedures
I. Asouhidou, D. Zosimidis, I. Pagiati, D. Charalampidis, A. Katsanevaki,
and X. Mortopoulou

S9 EN16-NA26 Efficacy of Dexmedetomidine in Preventing Sympathetic Overdrive During

Intracranial Procedures
I. Asouhidou, A. Katsanevaki, D. Charalampidis, D. Zosimidis, Z. Stergiouda,
and G. Topalidou

S9 EN16-NA27 A Comparison of Dexmedetomidine and Propofol for Monitored Anesthesia

Care in Patients Undergoing Surgical Treatment of Chronic Subdural Hematoma
S. Thamlaoui, S. Ben Khlifa, M. Farhat, I. Hamdi, N. Maatar, and C. Kaddour

S10 EN16-NA28 Dexmedetomidine Does not Affect Cerebral Autoregulation and CO2 Reactivity
During Sevoflurane Anesthesia
G.P. Rath, S. Banik, H. Prabhakar, and P. Bithal

S10 EN16-NA29 Dexmedetomidine During Supratentorial Craniotomy With Intraoperative

Neuromonitoring
S. Pacreu, A. León, E. Vilà , L. Moltó, C. Rodrı´guez, and J. Fernàndez Candil

S10 EN16-NA30 Anesthesia for High Volume, Multilevel Epidural Blood Patch (HVBP)
in Idiopathic Intracranial Hypotension (IIH)
A. Builes, M. Arango, S.P. Lownie, M. Sharma, and S. Panday

S11 EN16-NA31 Epidural Anesthesia For Placement of a Spinal Cord Stimulator by

Surgical Laminectomy
J. D’Haese, C. Vanlersberghe, M. Moens, and J. Poelaert

S11 EN16-NA32 Superficial Cervical Plexus Block for Postoperative Analgesia in Patients
Undergoing Infratentorial Surgeries and Occipital Craniotomies:
V. Sangai, and R. Gandhe

S11 EN16-NA33 Ropivacaine Scalp Block in Patients Undergoing Supratentorial Craniotomy:

Analysis of 30 Cases
S. Mitra, S. Purohit, M. Godara, D. Dutta, and S.P. Sharma

S11 EN16-NA34 Comparative Study of Ropivacaine Infiltration Versus Ropivacaine With

Clonidine Infiltration During Scalp Block in Patients Undergoing Supratentorial Craniotomy
S. Purohit

S12 EN16-NA35 L-Arginine Pathway Metabolites Predict Need for Intraoperative Shunt During
Carotid Endarterectomy
M. Tihamer, J. Lantos, S. Keki, E. Volgyi, G. Menyhei, and P. Szabo

S12 EN16-NA36 Investigating Renshaw Cell Circuitry in Human Neuromuscular System

M.G. Özyurt, G. Yılmaz, M. Dursun, M. Shabsog, S. Savran, and K.S. Türker

S12 EN16-NA37 Cerebral Oximetry: Sensibility and Specificity in Awake Carotid

Endarterectomy
H. Meleiro, I. Correia, and G. Afonso
S13 EN16-NA38 The Effects of PEEP, ZEEP, and Intra-abdominal Pressure Levels on Cerebral
Oxygenation (rSO2) in the Morbidly Obese Undergoing Sleeve Gastrectomy. Preliminary
Results
I.S. Seker, Y. Demiraran, Z. Salihoglu, T. Umutoglu, I. Ozaydýn, and S. Dogan

S13 EN16-NA39 Patient Satisfaction in Ablative Intracranial Surgery for Parkinson’s Disease
E. Pereira, A. Sampaio, S. Reˆgo, J. Santiago, A. Raimundo, and M.R. Orfão

S13 EN16-NA40 The Pharmacodynamic of Propofol During Awake Craniotomy

M. Soehle, CF. Wolf, M. Priston, A. Hoeft, and R.K. Ellerkmann

S14 EN16-NA41 Is There an Ideal Approach for Anesthesia Management of Awake

Craniotomies?
C. Yildirim Guclu, BC. Meco, I. Dogan, A. Turgay, and D. Yorukoglu

S14 EN16-NA42 Anesthetic Management for DBS Implantation. Experience at a Mexican

Private Setting
J. López Rodrı´guez, A. Obregón Corona, and M. Gómez Ramı´rez

S14 EN16-NA43 Local Anesthetic Toxicity That Developed During Deep Brain Stimulation
Operation
I.S. Seker, O. Ozlu, U. Er, S. Dikici, and G. Sezen

S15 EN16-NA44 The Effects of Intraoperative Dexmedetomidine, Propofol and

Remifentanil-based Sedation on Clinical Outcomes After Deep Brain Stimulation (DBS)
Surgery in Parkinsonian Patients: A Retrospective Study
J. Chui, A. Rizq, I. Herrick, A. Parrent, and R. Craen

S15 EN16-NA45 Anesthetic Management for Implantation of Deep Brain Stimulators in

Parkinson’s Disease: Remifentanil or Dexmedetomidine?
G. Serafini, S. Baroni, A. Marudi, A. Feletti, S. Contardi, and E. Bertellini

S15 EN16-NA46 General Anesthesia for Deep Brain Stimulation in Parkinson Disease: Our
Experience
N. Garcı´a Claudio, I. Gime´nez Jime´nez, E. Domenech Pascual, A. López Gómez,
A. Gutie´rrez Martı´n, and M.P. Argente Navarro

S15 EN16-NA47 Anesthetic Management of Awake Craniotomy for Brain Tumors: Our
Hospitals’ Experience.
I. Gime´nez Jime´nez, N. Garcı´a Claudio, F.I. Montero Sánchez, P. Pe´rez Caballero,
J.M. Loro Represa, and M.P. Argente Navarro

S16 EN16-NA48 Continuous Dexmedetomidine During Language, and Motor Mapping for
Tumoral Awake Craniotomies: A Case Series
A. Martinez Simon, A. De Abajo Larriba, M. Alegre Esteban, E. Cacho Asenjo,
S. Tejada Solis, R. Diez Valle, and MC. Honorato Cia

S16 EN16-NA49 Regional Anesthesia and Sedation Technique With Dexmedetomidine

for Awake Craniotomy
L. Moltó, C. Rodrı´guez, E. Vilà, J. Fernández-Candil, L. Castelltort, and S. Pacreu

S16 EN16-NA50 Tolerance of Awake Patients During Functional Brain Mapping

L. Pariente Juste, L. Garcı´a Huete, M. Juncadella Puig, L. Contreras López,
G. Elguezabal Sangrador, and A. Gabarrós Canals
S17 EN16-NA51 Anesthesia for Awake Craniotomy: Less is More?
I. Mladiæ Batinica, K. Rotim, T. Sajko, M. Zmajevic Schonwald, and S. Salkie´eviæ

S17 EN16-NA52 An Opioid-Free ‘‘Awake Throughout’’ Craniotomy Using Dexmedetomidine and

Nasal High Flow Oxygen in an Obese Man With Suspected Obstructive Sleep Apnoea (OSA)
M. McGinlay, C. Kelly, B. Mullan, N. Johnston, and T. Flannery

S17 EN16-NI01 Agitation in Trauma ICU, Prevention and Outcome

S. Mahmood, H. Al-Thani, and A. El Menyar

S18 EN16-NI02 Comparison of Dexmedetomidine With Fentanyl-Midazolam for ICU Sedation

in Head Injury Patients
B. Ashish, B. Sujoy, M. Randhir, and GP. Rath

S18 EN16-NI03 Retrospective Study About 211 Combat Casualties With Traumatic Brain Injury
by Gunshot or Improvised Explosive Devices Treated in the Spanish Military Hospital
Deployed in Herat (Afghanistan) From 2006 to 2014
R. Navarro-Suay, C. Rodrı´guez-Moro, A. Hernández-Abadia De Barbara,
E. López-Soberón, R. Tamburri-Bariain, R. Puchades-Rincón De Arellano,
and B. González De Marcos

S18 EN16-NI04 To Compare the Effects of 2 Different Techniques of Chest Physiotherapy on

Intracranial Pressure in Traumatic Brain Injury Patients: A Randomized Cross Over Study
G.S. Tomar, G.P. Singh, and P.K. Bithal

S19 EN16-NI05 Multimodal Brain Monitoring Before and After Decompressive Craniectomy
M. Veiga, A. Ferreira, J. Silva, and C. Dias

S19 EN16-NI06 Coagulation Profile in Patients With Traumatic Brain Injury

J.C. Gomez Builes, S. Rizoli, M. Sholzberg, K. Pavenski, A. Petropolis, A. McFarlan,
and L. de Oliveira.

S19 EN16-NI07 Mapping of Cerebral Microcirculation and Histology After Head Injury in
Experimental Models
J. Bellapart Rubio, S. Diab, L. Gabrielian, J. Parat, R. Boots, and J. Fraser

S19 EN16-NI08 Etomidate Versus Midazolam for Rapid Sequence Intubation in Severe
TBI Patients
J.D. Charry, M.A. Pinzón, A.M. Cuellar, J.C. Barrios, D.R. Gurierrez, and J.H. Tejada

S20 EN16-NI09 The Hyperoxic Challenge as a Surrogate to Evaluate the Regional Cerebral
Blood Flow Adequacy in Patients With Traumatic Brain Injury. Results of a Pilot Study
G. Harutyunyan, G. Mur, A. Sánchez-Guerrero, F. Arikan, G. Mkhoyan, and J. Sahuquillo

S20 EN16-NI10 Disturbed Cerebral Autoregulation, Assessed by Near Infrared Spectroscopy, can
Guide Patient-tailored Hemodynamic Approach in Postcardiac Arrest Patients
W. Eertmans, K. Ameloot, C. Genbrugge, F. Jans, J. Dens, and C. De Deyne

S20 EN16-NI11 Monitoring of Brain Oxygenation in Postcardiac Arrest Patients

During EEG-confirmed Status Epilepticus
W. Eertmans, J. Haesen, C. Genbrugge, F. Jans, J. Dens, and C. De Deyne

S21 EN16-NI12 Posterior Reversible Encephalopathy Syndrome After Brain Tumor Surgery
J. Benatar Haserfaty
S21 EN16-NI13 A Prospective Cohort Study on Long-term Outcome in Patients With Severe
Traumatic Brain Injury 10 to 15 Years After Trauma
E. Andersson, E. Svanborg, M. Ost, L. Csajbok, and B. Nellgård

S21 EN16-NI14 S100b and Neuron Specific Enolase (NSE) For In-Hospital Mortality Prediction.
Which One is More Valuable?
V. Traskaite, A. Vilke, D. Bilskiene, G. Banevicius, and A. Macas

S22 EN16-NI15 External Validation of Rotterdam Computed Tomography Score in the

Prediction of Mortality in Severe Traumatic Brain Injury
J.D. Charry, J.H. Tejada, M.A. Pinzón, J.O. Ve´lez, J.H. Tovar, and C. Calvache

S22 EN16-NI16 Outcomes of Traumatic Brain Injury: Use the Marshall CT Score, Rotterdam
CT Score, CRASH, and IMPACT Models
J.H. Tejada, J.D. Charry, M.A. Pinzón, W.A. Tejada, J.H. Tovar, and J.P. Solano

S22 EN16-NI17 Relationship Between The Bispectral Index, The Glasgow Coma Scale, and The
Intracranial Pressure in Patients With Severe Brain Injury
H. Kang, C. Jin Park, Y. Sup Jeong, and D. Hyun Baek

S22 EN16-NI18 Predicted Unfavorable Neurological Outcome is Overestimated by The Marshall

CT Score, CRASH, and IMPACT Models in Severe TBI Patients
M.A. Pinzón, J.D. Charry, M. Falla, W.A. Tejada, J.O. Ve´lez, and J.H. Tejada

S23 EN16-NI19 Clinical and Scanographic Factors of Early Mortality in Traumatic Brain Injury
Patients in Dijon Neurotrauma Unit
S. Mirek, J. Darphin, N. Opprecht, A. Nadji, S. Aho, B. Bouhemad, and C. Girard

S23 EN16-NI20 Hemodynamic Disturbances in the Early Phase After Subarachnoid

Hemorrhage: Regional Cerebral Blood Flow Studied by Bedside Xenon-Enhanced CT
H. Engquist, E. Rostami, and P. Enblad

S23 EN16-NI21 Management of Acute Aneurysmal Subarachnoid Hemorrhage at a Regional

Neurosciences Center
S. Ley, and SP. Young

S24 EN16-NI22 Long-Term Outcome 12-15 Years After Aneurysmal Subarachnoid Hemorrhage
(ASAH): A Prospective Cohort Study
E. Svanborg, E. Andersson, L. Csajbok, M. Ost, and B. Nellgard

S24 EN16-NI23 Higher Plasma M-Ficolin in Patients Developing Vasospasm and Cerebral
Ischemia After Spontaneous Subarachnoid Hemorrhage
L. Llull, S. Thiel, Á. Cervera, S. Amaro, A. Planas, and Á. Chamorro

S24 EN16-NI24 Efficacy of Stellate Ganglion Block in Cerebral Vasospasm: A Prospective

Clinical Trial
N. Samagh, NB. Panda, VK. Grover, V. Gupta, N. Bharti, R. Chhabra, and K. Jangra

S25 EN16-NI25 Cardiogenic Subarachnoid Bleed: A Case Report

I. Ghosh, D. Ghoshdastidar, and A.M. Rangarajan

S25 EN16-NI26 Optic Nerve Sheath Diameter Evaluated by Transorbital Sonography in Healthy
Volunteers From Pakistan
A.M. Ali, M. Hashmi, and A. Hussain
S25 EN16-NI27 Pulsatility Index and Resistive Index Measured by Transcranial Doppler and
Optic Nerve Sheath Diameter Measured by Ultrasonography Correlates With Opening
Intraventricular Intracranial Pressure
N. Kaloria, N.B. Panda, S. Sahu, H. Bhagat, V.K. Grover, R. Chhabra, and S. Dhandapani

S25 EN16-NI28 Measurement of Optic Nerve Sheath Diameter to Find its Correlation With
Raised Intracranial Pressure in Neurocritical Patients
D. Lahkar, M. Das, and H. Sapra

S26 EN16-NI29 Guillain-Barré Syndrome: A Clinical Evaluation and Comparison With Current
Literature
F. De Burghgraeve, C. Vandycke, L. Vanopdenbosch, and M. Bourgeois

S26 EN16-NI30 A Fulminant Case of Acute Disseminated Encephalomyelitis (ADEM)

in an Adult
X. Chen

S26 EN16-NI31 Predictors of Perioperative Hyperglicemia and its Effect on Neurological

Outcome in Aneurysmal Subarachnoid Hemorrhage
N.B. Panda, S. Koyyana, N. Bharti, and N. Singla

S27 EN16-NI32 Dysphagia Lusoria as a Rare Cause of Aspiration Pneumonia With Respiratory
Failure in a Stroke Patient
V. Spatenková, and J. Jedlicka

S27 EN16-NI33 Anti-NMDA Limbic Encephalitis: A Case of Secondary Epilepsy

F. Pereira, S. Pedrosa, H. Martins, and C. Dias

S27 EN16-NI34 Bacterial Meningitis Secondary to Postoperative Thigh Abscess: A Case Report
R. O’Connor Emmett

S28 EN16-NI35 Management of Cerebrospinal Fluid Fistulae: A Retrospective Analysis With

Lumbar Drainage
S. Nunes, C. Dias, and S. Freitas

S28 EN16-NI36 Role of Levetiracetam in Neurocritical Patients With Nonconvulsive Seizure

S. Kung

S28 EN16-NM01 BIS VISTA Bilateral Monitoring System (BVM): Make the Most of Your
Money
J.T. Herrera, A. Álvarez, I. Bilbao, M. Hernández, F. Iturri, and A. Martı´nez

S28 EN16-NM02 Density Spectral Array of BIS VISTA Monitoring System in Epilepsy Surgery
With Intraoperative Electrocorticography
L. Bosch, L. Castelltort, M. Lamora, E. Lopez, J. Fernández-Candil, and S. Pacreu

S29 EN16-NM03 Changes in Density Spectral Array of BIS VISTA Monitoring System With the
Administration of Etomidate and Propofol
E. López, L. Castelltort, M. Lamora, L. Bosch, J. Fernández Candil, and S. Pacreu

S29 EN16-NM04 Density Spectral Array of BIS VISTA Monitoring System During Wada Study
C. Rodrı´guez, S. Pacreu, L. Moltó, E. Vilà, R. Rocamora, and J. Fernàndez-Candil

S29 EN16-NM05 Comparing 2 EEG-based Indices of Anesthesia: qCON and qNOX Fall and
Rise Times During Loss and Recovery of Consciousness
PL. Gambus, U. Melia, and E. Weber Jensen
S30 EN16-NM06 Real Time Diagnostic of Cerebral Status in Traumatic Brain Injury Using
Neuro-fuzzy Networks
G. Emeriaud, S. Fartoumi, and M. Sawan

S30 EN16-NM07 Heart Rate Variability and Delayed Cerebral Ischemia

P. Löwhagen Hende´n, and S. Naredi

S31 EN16-NM08 Assessment of Heart Rate Variability at Different Propofol Effect Site
Concentrations in Patients With Supratentorial Tumors
M. Radhakrishnan, M. Mittal, G.S. Umamaheswara Rao, and Kavyashree

S31 EN16-NM09 Direct Motor-evoked Potentials and Cortical Mapping Using the NIM Nerve
Monitoring System: A Case Report
B. Suparna, H. Faizal, H. Matthew, and C. Jason C

S31 EN16-NM10 An Anesthesiologist’s Cognitive Aid for the Resolution of Crisis in

Intraoperative Neurophysiological Monitoring: an Imperative Need
F. Echeverri Gonzalez

S32 EN16-NM11 Predicting Unconsciousness After Propofol Administration: qCON,

BIS and the Power in the Alpha Band Frequency
J. Fernández-Candil, S. Pacreu, E. Vilà, L. Moltó, C. Rodrı´guez-Cosmen, and P. Gambús

S32 EN16-NM12 Reappraisal of the Reference Levels for the Energy Metabolites in the
Normal Brain
Á. Sánchez-Guerrero, G. Mur-Bonet, L. Castro, D. Gándara, A. Rey, and J. Sahuquillo

S32 EN16-NM13 The Effectiveness of Brain PAD (BP) Within a Controlled Prophylactic
Normothermia Strategy in 2 Neurosurgical Procedures
F. Iturri, J. González-Uriarte, A. González-Uriarte, JT. Herrera, A. Álvarez, and
A. Martı´nez

S33 EN16-NM14 Zero-Heat-Flux Cutaneous Thermometer for Core Temperature Measurements

in Extreme Situations
M. Vendrell Jordà, M. Lacambra Basil, E. Bassas Parga, M. Jose´ Bernat Álvarez,
J. Fernanz Antón, L. Gil Gomez, and E. Pujol Rosa

S33 EN16-NM15 Continuous Cerebral Saturation Monitoring During Therapeutic Hypothermia

in Out-of-Hospital Cardiac Arrest Patients
W. Eertmans, C. Genbrugge, I. Meex, J. Dens, F. Jans, and C. De Deyne

S33 EN16-NM16 Changes in Hourly Serum Lactate Levels in Postcardiac Arrest Patients
Treated With Therapeutic Hypothermia at 331C
H. Stragier, W. Eertmans, C. Genbrugge, F. Jans, J. Dens, and C. De Deyne

S34 EN16-NM17 Extracellular Glutamate is Significantly Elevated in the Hippocampus of

Awake-Behaving Aged Fisher-344 Rats Compared With Young Rats Following Craniotomy
M. Humeidan, S. Bergese, V. Davis, and G. Gerhardt

S34 EN16-NM18 Intraoperative Cerebral Oxygen Saturation and BIS Reduction may be
Associated With Postoperative Delirium and Cognitive Dysfunction Following Cardiac
Surgery
E.M. Aldana, J.L. Valverde, and I. Bellido
S34 EN16-NM19 Alzheimer-Connected CSF-Neuromarkers Tau and Beta-Amyloid
can Prospectively Predict Mortality in Patients With Acute Hip Fracture
R. Dutkiewicz, Z. Henrik, K. Blennow, and B. Nellgård

S35 EN16-NM20 Does Off-Pump Technique for Coronary Revascularization Have Lower
Incidence of Neurological Complications?
O. Torres, P. Carmona, E. Mateo, N. Almenara, and J. De Andre´s

S35 EN16-NM21 Propofol Versus Sevoflurane Anesthesia: Effect on Cognitive Functions and
Electrophysiological Findings
J. Kletecka, I. Holeckova, P. Brenkus, J. Pouska, J. Benes, and I. Chytra

S35 EN16-NM22 Systematic Review of Regional Cerebral Oxygen Saturation Changes Using
Near Infrared Spectroscopy During Neurosurgical Spine Operations in Prone Position and
our First Experience
S. Murniece, B. Mamaja, A. Skudre, and J. Stepanovs

S36 EN16-NM23 Cerebral Hemodynamic Response to an Orthostatic Challenge in Severe

Obstructive Sleep Apnea Patients Before and After 2 Years of Continuous Positive Air
Pressure Therapy
C. Gregori Pla, T. Durduran, and A. Fortuna Gutie´rrez

S36 EN16-NS01 Surgical Meningioma Resection: Retrospective Analysis of 65 Patients

M.H. Machado Lima, M. Fernandes, A.F. Ribeiro, A. Eufrásio, J. Gonc- alves, and R. Orfão

S37 EN16-NS02 The Role of American Society of Anesthesiologists Scores in Predicting

Meningioma Resection Outcome
M. Fernandes, H. Lima, A. Ribeiro, A. Eufrásio, and R. Órfão

S37 EN16-NS03 Tumor of the Posterior Fossa With Lesion of Cranial Base Pairs After Surgery.
Is it a Frequent Complication?
Y. Dominguez Dı´az, E. Guerra Hernández, Z. Hussein Dib González, P. Aguado Garcı´a, and
A. Rodrı´guez Pe´rez

S37 EN16-NS04 Anesthestic Implications of Aminolevulinic Acid Protoporphyrin IX Fluorescence

Guided Resection of Gliomas
S. Solanki Lal, S. Solanki, and M. Desai

S38 EN16-NS05 Length of ICU Stay, Morbidity, and Mortality in Neurocritical Unit After Brain
Tumor Surgery
J. Benatar Haserfaty

S38 EN16-NS06 Assessment of Postoperative Psychological Outcomes Associated With Awake

Craniotomy facilitated by a Dexmedetomidine-based Anesthetic Protocol
J.C. Gomez Builes, M. Garavaglia, A. Rigamonti, G. Hare, D. Sunit, and C. Adriana

S38 EN16-NS07 Failed Awake Craniotomy: Judicious Patient’s Selection is Essential

A. López Gómez, P. Ferrer Tárrega, M. Echeverri Ve´lez, L. Martı´nez Ferreiro,
MS. Matoses Jae´n, and P. Argente Navarro

S38 EN16-NS08 Perioperative Complications of Deep Brain Stimulation Surgery

C.A. Focaccio, L. Valencia, A. Rodrı´guez-Pe´rez, T. Sarmiento, A. Ramos,
and F. Robaina
S39 EN16-NS09 Symptomatic Intracranial Hemorrhagic Complications of Deep Brain
Stimulation for Parkinson’s disease
J. Benatar-Haserfaty, D. Mele´ndez Salinas, and A.L. Sierra Tamayo

S39 EN16-NS10 Active Surveillance of Health Care Associated Infection in Neurosurgical

Patients
S. Mohapatra, R. Agarwal, G. Prasad Rath, D. Gupta, and A. Kapil

S39 EN16-NS11 Incidence of Surgical Wound Infections in Patients Undergoing Craniotomy

During the Period 2007 to 2014
E. Vilà Barriuso, J.L. Fernández Candil, L. Moltó Garcı´a, C. Rodrı´guez Cosmen,
M. Sadurnı´ Sardà, S. Pacreu Terradas, and C. Garcı´a Bernedo

S40 EN16-NS12 Incidence and Predictors of Postoperative Pulmonary Complications in Patients

Undergoing Craniotomy and Excision of Posterior Fossa Tumors
S.K. Dube, B. Hooda, R.S. Chouhan, G.P. Rath, and P.K. Bithal

S40 EN16-NS13 The Clot Thickens. An Audit of Thromboprophylaxis in Neurosurgery

A.J. Watts

S40 EN16-NS14 Comparison of the Efficacy of Oral Oxycodone and Oral Codeine in the
Treatment of Postcraniotomy Pain
M. Lim, RM. Lee, CT. Chong, and B. Lim

S40 EN16-NS15 Outcomes in Carotid Endarterectomy in a Portuguese Tertiary Care Hospital

I. Correia, H. Meleiro, and G. Afonso

S41 EN16-NS16 Vascular Rupture During Surgery of Herniated Lumbar Disk

E. Guerra Hernández, Z. Hussein Dib González, P. Aguado Garcı´a, R. Fariña Castro,
L. Grosso, T. Sarmiento, and A. Rodrı´guez Pe´rez

S41 EN16-NS17 Duty of Candour: Honesty When Things go Wrong

S.W. Holly Chamarette

S41 EN16-NS18 Postoperative Requirements After Elective Craniotomies

M. Fontanals Caravaca, E. Carrero, R. Valero, J. Tercero, P. Hurtado, and N. Fàbregas

S42 EN16-NS19 National Survey on Postoperative Circuits After Neurosurgical

Procedures in Spain
N. Saiz-Sapena, R. Valero, E.J. Carrero, and F. Iturri

S43 EN16-NS20 Use Of ICM+ Software in the Management of Cerebral Spinal Fluid Pathology
at Hospital Clinic Barcelona: Preliminary Experience
J.J. González Sánchez, J. Torales, L. Reyes, S. Garcı´a, T. Topzcewski, and J. Enseñat

S43 EN16-PN01 Modified Sphinx Position for Surgical Procedures on Scaphocephalic Patients
M.J. Mayorga-Buiza, M.L. Tosca, M. Rivero-Garvia, and J. Marquez-Rivas

S43 EN16-PN02 Is Ventricular Endoscopy Safe in Term and Large Preterm Newborn Infants?
M.J. Mayorga-Buiza, M. Rivero-Garvia, and J. Marquez-Rivas

S43 EN16-PN03 Let us Save the Brain With Cerebral Oximetry

I.S. Seker, O. Ozlu, and A. Ozkan
S44 EN16-PN04 A Comparison of Dexmedetomidine and Propofol as Sole Sedative Agent for
Children Undergoing Cerebral Magnetic Resonance Imaging Examination: a Randomized
Prospective Study
T. Saber Souissi, F. Moadh, H. Ines, B.K. Siwar, M. Nidhar, and K. Chokri

S44 EN16-PN05 Tuberous Sclerosis Syndrome: an EEG-based Case Report of 2 Male Siblings
K. Jha, Y. Kumar, T. Kumar, R. Singh, L.Tiwari, and S. Kumari

S44 EN16-PN06 Perioperative Complications in Pediatric Endoscopic Third Ventriculostomies:

5 Years Revised
C. Costa, P. Santos, L. Pinto, and J. Oliveira

S45 EN16-PN07 Anesthetic Management of Children With Cervical Spine Injury:

A Retrospective Review of 112 Cases
Ch. Vikas, G.P. Singh, and G.P. Rath

S45 EN16-PN08 Seizures in Per Operative Brainstem Tumor in Pediatric Patients

A.L. Linder Alcantara, L. Carlos Salles, and Ch. Marcio

S45 EN16-PN09 Guidelines for Dual Approach of Craniopharyngioma by Craniotomy and

Simultaneous Access Transphenoidal in Pediatric Patients
A.L. Linder Alcantara, L. Carlos Salles, A. Accioly Guasti, and S.M. Souza de Lima

S46 EN16-PN10 Anesthetic Management for Tetralogy of Fallot (TOF) With Cerebral Abscess:
A Retrospective Review of 52 Children
S.K. Dube, M. Nitasha, I. Kapoor, G.P. Rath, and S. Mohapatra

S46 EN16-PN11 Posterior Fossa Surgery in Children

S. Serrano-Casabón, and D. Arte´s-Tort

S46 EN16-PN12 Late Onset Pompe Disease With Severe Kyphoscoliosis for Posterior Correction
of Deformity: the Anesthetic Considerations
P. Tan, J. Chan, S. Belaja, and N. Esa

S47 EN16-NR01 Incidence of Contrast-induced Acute Kidney Injury at a Major Tertiary

Interventional Neuroradiology Centre
M. Patek, and S. Payne

S47 EN16-NR02 Assessment of Outcome of Patients With Carotid Cavernous Fistula Undergoing
Embolization in Neuroradiologic Suite
G. Singh Tomar, H. Prabhakar, Ch. Mahajan, I. Kapoor, and P.K. Bithal

S47 EN16-NR03 General Anesthesia for Mechanical Thrombectomy in a Tertiary UK Hospital

G. Bose, V. Mehta, N. Qadir, G. Kakkar, and R. Mittal

S48 EN16-NR04 Comparison of a Single Dose of Dexmedetomidine and Clonidine in the Control
of Postanesthesia Shivering in Patients Undergoing Endovascular Treatment of Ruptured
Intracranial Aneurysms
S. Thamlaoui, M. Farhat, K. Ben Khlifa, N. Maatar, H. Souissi, and Ch. Kaddour

S48 EN16-NR05 Bilateral Wada Test With Etomidate and Bilateral Bispectral Index Monitoring
C. Costa, M. Veiga, P. Santos, and G. Durães
S48 EN16-NR06 Mechanical Thrombectomy for Acute Ischemic Stroke Treatment Under
General Anesthesia. Experience in a Tertiary Hospital
M. Garcia-Orellana, M. Mariscal, O. Romero, MA. Castaño, C. Jime´nez, J. Camiña, and
S. Miralbe´s

S49 EN16-NR07 Rate of Postinterventional Complications and Discharge Outcome Among Acute
Ischemic Stroke Patients Undergoing General Anesthesia for Mechanical Thrombectomy
M. Mariscal, M. Garcia-Orellana, O. Romero, M.A. Castaño, I. Legarda, J. Camiña, and
S. Miralbe´s

S49 EN16-NR08 Rescue Therapy in Cerebral Vasospasm at St George’s University Hospital

Fondation Trust
C. Fiandeiro, B. Wandschneiderr, J. Madigan, and D. Mathew

S49 EN16-NR09 ‘‘Puff of Smoke’’ in the Head: Moyamoya Disease in the Italian Patients
S. Baroni, A. Marudi, F. Ragusa, and E. Bertellini

S50 EN16-NR10 Anesthesia for Bypass Surgery in Moyamoya

F. Santos, P. Santos, and G. Durães

S50 EN16-NR11 Anesthesia and Brain Volumes on MRI

CH. Ng, and AKY. Lee

S51 EN16-NR12 Interference of Blood Pressure Control Within 24 Hours in Acute Ischemic
Stroke. Systematic Review
A. Alves da Silva, G.J. Martiniano Porfı´rio, G. Sampaio Silva, and A. Nagib Atallah
 SUPPLEMENT: EURONEURO 2016
Abstracts published in the Journal of Neurosurgical Anesthesiology have been
reviewed by the organizations or JNA Affiliate Societies at whose meetings the
abstracts have been accepted for presentation.These abstracts have not undergone
review by the Editorial Board of the Journal of Neurosurgical Anesthesiology.
9th International Update on Neuroanesthesia and
Neurointensive Care
EURONEURO 2016: Barcelona, Spain, April 14-16, 2016
NEUROANESTHESIA
EN16-NA01
Trends in Perioperative Treatment in Neurosurgery in Spain. A
National Survey
N. Saiz-Sapena, R. Valero, E. Carrero, F. Iturri, on behalf of Section of
Neurosciences of the “Sociedad Española de Anestesiologı́a y Rean-
imación”. Section of Neurosciences of the “Sociedad Española de Anes-
tesiologı´a y Reanimación” (SEDAR), Spain.
Background: We present the results of a national survey launched be-
tween June and October 2014 by the Section of Neurosciences of the
SEDAR (Spanish Society of Anaesthesia and Critical Care) on the
perioperative treatment of the neurosurgical patient.
Methods: The first part of the survey questioned about (A) the level of
pain scores used, treatment (drugs, type of prescription, combination of
drugs), preemptive treatment, knowledge about postcraniotomy chronic
pain and relationship between treatment of pain and chronification. (B)
Postoperative nauseas and vomit: its incidence in neurosurgical patients,
score risk used, need and use of multimodal prophylaxis, and the type or
combination of antiemetic treatment were questioned. (C) Antiepileptic
drugs prophylactic use, reasons to administer these drugs, type of anti-
epileptic’s, and also perioperative management of the patient already on
anticonvulsant therapy. The use of monitors to diagnose a seizure was
included in the survey. (D) The perioperative use of dexamethasone was
assessed: when, how, dosage, and monitoring of glycemia.
Results: We obtained a total of 45 answers from 30 hospitals (41.09% of
the hospitals in Spain). The analysis of the survey revealed very in-
dividual approaches to the neurosurgical patient among neuro-
anesthesiologist and hospitals. Even when the trend was toward what is
published in modern literature, there was no homogeneity found about
the basic treatment of this type of patient.
Conclusions: According to this national Spanish survey, there is no
standard of treatment of pain, emesis, perioperative anticonvulsant
treatment, or the use of perioperative corticoids among the Spanish
anesthesiologists who deal with the neurosurgical patient.
EN16-NA02
A Comparison of Various Doses of Hypertonic Saline on Brain
Relaxation During Supratentorial Brain Tumor Craniotomy
P. Doménech-Asensi, D. Fuentes-Garcı́a, C. Piqueras-Pérez,
S. Burguillos-López, J. Garcı́a-Ferreira, J. Hernández-Palazón.
Hospital Clı´nico Virgen de la Arrixaca, Murcia, Spain.
Background: Evidence from randomized-controlled trials suggest that
hypertonic saline (HS) is at least as effective, if not better than mannitol
for treatment of increased intracranial pressure. According to a recent
meta-analysis comparing intraoperative effects of HS and mannitol in
craniotomized patients, HS could significantly increase the odds of sat-
isfactory intraoperative brain relaxation. No prospective studies stated a
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
dose-response relationship of HS on brain relaxation in surgical setting.
A prospective, randomized, double-blind study was designed to assess
differences in brain relaxation between 2 doses of 3% HS during elective
supratentorial brain tumor surgery.
Methods: A total of 30 patients undergoing supratentorial craniotomy
for tumor resection were enrolled to receive either 3 mL/kg (group L) or
5 mL/kg (group H) of 3% HS administered at skin incision for 15 mi-
nutes. Brain relaxation was assessed after dura opening on a scale
ranging 1 to 4 (1 = perfectly relaxed, 2 = satisfactorily relaxed, 3 = firm
brain, 4 = bulging brain). Hemodynamic variables, temperature, urine
output, fluid balance, blood loss, and laboratory values (blood gases,
osmolarity, hematocrit, glycemia, lactate) were collected before HS in-
fusion and 30, 120, and 360 minutes after it. Head position, type and
location of lesion, presence and magnitude of midline shift, extubation
time, postoperative complications, ICU and hospital stay were also re-
corded as well as 30-day mortality.
Results: No significant differences between groups were found regarding
age, sex, BMI, and brain tumor location or size. In group L, 46% of
patients (group H, 61%) presented a midline shift (P = 0.362). The
median scores of brain relaxation (interquartile range) were 1.5 (1 to
2.75) and 2.0 (1.5 to 3) (P = 0.211) for patients in groups L and H,
respectively. If adjusted for the presence of midline shift, the use of a
higher dose of HS resulted in an odds ratio of 0.444 (0.214 to 0.923)
(P = 0.057) and use of a lower dose resulted in 0.800 (0.126 to 5.092)
(P = 0.813). So regarding effect of midline shift, relaxation score is not
affected by the dose used of HS. No significant differences in post-
operative complications or length of ICU and hospital stay were ob-
served.
Conclusion: Totally, 3 mL/kg of 3% HS results in similar brain relaxa-
tion scores as 5 mL/kg in patients undergoing craniotomy for supra-
tentorial brain tumor. If adjusted for the presence of midline shift,
patients in the higher dose group had not significantly differences in
relaxation scores compared with the lower dose group.
EN16-NA03
Comparison of 0.9% Saline Versus “Plasma-Lyte A” For Brain
Relaxation in Patients Undergoing Supratentorial Tumor
Resection
S. Shiv, VK. Grover, H. Bhagat, N. Panda, K. Jandra, SK. Gupta, P.
Dutta. Postgraduate Institute of Medical Education and Research,
Chandigarh, India.
Background: Fluid management is an important component of surgery
but it is more challenging for anesthesiologists in case of neurosurgery.
During craniotomy it is important to maintain adequate intravascular
volume and at the same time to reduce intracranial pressure. Intra-
operative fluids determine the serum osmolarity that governs the fluid
shift in brain. Normal saline is commonly used IV fluid but in large
amount it causes hyperchloremic metabolic acidosis. Plasma-Lyte A
(PA) is an electrolyte containing solution that maintains blood pH, se-
rum electrolyte, and serum osmolarity. We hypothesize that PA provides
good intraoperative conditions, decrease hospital stay, and improves
neurosurgical outcome.
www.jnsa.com | S1
Supplement: EuroNeuro 2016
Methods: This prospective, double blind, randomized trial was con-
ducted after getting approval of the Ethical Committee and written in-
formed consent. Eighty adult patients scheduled for elective resection of
brain tumor were assigned to either NS group (0.9% NaCl, n = 40) or
PA group (Plasma-Lyte A, n = 40). This study was commenced from
preinduction period till 24 hours after extubation or till the time patients
started receiving oral fluids, whichever was earlier. Both groups received
the assigned fluid in the perioperative period. The following parameters
were recorded; brain relaxation (at the time of bone flap elevation),
cerebral metabolism variables, arterial blood gases and serum osmolarity
(after induction, bone flap elevation, after tumor resection, and 24 h
after surgery), modified Rankin Scale (mRS) Score (at discharge), and
duration of hospital stay.
Results and Discussion: Both groups were comparable with respect to
age, sex, and clinical characteristics such as diagnosis, largest diameter of
tumor, significant midline shift, and mass effect. Brain relaxation was
better in PA group than NS group (P = 0.04). The total hospital stay
was shorter in PA group than NS group (P = 0.014). The mRS Score
was lower but not statistically significant in PA group than NS group
(P = 0.095).
Conclusions: We conclude that PA provides better brain relaxation,
lower mRS Score at discharge, and shorter hospital stay as compared
with NS.
EN16-NA04
Corticosteroid Therapy and Surgery Trauma Impact on Blood
Glucose Variability for Patients Undergoing Brain Tumor
Surgery
G. Banevicius, M. Kazlauskas, A. Vilke, D. Bilskiene, A. Macas.
Lithuanian University of Health Sciences, Lithuania.
Background: Most patients undergoing brain tumor surgery receive
perioperative corticosteroids to reduce tumor-associated edema. How-
ever, it has been shown to cause hyperglycemia. The goal of the study
was to evaluate the influence of corticosteroids and surgery start time on
blood glucose variability during operative day.
Methods: The prospective observational study was carried out at a
medical university hospital and 103 adult ASA I-III, nondiabetics
treated with dexamethasone before operation were involved. Patients
underwent brain tumor surgery under general anesthesia and they re-
ceived 8 mg dexamethasone IV during induction. They were grouped by
surgery start time: morning surgery group A (n = 75) and afternoon
surgery group B (n = 28). Blood glucose concentrations were measured
5 times within 24 hours on operative day. The data are presented as
mean ± SD. Statistical analysis was performed using Pearson test,
Friedman test, Student t test, and w2 test. P < 0.05 was defined as sig-
nificant.
Results and Discussion: There were no significant differences between the
groups regarding demographic data. Results of blood glucose concen-
tration (mmol/L) are listed comparing group A and group B: 9:00 PM
day before operation, 6.0 ± 1.8 versus 6.2 ± 1.9 (P = 0.61), 7:00 AM
operation day, 4.4 ± 1.2 versus 4.6 ± 1.0 (P = 0.50), anesthesia in-
duction, 3.6 ± 0.9 versus 4.0 ± 1.0 (P = 0.05), end of operation,
5.2 ± 1.4 versus 5.5 ± 1.3 (P = 0.40), 9:00 PM operation day, 6.6 ± 1.2
versus 6.8 ± 1.0 (P = 0.42). Preoperative corticosteroid therapy lasted
5.1 ± 0.5 days in group A and 5.9 ± 0.8 days in group B (P > 0.05). The
total dose of dexamethasone did not differ significantly between groups
(68.9 ± 5.0 vs. 77.9 ± 6.7 mg, P > 0.05). The total dose of dex-
amethasone on operation day was significantly higher in group A
(15 ± 3.3 vs. 13 ± 3.0, P < 0.05). Blood glucose concentration sig-
nificantly decreased on preoperative night (group A:  2.5 ± 0.3, group
B: 2.2 ± 0.5, P < 0.05) and significantly increased during surgery in
both groups (1.7 ± 0.2 vs. 1.5 ± 0.2, P < 0.05), but there were no dif-
ference between them (P > 0.05). Correlation between total dose of
dexamethasone and blood glucose level during perioperative period was
not identified.
Conclusions: The blood glucose level of patients with brain tumor and
corticosteroid therapy has increased significantly during operation but it
has not depended on surgery start time. Identified blood glucose varia-
tions within did not require correction.
S2 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NA05
Anesthesia Technique for Surgical Treatment of Insular Gliomas,
Choices, and Effects
B.Y. Gravesteijn, M. Keizer, J.W. Schouten, M. Klimek. Erasmus MC,
Rotterdam, Holland.
Background: Tumor resection or debulking has proven to give patients
longer progression-free survival and higher quality of life. However,
knowledge of treatment of insular gliomas remains limited. We therefore
analyzed a significant number of patients who underwent an awake
craniotomy or a craniotomy under general anesthesia for insular tumor
resection to gain a deeper insight in their clinical characteristics.
Methods: We retrospectively analyzed the charts of patients with an
insular neoplasm who underwent 1 of the 2 investigated procedures in
the Erasmus MC between 2004 and 2014. We analyzed and compared
the cases on parameters for what could have influenced the doctor’s and
patient’s choice of procedure and for some factors that could measure
the differences in clinical outcome.
Results: We treated 37 cases: 17 by means of an awake craniotomy and
20 by means of a craniotomy under general anesthesia. We found the
median KPS in both groups to be 90 (interquartile range [IQR], 90 to
100). However, the awake craniotomy group showed an IQR of 90 to
100, whereas the general anesthesia group showed an IQR of 80 to 90
(P = 0.07). Glioblastoma multiforme was treated more often by means
of a general anesthesia procedure (13 vs. 2 patients, P < 0.05).The me-
dian number of neurological deficits was 2 (IQR, 1 to 4) preoperatively
and 2 (IQR, 1to 3) postoperatively in the awake craniotomy group
(P < 0.05), whereas 1.5 (IQR, 1 to 2) preoperatively and 1 (IQR, 0 to 2)
postoperatively in the general anesthesia group (P = 0.08). A tumor
resection of 80% to 100% was reached in 11 (64.7%) patients in the
awake craniotomy group, whereas only in 5 (25%) of the cases in the
general anesthesia group such radical resection was achieved (P < 0.05).
Six (35.3%) patients in the awake craniotomy group died at the end of
follow-up and 14 (70%) of the patients in the general anesthesia group
(P < 0.05), with an odds ratio of 0.23 (95% confidence interval, 0.06-
0.93) for awake craniotomy versus general anesthesia. The median sur-
vival time was 8.8 years in the awake craniotomy group and 1.1 in the
general anesthesia group (P < 0.05).
Conclusions: In our population, patients suffering from primary insular
gliomas who were physically better and had less complicated lesions
were more likely to be treated by means of an awake craniotomy pro-
cedure. The treatment generally did result in a more extensive resection,
a significant loss of neurological deficits, a longer median survival time,
and lower mortality.
EN16-NA06
Management Strategy for Left Frontal Low-grade Glioma
Diagnosed During Pregnancy
K. Kamata, R. Fukushima, Y. Shimokado, A. Ijuin, N. Komayama, N.
Morioka, M. Ozaki. Department of Anaesthesiology, Tokyo Women’s
Medical University, Tokyo, Japan.
Background: Low-grade glioma is a slowly progressive tumor that often
occurs in childbearing years. It has been suggested that extent resection
of low-grade glioma is closely correlated with patient survival.1 Thus,
maximal surgical resection with a minimal risk of teratogenicity should
be used in pregnant women.
Case Report: A 30-year-old right-handed woman developed new-onset
generalized convulsive seizures at 18+6 weeks gestation. Seizures were
poorly controlled by anticonvulsant polytherapy. A 6 cm lesion located
in her left supplementary motor area was a suspected grade III glioma
according to the WHO guideline. After multidisciplinary conference,
awake craniotomy was planned at 27+2 weeks gestation. Fetal heart
rate monitoring and emergency C-section was arranged. After rapid
sequence induction, the supraglottic airway and gastric tube were placed.
Scalp infiltration was done with 0.3% ropivacaine. Sevoflurane and re-
mifentanil were given until the first intraoperative magnetic resonance
imaging. Supraglottic airway was removed when the patient awoke. The
tumor margin was dissected with subjective movements with the navi-
gation system. The second intraoperative magnetic resonance imaging
confirmed complete removal of the T2-weighted image area. Seizure and
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
vomiting was not observed during operation. Fetal heart rate was stable
at 130 bpm. At 35+2 weeks, the patient delivered a healthy baby of
2317 g. Pathologic examination revealed an anaplastic astrocytoma, thus
radiotherapy and chemotherapy began 2 months postdelivery. There is
no evidence of tumor recurrence in the patient and the child did not
show any medical or developmental concerns at the 1-year follow-up.
Discussion: As evidence on use of adjuvant therapy in pregnancy is
limited, extent resection with functional monitoring is recommended if
the tumor is presumed malignant.2 In our patient left frontal supple-
mentary motor area glioma that causes uncontrolled seizures was di-
agnosed in the second trimester. Awake craniotomy is considered
advantageous to pregnant patients because subjective movement
preserves the patient’s motor function and reduces fetal exposure to
anesthetics. On the basis of the multidisciplinary discussion in the de-
cision-making process and careful perioperative preparation, awake
craniotomy should be considered even in patients who are pregnant.
Learning Points: Awake craniotomy is a therapeutic option to pregnant
patients when malignant brain tumor is in or adjacent to the eloquent
area.
References:
1. Nitta M, Muragaki Y, Maruyama T, et al. Proposed therapeutic
strategy for adult low-grade glioma based on aggressive tumor resection.
Neurosurg Focus. 2015;38:E7.
2. Jayasekera BA, Bacon AD, Whitfield PC. Management of glio-
blastoma multiforme in pregnancy. J Neurosurg. 2012;116:1187–1194.
EN16-NA07
Dexmedetomidine an Alternative Medication for Awake
Fiberoptic Intubation in a Patient With C2 Axis Fracture
L.M. Martı́nez Parra, C.J. Salazar Bonilla, M.A. De Juan Jiménez, M.C.
Martı́n Lorenzo, N. Montón Giménez, V. González Fariña. University
Hospital of Canarias, Spain.
Background: Mismanagement and inappropriate handling of unstable
cervical-spine column injuries may convert a simple bone injury into a
serious spinal cord injury. Awake fiberoptic intubation (AFOI) is the
“gold standard” and requires sedation, anxiolysis, and relief of dis-
comfort without impairing ventilation and depressing cardiovascular
function. The main goal is to allow the patient to be responsive and
cooperative. Medications such as Fentanyl, Remifentanyl, Midazolam,
and Propofol have been reported to assist AFOI; however, these agents
have been associated with cardiovascular and respiratory adverse effects.
Dexmedetomidine has been an effective alternative to facilitate this
procedure. Dexmedetomidine is a selective a-2-adrenal receptor agonist
that cause sedation, anxiolysis, analgesic sparing, reduced salivary se-
cretion, and minimal respiratory depression.
Case Report: We reported a case of 68-year-old man with diabetes type
II and hypertension. He had a 2 m fall and came to the hospital with
cervical pain. After cervical spine inmobilization, cervical computed
tomography was made. It showed a C2 fracture. The patient was pro-
posed for posterior cervical spine fusion surgery.
The patient was premedicated with Midazolam 0.02 mg/kg IV, 30 mi-
nutes before surgical procedure, and the standard monitoring was used
in the operating room. Tetracaine with epinephrine were applied to the
left nostril and puffs of 10% lidocaine were sprayed for the top-
icalization of tongue and hypopharynx. After that dexmedetomidine
(0.8 mcg/kg) was infused over 15 minutes, followed by a maintenance
infusion of 0.4 mcg/kg/h. Bronchoscopy was performed through nasal
approach after achieving a score Z2 in Ramsay sedation scale. The
spray-as-you-go technique was performed. After proper placement of
endotracheal tube, general anesthesia was induced. The AFOI man-
agement was very comfortable for the patient, and no cough, grimacing,
verbal objection, defensive movement of head or hand were present. The
patient’s airway was never obstructed and SpO2 during the entire pro-
cedure was 100%. The patient was sedated but able to respond to simple
commands and cooperative. There were no significant changes in the
heart rate and MAP. Neurophysiological monitoring took place without
“warnings” for spinal cord injury and cervical spine fusion was per-
formed without complications.
Discussion: AFOI was an optimal, safe, and reliable approach technique
in patients with axis fracture to reduce spinal cord injury. The patient
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
cooperation with dexmedetomidine and the reduced anxiety could play
an important role in securing the airway of patients with an unstable
cervical spine.
Learning Points: Dexmedetomidine is more effective than other drugs
during AFOI, as it provides better intubation conditions, hemodynamic
stability, and adequate sedation without respiratory depression.
EN16-NA08
Laryngeal Mask Ventilation During Lumbar Spine Neurosurgery
in Knee-Chest Position is Feasible
P. Hurtado, M. Lopez, J. Tercero, A. Lopez, N. Fábregas, R. Valero.
Hospital Clinic de Barcelona, Neuroanesthesia section, Spain.
Background: The aim of this retrospective study was to describe our
experience with laryngeal mask (LM) airway management inserted after
induction of anesthesia in prone self-positioned patients undergoing
lumbar spine neurosurgery.
Methods: Airway management (need for LM repositioning, orotracheal
intubation because of failed LM insertion), anticipated difficult airway
and airway complications (laryngeal spasm, bronchospasm, leaks re-
quiring LM repositioning, arterial oxygen desaturation [ < 95%], and
bronchial aspiration) were registered. Details of airway management
strategies for intubated patients were recorded. Duration of surgery was
also recorded. Statistics were compared between groups with the t test or
the w2 test, as appropriate.
Results: A total of 358 cases were reviewed from 2008 to 2013. Tracheal
intubation was performed in 108 patients and LM was chosen for 250
patients (69.8%). Intubated patients had a higher mean age and rate of
anticipated difficult airway; duration of surgery was longer (P < 0.001,
all comparisons). LM insertion and anesthetic induction proved effective
in 97.2% of the LM-ventilated patients; 7 patients (2.8%) were intubated
because of persistent leakage. Incidences with airway management were
resolved without compromising patient safety.
Conclusions: Our data support the clinical effectiveness and feasibility of
anesthetic induction and insertion of a LM airway after patients have
placed themselves in knee-chest position for lumbar neurosurgery. LM
airway management during lumbar neurosurgery in knee-chest position
is feasible when the anesthetist is experienced.
EN16-NA09
Relevance of Automatic Cuff Pressure Controller for Assessment
of Endotracheal Tube Cuff Pressure in Neurosurgeries
M. Jain Kumar, C.B. Tripathi. Institute Of Human Behaviour And Allied
Sciences. India.
Background: Inflation and assessment of the endotracheal tube cuff
(ETTc) pressure is often underappreciated as a critical aspect of endo-
tracheal intubation. On the basis of the recent recommendations, the cuff
pressure should be maintained around 25 cm H2O in critically ill in-
tubated and mechanically ventilated patients. Cuff pressure more than
tracheal mucosal capillary perfusion pressure (25 to 30 cm H2O) leads to
injury of mucosa and surrounding tissues, whereas less cuff pressure
leads to aspiration and hypoventilation. Correlations between manual
methods of assessing the pressure by an experienced anesthesiologists
and assessment with maintenance of the pressure within the normal
range (20 to 30 cm H2O, fixed at 25 cm H2O) by the automated pressure
controller device were studied.
Methods: The study was a prospective observational study by trained
anesthesiologists. After obtaining the institutional ethical committee
clearance and written consent, 100 patients were randomly selected of
either sex and age between 20 and 65 years of ASA grade I and II and
MPG I and II. These patients were divided into 2 groups of 50 patients;
group M: in this group, the ETTc was inflated manually by a trained
anesthesiologist and checked for its pressure and reset ETTc at 25 cm
H2O and then ETTc checked hourly by cuff pressure monitor and group
C: in this group, ETTc was inflated by automatic cuff pressure controller
and pressure was maintained at 25 cm H2O throughout the surgeries. We
observed for the ETTc pressure after manual inflation, any effect of BMI
on ETTc, any effect of ETTc on delivered tidal volume/EtCO2/airway
pressure, any change in the ETTc during surgery, complications (if any),
and any other observation. The mean duration of surgery was 5.2 hours.
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Supplement: EuroNeuro 2016
Repeated measure ANOVA, the multiple comparisons analysis with
Bonferroni correction test was applied to compare each time measured
pressure with constant pressure.
Results: We observed that in group M, P-value = 0.000 was highly
statistically significant, whereas in group C, as there was constant ETTc
pressure, that is, 25 cm H2O, there was no need of statistical calculations,
and group M and group C may not be compared. Interaction effect
between ETTc pressure and EtCO2, ETTc pressure and tidal volume,
and ETTc pressure and EtCO2 and tidal volume were not significantly
different. The main complications of high ETTc are sore throat, cough
and hoarseness of voice, and the rate of incidence of complications are
higher in manual group.
Conclusions: We concluded that the ETTc pressures were significantly in
the higher range when ETTc was inflated manually, even with the suf-
ficient experienced anesthetist. Further in case of cervical spine surgeries
through anterolateral approach, the ETTc has increased too much due
to pressure of retractors. The known complications of high ETTc
pressure may be avoided if the cuff pressure controller device is used.
EN16-NA10
Reduction in End-Tidal Carbon Dioxide as an Indicator for
Venous Air Embolism in Sitting Neurosurgical Procedures
C. Harper, A. Abcejo, J. Pasternak. Mayo Clinic, Rochester, NY, USA.
Background: Venous air embolism (VAE) is a known complication of
procedures performed in the sitting position.1 Changes in end-tidal
carbon dioxide (ETCO2) occur during VAE due to the development of
dead space. The objective of this study is to determine the utility of
observed changes in ETCO2 level as a predictor of VAE.
Methods: Anesthetic records and operative reports were individually
reviewed for patients having neurosurgical procedures in the sitting
position between January 2000 and October 2013 at Mayo Clinic,
Rochester. Those patients with documented air detected on trans-
esophageal echocardiogram were identified and stratified according to
ventilation type (mechanical vs. spontaneous) and VAE severity (mild
vs. moderate vs. severe, based on predefined criteria). Baseline ETCO2
values were obtained from approximately 30 minutes before the docu-
mented VAE, and absolute and relative change in ETCO2 were calcu-
lated using the lowest ETCO2 value obtained within the range of
15 minutes before to 15 minutes after the documented VAE event.
Results and Discussion: For mechanically ventilated patients (n = 84),
there was a statistically significant decrease in ETCO2 from baseline
during the event (P < 0.0001) as well as a statistically significant dif-
ference in both absolute and relative reduction in ETCO2 between
moderate versus mild (P < 0.0001) and severe versus mild (P < 0.005)
VAEs, but not between moderate versus severe VAE’s. For sponta-
neously ventilating patients (n = 15), there was a statistically significant
reduction in ETCO2 from baseline during the event (P < 0.0001). There
was no difference in absolute or relative reduction in ETCO2 between
different severity groups in spontaneously ventilated patients.
Conclusions: Reduction in ETCO2 is a strong indicator of clinically
significant VAE in mechanically ventilated patients. A larger sample size
may be needed to accurately assess whether ETCO2 is a reliable pre-
dictor of VAE in spontaneously ventilated patients.
Reference:
1. Matjasko J, Petrozza P, Cohen M, et al. Anesthesia and
surgery in the seated position: analysis of 554 cases. Neurosurgery.
1985;17:695–702.
EN16-NA11
Detection of Venous Air Embolism With TEE in Posterior Fossa
Surgery in the Sitting Position: A 4-Year Analysis of our
Institutional Practice
S. Goraksha, B. Thakore, R. Chelani, B. Misra, J. Monteiro. P D
Hinduja Hospital and Medical Research Centre, India.
Background: The posterior fossa is a rigid compartment with poor
compliance and any critical brain lesions cause brainstem compression
and herniation. The sitting position offers better surgical access. The
potential for serious complications such as venous air embolism (VAE),
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
cardiovascular instability, and postoperative neurodeficits was respon-
sible for a decline in its use. We have revisited this position over the last
few years with better safety measures, appropriate patient selection, and
better intraoperative monitoring. We used intraoperative trans-
esophageal echocardiography (TEE) to help in early detection of VAE.
We assessed patient safety and reviewed perioperative complications.
Methods: In total, 300 patients were reviewed over a 4-year period from
2011 to 2015. Preoperative assessment included a 2D ECHO to rule out
patent foramen ovale. Anesthesia was induced with propofol, fentanyl,
atracurium, and IPPV with 50% air:oxygen and maintained with pro-
pofol:fentanyl. Continuous radial arterial pressure, CVP, EtCO2 moni-
tored. TEE used to detect and grade VAE by Hemmerling and Schmidt
classification. During VII and VIII nerve testing, atracurium was dis-
continued and TOF monitoring used. Any intraoperative and post-
operative complications were noted.
Results: Intraoperative: Cardiovascular instabilty 50% Bradycardia
15%.VAE (detected by TEE and EtCO2) 10% to 30 patients. Grade I:
12, grade II: 10, grade III: 5, grade IV: 3. Postoperative:
Pneumoenchephalus—all patients—no intervention required. Face
swelling/Macroglossia—1 patient required reintubation. Neurodeficits:
blindness 1, foot drop 1—resolved spontaneously, quadriplegia 1—
partial recovery.
Discussion: Sitting position aids surgical access for posterior fossa sur-
gery and improves cerebral venous and cerebrospinal fluid drainage.
However, it is associated with serious complications. Fluid admin-
istration and pneumatic compression stockings can prevent hypotension.
Adequate positioning and padding minimizes the risk of neuropathies.
VAE resulting in hypoxia, hypotension, and paradoxical air embolism
can cause ischemic neurological deficits. TEE can detect 0.02 mL/kg of
air. It permits detection venous emboli and PAE.
Conclusions: Intraoperative TEE helped in early detection and resolution
of VAE. After screening to rule out PFO and intraoperative TEE, eli-
gible patients would benefit from vigilant monitoring leading to the safe
conduct of posterior fossa surgeries in the sitting position.
EN16-NA12
Adenosine Flow Arrest to Facilitate Cerebral Aneurysm Clipping:
2-Year Institutional Experience
S. Goraksha, R. Chelani, B. Thakore, B. Misra, J. Monteiro. P D
Hinduja Hospital and Medical Research Centre, India.
Background: A cerebral aneurysm is a localized dilatation of the blood
vessel due to weakness in the vessel wall. Incidence is about 4% and rate
of rupture 0.05% to 6% per year. Treatment is surgical clipping or
endovascular coiling. Variable location of aneurysm can result in diffi-
cult surgical exposure. Temporary clip ligation of proximal vessels, or
deep hypothermic circulatory arrest on cardiopulmonary bypass assist in
decompressing the aneurysm. We used adenosine to induce transient
flow arrest to facilitate clipping. The use of adenosine to aid surgical
clipping is associated with transient flow arrest and hypotension. We
reviewed efficacy and patient safety.
Methods: We studied 49 patients from 2014 to 2015. Only cases in which
adenosine was used were included. Patients with cardiac disease, heart
blocks, bronchial asthma, and COPD were excluded. Preoperative 2D
ECHO, ECG, and 24 hours preoperative cardiac enzyme levels were
carried to rule out cardiac issues. Patients were induced with fentanyl,
propofol, atracurium, and maintained with IPPV:O2:air:propofol:
atracurium. Continuous ECG, radial arterial pressure, CVP, EtCO2,
urine output, and TOF was monitored. Transcutaneous pacing pads
were applied. Phenylephrine was used if needed, to maintain blood
pressure. Before application of permanent clip, adenosine 0.3 to 0.4 mg/
kg was given. Duration of bradycardia (HR < 30 bpm), asystole, and
hypotension (SBP < 80 mm Hg) were noted. Any complications were
noted.
Results and Discussion: We used adenosine safely with spontaneous re-
turn of rhythm in all cases. The median dose required to cause a flow
arrest of 30 seconds was 18 mg. The surgeon was able to clip the
aneurysm in all cases. The decision to give adenosine was made in co-
operation with the neurosurgeon and the anesthesiologist. Adenosine, an
endogenously occurring nucleoside analog, reduces heart rate by pro-
longing conduction through SA and AV nodes. Its action is self-limited
with a half-life of <10 seconds. The aneurysm was successfully clipped
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
in all cases. Cardiac enzymes monitored postoperatively were normal.
We did not observe any immediate or late adverse events related to
administration of adenosine.
Conclusions: We conclude that use of adenosine in patients after careful
preoperative screening to rule out cardiac and respiratory contra-
indications, will facilitate surgical clipping of aneurysms.
EN16-NA13
Opthlamic Aneurism: A Case Report
E. Guerra Hernández, Z. Hussein Dib González, M. Mourad, A.
Rodrı́guez Pérezar, T. Sarmiento, A.L. Cervantes, L. Grosso. Hospital
Universitario de Gran Canaria Doctor Negrı´n, Spain.
Background: Elective clipping of a nonruptured intracranial aneurysm
requires precise physiological goals and monitoring to prevent poten-
tially devastating complications.
Case Report: A 19-year-old woman presented with sudden and severe
headache likely due to tension. An magnetic resonance imaging was per-
formed showing an incidental left ophthalmic aneurysm. A computed to-
mographic angiography showed an internal carotid artery aneurysm in the
left paraclinoid. The ophthalmic artery emerged from the aneurysmal sac.
Aneurysmal clipping under elective general anesthesia was scheduled. In-
duction was carried out with propofol, remifentanil, and cisatracurium with
tight control over blood pressure, with invasive arterial pressure monitor-
ing. First, dissection of the left carotid tripod was performed along with
control of the left ICA. Then pterional craniotomy was carried out and
clipping of the left ophthalmic artery aneurysm with preservation of this
artery. The surgery was without incident from an anesthetic point of view.
The patient was transferred to the postsurgical critical care unit extubated,
with GCS 15 and strength 5/5 in the 4 extremities. Pupils were isochoric and
reactive, with cranial pairs preserved.
Discussion: The global prevalence of cerebral aneurysms is 3.2%. It is
more frequent in women, patients with polycystic kidney disease, a
family history of intracranial aneurysms, or subarachnoid hemorrhages.
The majority are found in the anterior circulation and have a strong
tendency to rupture when they are larger than 7 mm. There are 4 general
objectives of intraoperative anesthetic management for craniotomy and
clipping of aneurysms: (1) minimize any change in the transmural gra-
dient of the aneurysm; (2) maintaining adequate cerebral perfusion
pressure; (3) cerebral relaxation; and (4) wake the patient up quickly and
calmly after surgery to evaluate neurological state.
Learning Points: Nonruptured cerebral aneurysms are usually asympto-
matic and are found incidentally, generally by studying causes of headache.
Intraoperative anesthetic management is based on minimize any change in
the transmural gradient of the aneurysm, maintain an adequate cerebral
perfusion pressure, lower edema, and wake the patient rapidly and calmly
after surgery to evaluate neurological state. Immediate postoperative phase
should be performed in the postsurgical critical care unit.
EN16-NA14
Noncardiogenic Electrocardiographic Abnormalities In Cervico-
medullary Junction Tumor
C.H. Goh*, Y. Kennyw, T. Peterz, A. Wongw. *Department of Neuro-
science, Hospital Universiti Sains Malaysia, Jalan RPZ II, Kubang
Kerian, Kelantan, Malaysia. wSarawak General Hospital, Department of
Neurosurgery, Jalan Hospital, Kuching, Sarawak, Malaysia. zSarawak
General Hospital, Department of Anaesthesiology, Jalan Hospital,
Kuching, Sarawak, Malaysia.
Background: We illustrate the case of a 22-year-old man with underlying
neurofibromatosis.
Case Report: The patient had noncardiogenic electrocardiogram (ECG)
abnormalities during his treatment for cervicomedullary junction tumor
in our center. He presented with a 1-year history of occipital headache,
associated with progressive limb numbness and pyramidal weakness 1
week before seeking emergency care. His gait and balance were made
worse by cerebellar symptoms. Magnetic resonance imaging revealed
large extradural paraspinal C1 mass with intraspinal and intracranial
extension by foramen magnum, compressed at cervicomedullary junction
with cord edema and obstructive hydrocephalus. Radiologic features
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
were suggestive of schwannoma. He developed bulbar palsy in the ward
and nasogastric tube feeding was needed due to difficulty in swallowing.
He aspirated and had respiratory failure before scheduled surgery. He
was hypotensive and tachycardic. Immediate endotracheal intubation
was conducted and postintubation ECG showed Q wave II, III, aVF; ST
elevation V1 and V2. Cardiac enzyme and troponin were not elevated.
Echocardiogram revealed normal ejection fraction with hyperkinetic wall
motion. Coronary angiography was performed and no significant lesion
was observed. Computed tomographic pulmonary angiography was
negative. He was managed under intensive care unit and ECG sub-
sequently normalized spontaneously.
Discussion: ECG abnormalities is known to accompany brain disease, par-
ticularly subarachnoid hemorrhage.1–3 However, brainstem tumor association
is uncommon. Neurohormonal system dysfunction and vagal tonicity were
hypothesized; however, exact pathophysiology still remains unclear. Neuro-
fibromatosis may be associated with vasculopathy and acute coronary syn-
drome at young age, nonetheless a neurogenic cause of ECG abnormalities
must be considered especially in case of cervicomedullary compression.
References:
1. Lopez-Lluva MT, Arizon-Munoz JM, Gonzales F, et al. Electro
cardiographic changes underlying central nervous system damage.
Rev Esp Cardiol. 2012;65:958–960.
2. Koepp M, Kern A, Schmidt D. Electrocardiographic changes in
patients with brain tumors. Arch Neurol. 1995;52:152–155.
3. Rodehill A, Olsonn Gl, Sundquist K, et al. ECG abnormalities in
patients with subarachnoid haemorrhage and intracraneal tumors.
J Neurol Neurosurg Psychiatry. 1987;50:1375–1378.
EN16-NA15
Rapid Ventricular Pacing For Neurovascular Surgery: A Safety
Study For Brain And Heart
V. Saldien, K. Van Loock, T. Schepens, T. Menovsky. University Hos-
pital Antwerp, Belgium.
Background: Intraoperative rupture of a cerebral aneurysm increases
perioperative morbidity and mortality. Rapid ventricular pacing (RVP)
lowers the blood pressure significantly in a controlled and directly re-
versible manner during dissection and clipping of the aneurysm. The aim
of the study was to investigate the safety of repetitive RVP for heart and
brain, using troponin levels (cTnI) and magnetic resonance (MR)
imaging.
Methods: After local Ethics Committee approval, 27 patients undergoing
craniotomy for a cerebrovascular disorder were included. Anesthesia
was standardized. Bipolar pacing electrode was positioned and con-
firmed. During exposure and clipping of the aneurysm rapid pacing was
performed during short periods. Troponin levels were measured before
pacing, postoperatively and 24 hours after surgery. MR imaging of the
brain was performed preoperatively and postoperatively.
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Supplement: EuroNeuro 2016
Results and Discussion: Patients were paced at 180 bpm for 29 seconds
(range, 7 to 60 s) with a total duration of pacing of 29 seconds (range, 20
to 194 s). Postoperatively MR images showed no new areas of diffusion
restriction in the contralateral hemisphere or fossa posterior. Post-
operative troponin levels 0.044 (0.025 to 0.093 mg/L) were elevated
compared with the prepacing levels 0.014 (0.014 to 0.094 mg/L) (Fig. 1).
In 12 patients troponin levels exceeded the cut off value of 0.045 mg/L.
None of the cTnI levels exceeded the cut-off value for myocardial in-
farction of 0.600 mg/L. Troponin levels 0.014 (0.014 to 0.042 mg/L) nor-
malized 24 hours after pacing.
Conclusions: On diffusion-weighted images no RVP related ischemia was
observed. Besides the low and brief increase of troponin levels, RVP was
not associated with cardiac events. RVP seems to be a safe blood
pressure lowering technique for the brain and heart.
EN16-NA16
ST-Segment “Hump Sign” in Resting Electrocardiogram. Is it a
New Independent Predictor of the Risk of Acute Diastolic Heart
Failure in Neurosurgical Patients?
P. Kumari. Department of Clinical Physiology. Government Medical
College, Haldwani, Uttrakhand, India.
Background: ST-segment hump sign (STHS), which is the discrete up-
ward deflection of ST segment in ECG, is normal during exercise testing.
Case Report: A case of a 72-year-old man with long-standing hyper-
tension, scheduled for temporoparietal glioma excision is presented.
Resting ECG revealed STHS in the inferior and the lateral leads.
Standard general anesthesia was administered. Surgery was uneventful
and blood loss was 400 mL. Forty minutes after surgery, in the recovery
room he complained of shortness of breath with raised blood pressure.
Bilateral fine crepitation with S4 gallop was present. Echocardiography
revealed severe LV diastolic dysfunction (LVDD) with a restrictive
pattern. Nitroglycerin was started and titrated to maintain blood pres-
sure of 140/90 mm Hg.
Discussion: LVDD appears in hypertension or aging individuals.1
LVDD is useful to confirm diastolic heart failure.2 STHS during exercise
correlates with LVDD.
Learning Points: STHS on ECG, can be a cause of perioperative acute
diastolic heart failure in a previously asymptomatic patient.
References:
1. Pirracchio R, Cholley B, De Hert S, et al. Diastolic heart failure in
anaesthesia and critical care. Br J Anaesth. 2007;98:707–721.
2. Zile MR, Gaasch WH, Carroll JD, et al. Heart failure with a normal
ejection fraction: is measurement of diastolic function necessary to
make the diagnosis of diastolic heart failure? Circulation. 2001;104:
779–782.
EN16-NA17
Different Subtypes of Trigeminocardiac Reflex in the Same
Patient During Craniotomy
P. Tan*, I. Kong*, A. Ngw, N. Eza*. *Department of Anaesthesia &
Intensive Care, Sarawak General Hospital. wDepartment of Neurosurgery,
Sarawak General Hospital, Malaysia.
Background: Reflex bradycardia, hypotension, and asystole that occur
during neurosurgery are potentially life threatening for which trigemi-
nocardiac reflex (TCR) and brain-stem handling are the most common
causes.1–3
Case Report: A 51-year-old woman with left orbital hyperostosis presented
for left pterional craniotomy and optic nerve decompression. Induction
was performed with intravenous propofol, maintained with sevoflurane
and supplemented with target-controlled infusion of remifentanil. There
was dural involvement of the hyperostosis with moderate vascularity over
the left temporal bone. During cauterization of the blood vessels at the
dura, the patient went into asystole. The surgeon was alerted and within
<10 seconds, blood pressure (BP) and heart rate (HR) normalized after
prompt cessation of manipulation. A similar asystole occurred while the
surgeon was working around the area of Gasserian ganglion but again her
BP and HR spontaneously recovered after immediate removal of the
stimulus. During suturing of the scalp, the patient experienced severe
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
bradycardia and hypotension while the surgeon flushed the subgaleal drain
site with saline and applied low pressure suction to the drain. This was
followed by another episode of asystole when the subgaleal drain was
connected to a vacuum drainage bottle. Both episodes were self-limiting
after instant release of negative pressure suction. The patient had third
nerve and opthalmic branch of trigeminal nerve palsy but gradually im-
proved in extraocular eye motion after the surgery.
Discussion: Severe hemodynamic instability encountered was attributable
to Gasserian ganglion subtype of TCR and peripheral TCR. Acute in-
tracranial hypotension following the application of negative suction pres-
sure may also account for its recurrence at the end of surgery. Immediate
removal of manipulation is the first line of treatment. Although the depth
of anesthesia was not monitored, MAC of sevoflurane was constantly kept
at 0.8 to 1.0 in addition to target-controlled infusion of remifentanil at 2 to
3 ng/mL. Nevertheless, the use of remifentanil may further enhance the
degree of bradycardia caused by TCR and a lighter plane of anesthesia was
allowed upon completion of surgery. Hypoxia, hypercarbia, and acidosis
can potentiate this response and should be corrected, if present.
Learning Points: The managing team must be aware, anticipate, and able
to treat such complications. Vigilant monitoring of patient is warranted
even till the very late of surgery.
References:
1. Chowdhury T, Mendelowith D, Golanov E, et al. Trigemino-Cardiac
Reflex Examination Group. Trigeminocardiac reflex: the current
clinical and physiological knowledge. J Neurosurg Anesthesiol.
2015;27:136–147.
2. Meuwly C, Chowdhury T, Sandu N, et al. Anesthetic influence on
occurrence and treatment of the trigemino-cardiac reflex: a systematic
literature review. Medicine (Baltimore). 2015;94:e807.
3. Karamchandani K, Chouhan RS, Bithal PK, et al. Severe bradycardia
and hypotension after connecting negative pressure to the subgaleal
drain during craniotomy closure. Br J Anaesth. 2006;96:608–610.
EN16-NA18
Diaphragmatic Pacing Stimulation: Anesthetic Management at
Institut Guttmann
N. Alegret Monroig, P. Serra, J. Pere Pessas. Institut Guttmann,
Barcelona, Spain.
Background: Diaphragm pacing (DP) has been shown to successfully
replace mechanical ventilators for patients affected by spinal cord in-
juries, amyotrophic lateral sclerosis, and other neurological injuries with
chronic respiratory insufficiency, improving quality of life and decreas-
ing morbidity, mortality, and health costs. From an anesthetic per-
spective, both the surgery and the patient population present several
unique challenges. The aim of this study is the analysis of the anesthetic
management and intraoperative complications of patients undergoing
insertion of a DP in our institution.
Methods: With IRB approval, retrospective review was conducted from
December 2007 to July 2015. Data register of patient previous state,
anesthetic technique, and intraoperative complications due both to an-
esthetic technique or surgery were collected.
Results: We included 16 patients (5 pediatric) with DP indication due to
spinal cord injuries, 63%; amyotrophic lateral sclerosis, 25%; or other
neurological diseases, 12%. General anesthesia was required for the
abdominal laparoscopy; we used intravenous 87% versus inhalatory
induction 13% and total intravenous anesthesia (TIVA) 50% versus
balanced 50% for maintenance anesthesia. Succinylcholine was ad-
ministered to 31% of the patients for orotracheal intubation. Anesthetic
deepening was needed during the surgery for pneumoperitoneum toler-
ance in 50% of the cases in the balanced anesthesia group and in 25% of
the cases in the TIVA group. Registered complications were: 31%
mechanical ventilation difficulty during laparoscopy, pneumotorax
12.5%, and autonomic dysreflexia 6%.
Discussion: Although few studies about perioperative management for DP
surgery and none in pediatric patients are available, all agree in the need of
diaphragmatic contraction visualization during the procedure, so neuro-
muscular blocking agents should be avoided during surgery. Our report is
the first using depolarizing neuromuscular blocker at the anesthetic
induction with no consequences on the diaphragmatic mapping. We are
describing for first time inhalatory induction through tracheostomy and
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
TIVA for maintenance anesthesia in DP surgery with satisfactory results.
Our incidence of complications is comparable to other studies.
Conclusions: The implantation of DP is a safe technique with the potential
to improve the quality of life of patients dependent on mechanical ven-
tilation. Appropriate intraoperative care is fundamental to achieving better
results. Nevertheless larger, randomized, prospective studies are required.
EN16-NA19
Management of Cardiac Arrest During Neurosurgery: Survey of
Anesthetists in a Neurosurgical Unit in the UK
G. Bose, S. Salib, A. Sztucki, R. Mittal. Department of Anaesthesia,
Royal Stoke, University Hospital, Stoke-on-Trent, UK.
Background: Cardiac arrest during neurosurgery is very rare. Surgical and
positioning factors pose significant challenges in effective resuscitation of
cardiac arrest during neurosurgery. Successful resuscitation requires ef-
fective resource management and treatment of underlying cause.1 Guide-
lines on Management of Cardiac Arrest during Neurosurgery have been
published recently.2 We conducted a survey to assess the learning needs
and awareness of these guidelines among anesthetists in our hospital.
Methods: An anonymous questionnaire was distributed to anesthetic
consultants and trainees over 3 months. Questions included management
of bradycardia during neurosurgery, single best answer questions on car-
diopulmonary resuscitation (CPR) if the patient was supine, in pins, lat-
eral, prone or sitting, and on the dose of adrenaline in cardiac arrest during
neurosurgery. Responses were collected on the same day of distribution.
Results: We received 34 responses. Almost 90% of respondents correctly
identified removal of cause and administration of an anticholinergic in
management of bradycardia during neurosurgery, but very few men-
tioned the role of adrenaline infusion and pacing. In total, 83% would
change patient position from lateral or sitting to supine before com-
mencing CPR. In prone patients, 52% would immediately commence
chest compressions without change in position of the patient. In patients
with pins, 67% would remove pins before chest compressions. Only 10%
knew the correct dose of adrenaline in cardiac arrest during neuro-
surgery.
Conclusions: Our response rate was 81%. Awareness of different compo-
nents of the guidelines was good; however, specific knowledge about CPR
in prone position and in pins could have been better. To achieve this, we
have presented these guidelines in our department. In the future, we aim to
run simulation training scenarios to help manage real life situations.
References:
1. Chowdhury T, Petropolis A, Cappellani RB. Cardiac emergencies in
neurosurgical patients. BMRI.2015, Article ID 751320,14pp, 2015.
2. Working Group of the Resuscitation Council (UK), NASGBI and
SBNS. Management of cardiac arrest during neurosurgery in adults.
Guidelines for healthcare providers. 2014, 1–24.
EN16-NA20
Use of Cerebral Oximetry in Patients With Cerebral Vasospasm
After Spontaneous Subarachnoid Hemorrhage (SAH)
B. Limw, J. Rao*, S.Y. Chongw, C.G. Guw, V. Ng*, J. Tanw. *National
Neuroscience Institute. wTan Tock Seng Hospital, Singapore.
Background: Delayed cerebral ischemia (DCI) secondary to cerebral
vasospasm occurs in 30% of patients after spontaneous subarachnoid
hemorrhage (SAH). Cerebral oximetry utilizes near-infrared light to
provide quantitative measurement of cortical oxygen saturation. This
offers the advantage of real-time monitoring for vasospasm but its use in
SAH is not well established. In this case series, we describe our experi-
ence of using cerebral oximetry in 3 patients with vasospasm after SAH.
Case Reports: Patient 1 was a 45-year-old female who underwent a suc-
cessful clipping of ruptured left anterior communicating artery (ACOM)
aneurysm. On day 10 (D10) SAH, she developed DCI secondary to vaso-
spasm of bilateral middle cerebral artery (MCA). Cerebral oximetry probe
was applied and the readings showed rapid improvement after initiation of
triple H therapy. Her GCS improved 3 hours later. Patient 2 was a 53-year-
old man who underwent clipping of left ACOM aneurysm. On D5 SAH, he
developed DCI with elevated transcranial Doppler reading and drowsy GCS
(E3V2M6). A few hours before diagnosis, cerebral oximetry reading showed
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
a decreasing trend, which improved after initiation of triple H therapy. A
few days later, patient developed left-sided infarct, which correlated with a
persistently low left oximetry reading. Patient 3 was a 66-year-old woman
who was admitted for ruptured left PCOM aneurysm. On D10 SAH, CT
angiogram showed left MCA vasospasm but she was treated conservatively
as her GCS and cerebral oximetry readings were stable. On D13, cerebral
oximetry showed a decreasing trend before a drop in motor power of her
right upper limb. Subsequently, cerebral angiogram confirmed vasospasm of
bilateral ICA, MCA, and ACA.
Discussion: The above cases illustrated the correlation of cerebral oxi-
metry with DCI and vasospasm. Cerebral oximetry decreased before
diagnosis of DCI in the last 2 patients, suggesting a role in early de-
tection of DCI. In addition, cerebral oximetry was able to differentiate
between symptomatic and radiologic vasospasm in patient 3. However,
more work needs to be done to investigate how cerebral oximetry varies
in patients with different sites of vasospasm as well as to establish the
appropriate cutoff values for diagnosis of vasospasm.
EN16-NA21
Immediate Increase in Cerebral Oxygenation Induced by
Successful Electrical Cardioversion of Atrial Fibrillation is Not
Maintained at Long-Time Follow-Up
S. Louage, E. Jorissen, C. Genbrugge, F. Jans, J. Dens, C. De Deyne.
Ziekenhuis Oost-Limburg, Department of Anaesthesiology, Intensive
Care, Emergency Medicine and Pain Therapy, Genk, Belgium.
Background: Successful electrical cardioversion (ECV) of atrial fi-
brillation (AF) was reported to increase cerebral tissue oxygenation
(rSO2) while unsuccessful ECV did not.1 This can have implications for
the management of patients developing postcardiac surgery AF. In these
patients, who are at high risk of postoperative cognitive dysfunction,
immediate optimization of rSO2 might be crucial. The study aimed to
confirm the beneficial effect of ECV on rSO2 and to examine whether
this effect is longlasting.
Methods: A prospective, observational study was performed in 60 con-
secutive AF patients scheduled for ECV. rSO2 was measured with NIRS
(Equanox Nonin, Plymouth, MI). A first measurement period started
before propofol induction for ECV and ended 15 minutes after regaining
consciousness. A second measurement period (5 min) took place at fol-
low-up consultation, 4 to 6 weeks after ECV.
Results and Discussion: ECV was successful in 50 AF patients. There
were no significant differences between the groups (successful vs. un-
successful ECV) in baseline rSO2 (70% ± 6% vs. 69% ± 5%; P = 0.87).
We found no correlation between baseline rSO2 and left ventricular
ejection fraction (P = 0.76), baseline mean arterial pressure (P = 0.39),
baseline heart rate (P = 0.49), or age (P = 0.34). rSO2 increased imme-
diately after successful ECV (70% ± 6% vs. 71% ± 6%; P = 0.03), but
not after unsuccessful ECV (69% ± 5% vs. 68% ± 4%; P = 0.48). At
follow-up after successful ECV, rSO2 values were no longer increased
compared with baseline (70% ± 6% vs. 68% ± 5%; P = 0.08). Our
results demonstrate that the beneficial effect of ECV on rSO2 is not
longlasting. We hypothesize that adaptive responses of cerebral vascu-
lature are responsible for the observed return to baseline rSO2 values.
Conclusions: Successful ECV of AF increases rSO2 while unsuccessful
ECV does not. However, this immediate increase in rSO2 is not main-
tained at long-time follow-up.
Reference:
1. Wutzler A, Nee J, Boldt LH, et al. Improvement of cerebral oxygen
saturation after successful electrical cardioversion of atrial fi-
brillation. Europace. 2014;16:189–94.
EN16-NA22
Effects Of Subanesthetic Doses of Ketamine on Bilateral Bis-
pectral Index During Stable Target Controlled Infusion (TCI)
General Anesthesia
A.M. Araujo*, C.S. Nunesw, M. Campos*. *Centro Hospitalar do Porto.
wUniversidade Aberta and Centro Hospitalar do Porto, Portugal.
Background: Ketamine is increasingly used in subanesthetic doses as an
analgesic in a wide range of pain settings. The purpose of the present
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study was to assess the effect of a bolus of ketamine in bispectral index
(BIS), spectral edge frequency (SEF), and density spectral array during a
stable target controlled infusion (TCI) general anesthesia.
Methods: A prospective, single-blind and randomized study on adult
patients scheduled for elective spine surgery. Patients were submitted to
a general anesthesia with a TCI of propofol (200 mL/h until loss of
consciousness), remifentanil (effect-site concentration 3 ng/mL), and
rocuronium (0.6 mg/kg). After anesthesia induction, when a stable BIS
value (45 to 55) was achieved, with MAP values higher than 70% of
patient basal value and PaCO2 between 34 and 42 mm Hg, we started the
automatic recording of BIS, SEF, and DSA. These data were recorded
during 9 minutes. Subsequently, according to randomly assigned group
where the patient is inserted, we administered a ketamine bolus dose of
0.2 mg/kg (group 1), 0.5 mg/kg (group 2), or 1 mg/kg (group 3) and the
same parameters were registered for additional 9 minutes in the absence
of any surgical stimulus. Results are presented as mean ± SD. Paired t
test was used to compare BIS and SEF values before and after ketamine
bolus and a P-value <0.05 was considered significant.
Results and Discussion: Thirty-nine patients were enrolled in the study.
No statistical difference was found among the groups except for age
(53.77 ± 10.47, 49.85 ± 12.56, and 43.46 ± 8.09, for groups 1, 2, and 3,
respectively). In respect to group 1, our results show an increase of SEF
value by 1.34 ± 0.99 after ketamine bolus (P < 0.001). Regarding group
2, our results establish an increase of SEF value by 3.03 ± 2.04
(P < 0.01) and an increase of BIS value by 6.65 ± 7.40 (P = 0.008). In
group 3, we also find an increase of SEF and BIS values, by 3.30 ± 2.77
(P = 0.01) and 6.85 ± 10.35 (P = 0.034), respectively. DSA demonstrate
a shift in the frequency range and power distribution toward higher
frequencies.
Conclusions: When ketamine is used intraoperatively, the anesthetist
should anticipate an increase in SEF and BIS values, which will not be
associated with the level of hypnosis.
EN16-NA23
Individual Effect-Site Concentrations of Propofol at Return and
Loss of Consciousness are Correlated
A.L. Ferreira*, C.S. Nunesw, A.C. Ferreiraz, S. Videw, R. Correiay, P.
Amorimw. *Faculdade de Engenharia da Universidade do Porto, Porto,
Portugal. wUniversidade Aberta, Departamento de Ciências e Tecnologia,
Delegac¸ão do Porto, Porto, Portugal. zCentro de Investigac¸ão Clı´nica em
Anestesiologia, Servic¸o de Anestesiologia, Centro Hospitalar do Porto,
Porto, Portugal. y INEGI, Faculdade de Engenharia da Universidade do
Porto, Porto, Portugal.
Background: It is known that anesthetic concentrations at loss (LOC)
and return (ROC) of consciousness exhibit hysteresis, but it has been
said that increased sensitivity to induction of anesthesia could be used to
predict emergence from anesthesia.1 Our goal was to investigate whether
a patient’s propofol effect-site concentration at ROC was related to the
propofol effect-site at LOC.
Methods: Under IRB approval, 29 patients undergoing surgery received
fentanyl (3 mg/kg) followed by 1% propofol at 3.3 mL/kg/h until LOC
(modified OAAS score of 0). Propofol cerebral concentrations (Ce) were
calculated using Schnider’s PK model. At LOC the amount of propofol
given and the predicted Ce were noted and the pump (Fresenius Or-
chestra) was switched to effect-site TCI. Propofol was titrated to a BIS of
40 to 60. Remifentanil by TCI was started 30 minutes after LOC, titrated
during surgery. At the end of surgery it was set at a Ce of 2 ng/mL and
propofol was stopped. The patient was called every 10 seconds. At eye
opening (ROC) propofol Ce was recorded. Data are mean ± SD. Sta-
tistics used t test.
Results and Discussion: Patients were ASA I, II; 60 ± 12 years;
67.7 ± 11.0 kg; 163 ± 0.07 cm; BMI 25.4 ± 2.9; 14 women. The BIS
values at LOC were 75.8 ± 13.9. At LOC, propofol (Ce) concentration
was 4.3 ± 1.6 mg/mL and fentanyl Ce concentration was 3.4 ± 0.5 ng/
mL. At ROC, propofol and remifentanil concentration were
1.13 ± 0.48 mg/mL and 2.0 ± 0 ng/mL, respectively. BIS values at ROC
were 57.3 ± 45.6. A statistically significant correlation (P = 0.004) was
observed between propofol concentration at ROC and LOC (Fig. 1).
The BIS values at LOC and ROC were not statistically correlated with
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
the propofol effect-site concentrations at LOC or ROC. Body mass
index was not related to the ROC or LOC concentrations.
Conclusions: Knowledge of a patient’s propofol requirement for LOC
may be useful to anticipate the Ce at which that same patient will return
consciousness, which appears clinically very useful.
Acknowledgements: FCT-UID/SEM/50022/2013;SFRH/BD/98915/2013.
Reference:
1. Tarnal V, Vlisides PE, Mashour GA. The neurobiology of anesthetic
emergence. J Neurosurg Anesthesiol. 2015. [Epub ahead of print].
FIGURE 1: Linear regression between the propofol effect-site concen-
tration at return to consciousness (ROC) and the propofol effect-site
concentration at loss of consciousness (LOC) in the 29 patients. Statis-
tically significant correlation (R = 0.518, P = 0.004) and positive slope
(P < 0.05).
EN16-NA24
Comparison of the Effect of Intravenous Dexmedetomidine and
Lignocaine Spray Instilled Into the Endotracheal Tube on
Extubation Response in Patients Undergoing Spine Surgery
D. Dutta, S. Purohit, M. Khandelwal, R. Meena. Swai Man Singh
Medical College, Jaipur, Rajasthan, India.
Background: It is prudent to have rapid emergence and extubation
without any adverse hemodynamic and airway changes in spine surgery
where early neurological examination is commonly needed. Tracheal
extubation is almost always associated with rise in arterial blood pres-
sure, heart rate, arrhythmias and also with increased airway responses.
Here we have studied the effect of a-2 agonist—dexmedetomidine (IV)
and lignocaine spray instilled into the endotracheal tube at the end of
procedure to attenuate the above mentioned responses after tracheal
extubation.
Methods: A total of 45 patients of ASA grade I-II, aged 18 to 65 years,
undergoing for spinal surgery at the level of cervical, thoracic, lumber, or
sacral region, were randomly allocated into 3 groups. After the last skin
closure, in group-D: dexmedetomidine 0.3 mg/kg IV, group-L: 10%
lignocaine spray 1.5 mg/kg through endotracheal route, and group-P:
normal saline IV given over 60 seconds. Hemodynamic responses (SBP,
DBP, MAP, HR, SpO2) were recorded before and after administration
of drugs and also duration of emergence, extubation, quality of ex-
tubation, and postop sedation level were evaluated.
Results: All groups were comparable without any significant differences
in demographic profiles such as age, sex, weight, ASA grade and base
line MAP, heart rate, time of emergence, extubation, and postoperative
sedation level. The increase in MAP and heart rate during extubation
were significantly less in group-D than group-L and group-P, 2 minutes
after administration of the respective drugs (P < 0.05). Although there
was no significant differences in the grade of cough after extubation,
number of patients with cough grade zero was more in group-D
(86.67%) than group-L (60%) and group-P (53.34%). In group-P,
6.67% patients had cough grade of 2 but there was no incidence of
laryngospasm and undue sedation after the extubation in these 3 groups.
Conclusions: Dexmedetomidine (0.3 mcg/kg) attenuates hemodynamic
response better than lignocaine spray(1 mg/kg) during emergence and
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
extubation. It also provides smooth extubation and easy recovery
without any postoperative sedative effect.
EN16-NA25
Assessment of Dexmedetomidine Versus Esmolol in Preventing
Emergence Agitation After Neurosurgical Procedures
I. Asouhidou, D. Zosimidis, I. Pagiati, D. Charalampidis, A. Katsane-
vaki, X. Mortopoulou. Department of Anesthesiology “G.Papanikolaou”
General Hospital, Thessaloniki, Greece.
Background: Patients after intracranial operations are more vulnerable
to the stress resulting from emergence agitation during the recovery from
general anesthesia.1 The incidence of agitation is about 29% in patients
after intracranial operations. The aim of this study was to compare the
recovery of 2 bispectral index (BIS)-guided anesthesia protocols combining
sevoflurane-esmolol or sevoflurane-dexmedetomidine administered during
craniotomy.
Methods: Twenty patients scheduled for intracranial surgery were
randomized to receive Dex 1 mg/kg followed by 0.7 mcg/kg (group D) or
esmolol 500 mg/kg followed by 300 mg/kg/min (group E). Anesthesia was
adjusted to maintain BIS values between 40 and 50. The levels of agi-
tation and sedation will be evaluated by a Sedation-Agitation Scale
(SAS) and Aldrete score. Agitation is defined as a SAS score of 5 to 7.
Results: Emergence from anesthesia was successful in all patients. Time
to extubation was not different between the 2 groups (10.9 ± 2.92 vs.
12.9 ± 3.22, P = 0.15). Although SAS score did not differ between 2
groups (3.7 ± 0.48 for group D and 3.7 ± 1.06 for group E, P > 0.05),
more patients achieved a SAS score 4 (7 patients) where at group E most
patients reach a SAS score 3 or 5 (8 patients). Also, time to achieve an
Aldrete score to 10 at the first 5 minutes after extubation did not differ.
Conclusions: Both esmolol and dexmedetomidine seems to ensure a
smooth postextubation period. However, the use of dexmedetomidine
seems to reduce the incidence of agitation during the first hour. A pos-
sible mechanism of action is the a2 adrenergic-receptor-agonist effect in
the central nervous system.
Reference:
1. Lepouse C, Lautner CA, Liu L, et al. Emergence delirium in adults in
the post-anaesthesia care unit. Br J Anaest. 2006;96: 747–753.
EN16-NA26
Efficacy of Dexmedetomidine in Preventing Sympathetic Over-
drive During Intracranial Procedures
I. Asouhidou, A. Katsanevaki, D. Charalampidis, D. Zosimidis, Z.
Stergiouda, G. Topalidou. Department of Anesthesiology,
“G.Papanikolaou” General Hospital, Thessaloniki, Greece.
Background: Patients undergoing intracranial procedures may experi-
ence intraoperative hypertension and tachycardia due to intracranial
hypertension and to increased release of adrenaline.1 Moreover, ex-
tubation maybe arise sympathetic stimulation leading to O2 con-
sumption, with consequently ischemia and edema. Dexmedetomidine is
a selective a2 receptor that provides anxiolytic, sedation, analgesia
without any respiratory depression.2 The aim of this study is to evaluate
the efficacy of intraoperative infusion of dexmedetomidine (Dex) to
decrease sympathetic tone in patients undergoing intracranial procedure.
Methods: Twenty-five patients ASA I-III were scheduled for elective
craniotomy. After induction of anesthesia they received Dex 1 mcg/kg
over 10 minutes followed by continuous infusion of Dex 0.7 mcg/kg/h.
Patients were subjected to a standardized anesthesia comprising a in-
duction with propofol, fentanyl, single dose of rocuronium, and main-
tained with oxygen-air: 1/1, sevoflurane, and bolus fentanyl. The
hemodynamic variables at various stages of surgery (HR-heart rate,
MAP-mean arterial pressure) and recovery characteristics were re-
corded.
Results: There was no episode of intraoperative hypotension or brady-
cardia (HR < 45/min). The mean duration of anesthesia was
267 ± 102 minutes. Patients received intraoperative 0.352 ± 0.22 mcg
fentanyl. Emergence from anesthesia was successful and uneventfully
and all patients was extubated 12.7 ± 2.25 minutes after skin closure.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
Only 1 patient had increased systolic arterial pressure during the
extubation and he received 5 mg nifedipine. None of the patients expe-
rienced hypertension during the first postoperative day. Postoperative,
none patient reported headache.
Discussion: Dexmedetomidine attenuate successfully the intraoperative
sympathetic overdrive during intracranial procedures without raising the
intraoperative requirements for opioids and this might minimize also the
postoperative hyperalgesia.
References:
1. Bilotta F, Lam AM, Doronzio A, et al. Esmolol blunts postoperative
hemodynamic changes after propofol-remifentanil total intravenous
fast-track neuroanesthesia for intracranial surgery. J Cl Anesth.
2008;20:426–430.
2. Tanskanen PE, KyttOL JV, Randell TT, et al. Dexmedeto-
midine as an anaesthetic adjuvant in patients undergoing intracranial
tumour surgery: a double-blind, randomized and placebo-controlled
study. Br J Anaesth. 2006;97(5):658.
EN16-NA27
A Comparison of Dexmedetomidine and Propofol for Monitored
Anesthesia Care in Patients Undergoing Surgical Treatment of
Chronic Subdural Hematoma
S. Thamlaoui, S. Ben Khlifa, M. Farhat, I. Hamdi, N. Maatar, C.
Kaddour. National Institute of Neurology, Tunisia.
Background: Chronic subdural hematoma is common among elderly
patients, who are usually presented to surgical procedure with serious
coexisting systemic disease. General or local anesthesia are not com-
fortable for either patient or surgeon. Monitored anesthesia care with
dexmedetomidine (DEX) may be suitable as an alternative method of
anesthesia. In this preliminary, prospective, randomized, clinical study
we evaluate the utility of DEX compared with propofol (PROP) during
surgical treatment of CSHD.
Methods: Sixty patients of ASA physical status I to IV, aged 18 to 80
years, who were scheduled for surgical evacuation of CSDH under
monitored anesthesia care, were randomly allocated to receive sedation
with either DEX (n = 30) or PROP (n = 30). DEX was administered IV
at 2 mg/kg over 10 minutes followed by a continuous infusion of 1 mg/kg/
h; if not, a second bolus of 2 mg/kg was repeated over another 10 mi-
nutes. PROP was infused IV over 10 minutes at 2.5 mg/kg, followed by a
maintenance infusion of 3 to 4 mg/kg/h, the goal was to achieve a
minimum Ramsay Sedation Score (RSS) of 4 to 5. Patients who continue
to move after the second bolus or while the procedure is in progress were
excluded. Patients did not received premedication al all. Neurological
status was evaluated by Markwalder’s Neurological Grading scale
(MNGs). During the study blood pressure (BP), heart rate (HR), res-
piratory rate (RR), and oxygen saturation (SpO2) were recorded. Pa-
tients were transferred to the recovery room until the RSS returned to
level 1. Pain intensity was evaluated every 30 minutes till 6 hours post-
operatively using the visual analog scale (VAS), and patient and surgeon
satisfaction were evaluated by a Likert-like Verbal Rating (LlVRs) scale
(1 extremely dissatisfied to 7 extremely satisfied).
Results: There were no differences between the 2 groups regarding the
age, weight, sex ratio, MNGs score, and operation time. The 2 groups
were similar in baseline measurement of RR, HR, BP, and SpO2. During
sedation, in PROP group RR and SpO2 value were significantly lower
than those in the DEX group (P < 0.05). During this period, 5 patients
of PROP group presented apnoea necessitating manual ventilation.
There were no differences in the mean BP and HR values between the
PROP and DEX groups (P > 0.05). During recovery period, in PROP
group HR value were significantly higher than in DEX group (P < 0.05).
VAS values in DEX group at 30 minutes were significantly lower than
those of PROP group (P < 0.05), therefore, 14 patients in PROP group
required analgesic agent such as paracetamol. The surgeon was satisfied
with the anesthesia procedure, with a LlVRs score at 6.1 ± 0.6. Patient
satisfactory was significantly better in DEX group than in PROP group
(P < 0.05).
Conclusions: We concluded that surgery for CSDH under monitored
anesthesia care with dexmedetomidine provided safe and adequate an-
algesia, it facilitate patient and surgeon comfort.
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EN16-NA28
Dexmedetomidine Does not Affect Cerebral Autoregulation and
CO2 Reactivity During Sevoflurane Anesthesia
G.P. Rath, S. Banik, H. Prabhakar, P. Bithal. Department of Neuro-
anesthesiology & Critical Care. All India Institute of Medical Sciences,
New Delhi, India.
Background: The effect of dexmedetomidine, as an anesthetic adjuvant,
on cerebral autoregulation has not been adequately studied.
Methods: Thirty consecutive ASA I patients aged 18 to 60 years, un-
dergoing lumbar spine surgery, were randomized into 2 groups to receive
infusions of either dexmedetomidine (group D) or 0.9% normal saline
(group C). Anesthesia was induced with fentanyl, 2 mg/kg; propofol, 1 to
2 mg/kg; and vecuronium, 0.1 mg/kg and was maintained with
O2:N2O = 50:50 and sevoflurane (0% to 4%) at fresh gas flow of 2 L/
min. After 5 minutes of constant BIS value (40 to 50) and normocapnia,
the right middle cerebral artery flow velocity (MCAFV) was recorded
using transcranial Doppler (TCD). The Transient Hyperemic Response
(THR) test was performed by compressing the right common carotid for
5 to 7 seconds. The patient was then hyperventilated to test CO2 re-
activity. Hemodynamics, PaCO2, SpO2, MCAFV, BIS, and MAC of
sevoflurane were recorded before and after hyperventilation. Surgery
was subsequently performed and dexmedetomidine infusion was con-
tinued until 10 minutes before skin closure. The time to recovery and
extubation, modified Aldrete score, and emergence agitation were re-
corded.
Results: The demographic data, durations of surgery and anesthesia were
comparable in between the 2 groups. THR ratio (group D: 1.26 ± 0.10
vs. group C: 1.24 ± 0.05; P = 0.35), relative CO2 reactivity (group D:
8.79 ± 9.80 vs. group C: 9.36 ± 7.78; P = 0.55), were comparable be-
tween the 2 groups, as were MAP, SpO2, BIS, MCAFV, times to recovery
and extubation, and the modified Aldrete scores. Fentanyl used in group
D was significantly lower than group C (P = 0.0001). MAC before and
after hyperventilation in group D was significantly lower as compared
with group C (P = 0.003 and 0.01, respectively).
Conclusions: Dynamic cerebral autoregulation, as assessed by THR test
and CO2 reactivity, remained intact after use of dexmedetomidine, in
patients undergoing lumbar spine surgery.
EN16-NA29
Dexmedetomidine During Supratentorial Craniotomy With
Intraoperative Neuromonitoring
S. Pacreu, A. León, E. Vilà, L. Moltó, C. Rodrı́guez, J. Fernández
Candil. Department of Anaesthesiology, Parc de Salut Mar, Barcelona,
Spain.
Background: Dexmedetomidine has been shown to be an useful agent as
an adjunct to an opioid-propofol total intravenous anesthesia (TIVA).1
Intraoperative neurophysiological monitoring (IOM) is used in supra-
tentorial surgery involving eloquent areas of the brain to allow the
maxim extent of resection, minimizing the risk of postoperative neuro-
logical deficits. We compared propofol and remifentanil consumption,
and the effects of TIVA and TIVA with Dex on transcranial motor and
somatosensory-evoked potentials (MEPs and SSEPs).
Methods: After approval by the Ethical Committee, 14 patients sched-
uled for supratentorial craniotomy with IOM entered the study. During
the first 30 minutes of anesthesia all patients received TIVA. Afterwards
they were randomized in 2 groups to receive: propofol plus remifentanil
and physiological saline infusion (PR, n = 7) or propofol plus re-
mifentanil and Dex infusion (0.5 mg/kg/h) (PRD, n = 7), to maintain a
bispectral Index between 45 and 60. Propofol and remifentanil require-
ments at 30 (baseline) and 45 minutes were evaluated. The threshold
intensity, the latency and the amplitude of MEPs and SSEPs were re-
corded at 30 and 45 minutes.
Results: Propofol requirements were lower in PRD group, but without
significant differences between groups (P = 0.08). There was statistically
significant difference in lactic acid, it was minor in PRD group
(P = 0.016). MEPs and SSEPs were elicited safely in all patients. There
were no statistically significant differences in threshold intensity, laten-
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
cies, and amplitudes between groups. Postoperative morphine require-
ments were similar in both groups.
Discussion: We observed a tendency to lower value of propofol in PRD
group. Dex does not seem to alter MEPs and SSEPs for IOM in su-
pratentorial surgery.2,3 The lactic acid was significantly lower in PRD
group. More patients are necessary to confirm these results.
References:
1. Tanskanen PE, Kytta JV, Randell TT, et al. Dexmedetomidine
as an anaesthetic adjuvant in patients undergoing intracranial tumor
surgery: a double-blind, randomized and placebo-controlled study.
Br J Anaesth. 2006;97(5):658–665.
2. Wang AC, Than KD, Etame AB, et al. Impact of anesthesia on
transcranial electric motor evoked potential monitoring during spine
surgery: a review of the literature. Neurosurg Focus 2009; 27(4):1–4.
3. Rozet I, Metzner J, Brown M, et al. Dexmedetomidine does not affect
evoked potentials during spine surgery. Anesth Analg 2015;121(2):
492–501.
EN16-NA30
Anesthesia for High Volume, Multilevel Epidural Blood Patch
(HVBP) in Idiopathic Intracranial Hypotension (IIH)
A. Builes, M. Arango, S.P. Lownie, M. Sharma, S. Panday. Western
University, Canada.
Background: Epidural blood patch (EBP) is the cornerstone to treat
idiopathic intracranial hypotension (IIH).1–3 New hypothesis was for-
mulates that cerebrospinal fluid (CSF) is leaked as a result of a negative
pressure produced by epidural veins drainage to the inferior vena cava
system. This brought the idea of positive pressure over the entire spine to
stop pressures gradient.
Case Reports: Three patients with IIH with no evidence of CSF leak were
treated. Case 1: Male, 55 years old, 1 month of symptoms, required se-
dation for a high volume multilevel epidural blood patch (HVBP) of
55 mL. Case 2: Male, 56 years old, with 3 previous EBP, required 3 HVBP
(total of 85, 115, and 125 mL were injected), first 2 occasions sedation and
the last general anesthesia (GA) were required. Case 3: Male, 60 years old
with 4 previous EBP, EVD, decompressive craniectomy and C1 lam-
inectomy, exploration of anterior-middle cranial fossa. Required 3 HVBP
and 120 mL was infused every time, the first time with sedation and last 2
times with GA. Sedation using propofol and fentanyl was given for the
first procedure to identify maximum tolerable blood volume. GA with
sevoflorane and fentanyl or remifentanil and endotracheal intubation was
required after the first patch due to patient discomfort. Arterial line was
canalized for monitoring and to obtain blood. Patients were discharged
next day with no complications. All patients perceived improvement of
symptoms lasting longer than after other interventions.
Discussion: New procedures are emerging toward less invasive treat-
ments using new technologies, in this case multilevel EBP through
catheter. These advances require anesthesiologist to adapt and in-
corporate expertise to manage challenges of sedated patients in prone
outside OR. To the knowledge of the authors, no other group has in-
corporated the anesthesia care in their publications. The injection of
higher volumes of blood can be explained by analgesia provided and
maybe a determinant factor for the success.
Learning Points: Change in paradigm supports that IIH is a mechanical
problem with a mechanical solution: HVBP for positive pressure on the
spine. Sedation is preferred for neurological monitoring and might be a
key for success.
References:
1. Murphy D, Chandna A, Laing A, et al. Spontaneous intracranial
hypotension and single entry multi-site epidural blood patch. Asian J
Neurosurg. 2015;10(3):262.
2. Mokri B. Spontaneous CSF leaks low CSF volume syndromes. Neurol
Clin. 2014;32:397.
3. Franzini A, Messina G, Chiapparini L, et al. Treatment of sponta
neous intracranial hypotension: evolution of the therapeutic and di-
agnostic modalities. Neurol Sci. 2013;34 (Suppl 1):S151–S155.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016 Supplement: EuroNeuro 2016

EN16-NA31 breakthrough pain was managed with intravenous. Paracetamol 1 g and

Epidural Anesthesia For Placement of a Spinal Cord Stimulator intravenous fentanyl 50 mg boluses.
by Surgical Laminectomy Results: Average VAS scores with both groups showed significant var-
iation over the study period. The mean VAS score for group B (test
J. D’Haesew, C. Vanlersberghe*, M. Moens*, J. Poelaertw. *Universitair
Ziekenhuis Brussel; wUniversitiar Ziekenhuis Brussel, Belgium. group) was 1.57 ± 0.285 and that of group C (control group) was
Background: Epidural paddle electrodes for spinal cord stimulation 4 ± 0.33 with P-value <0.001 and 80% power of the study. The median
(SCS) are usually placed under local anesthesia that often produce pain requirement of the adjuvant analgesic doses in group B (test group) was
and discomfort to the patient or under general anesthesia. We pro- 1 as compared with group C (control group) was 3.
spectively evaluated an epidural anesthesia technique for surgical Conclusions: This study showed that the superficial cervical plexus block
was an effective postoperative analgesic technique for infratentorial
placement of epidural paddle electrodes.
surgeries and suboccipital craniotomies. It decreased the requirement of
Methods: A total of 57 patients were included in the study. All patients
had neuropathic pain (FBSS, vascular pain) and were never treated with adjuvant analgesic doses significantly.
a SCS before. The anesthetic epidural catheter was placed 1 or 2 seg-
ments lower than the level of the surgical placement of the SCS probe. EN16-NA33
After the insertion of the epidural catheter, a volume of 8 mL of 0.5% Ropivacaine Scalp Block in Patients Undergoing Supratentorial
ropivacaine with 1 mg of sufentanil per mL was injected. A top-up dose
Craniotomy: Analysis of 30 Cases
of 4 mL was given if the level of analgesia was too low. When the an-
esthetic level was appropriate (± Th 6), the patients were positioned in S. Mitra, S. Purohit, M. Godara, D. Dutta, S.P. Sharma. Sawai
the ventral decubitus position and surgery was started. During surgery Mansingh Medical College, Jaipur, Rajasthan, India.
pain was evaluated using the Visual Analog Scale (VAS) score. Hemo- Background: Scalp block with local anesthetics for craniotomy deters
dynamic parameter (BP and HR) were evaluated during the start of the sympathetic stimulation associated with the application of head pins and
epidural anesthesia and during the surgical procedure. skin incision along with improvement in intraoperative hemodynamic
Results and Discussion: The level of the placed epidural catheter was stability and diminution in anesthetic and analgesic needs. This pro-
between Th11 and L3. The mean dose of ropivacaine was 81 (± 19) mg spective study was undertaken to evaluate the intraoperative hemody-
or 16 ( ± 4) mL. The analgesic level (Th 6) was reached between 15 and namic and analgesic effects of ropivacaine scalp block in patients posted
30 minutes after the first epidural naropin injection. The VAS scores are for elective supratentorial craniotomies.
shown in Table 1. In 6 patients the quality of analgesia was unsatisfied Methods: Thirty patients of ASA grade I and II of both sexes, aged 20 to
and 8 mL of lidocaine 2% was injected subcutaneously by the surgeon. 55 years undergoing supratentorial craniotomies received scalp block
The hemodynamics are shown in Table 2. with ropivacaine (0.5%) 20 mL. Propofol was used for induction of
anesthesia in all the patients. Propofol infusion was started at 25 mg/kg/
TABLE 1. VAS Score (0 to 10) min and accordingly titrated at 5 mg/kg/min to maintain BIS between 50
and 60 throughout the surgery and stopped immediately after dural
Time (min) 0 15 30 45 60 closure. Fentanyl 0.5 mg/kg IV was given when 20% increase in heart
VAS 0 0.6 0.2 0.2 0.2 rate (HR) and/or mean arterial pressure was observed. HR, systolic,
diastolic, and mean blood pressure (SBP, DBP, and MAP, respectively)
were recorded at the time of skin incision (given 15 min after scalp
TABLE 2. block), 5, 10, 15, 30 minutes and thereafter every 30 minutes till end of
Epid Epid Epid Surg Surg Surg Surg surgery. Total propofol and fentanyl consumptions were assessed.
Time (min) 0 10 15 0 15 30 45 Results: A significant increase in mean HR was seen from the time of skin
incision (ATSI) till 90 minutes from baseline value (ATSI, P < 0.001; 5 min,
Pulse 73 73 72 76 75 73 71 P < 0.001; 10 min, P < 0.001; 15 min, P = 0.001; 30 min, P = 0.002;
(/min) 60 min, P < 0.001; 90 min, P < 0.001). No significant changes in the mean
Diast BP 78 75 72 72 68 66 66 SBP, the mean DBP, the mean MAP from baseline value were noted at any
(mm Hg) point of time. Cumulative propofol and fentanyl required were
Syst BP 135 126 123 119 114 113 112 398.43 ± 66.6 mg and 174.4 ± 28.67 mg, respectively, for whole duration of
(mm Hg) surgery. The mean duration of surgery was 210.33 ± 42.22 minutes.
Conclusions: Ropivacaine scalp block failed to control heart rate during
initial stages of craniotomy although the blood pressures were well
Conclusions: Epidural anesthesia for surgical placement of DCS electrodes maintained. A controlled clinical trial would be useful in quantifying the
was associated with excellent patient comfort and stable hemodynamic effects of ropivacaine for scalp block.
parameters in the ventral decubitus position. All patients could be easily
stimulated and tested for finding the optimal place of the SCS electrode.
EN16-NA34
Comparative Study of Ropivacaine Infiltration Versus Ropiva-
EN16-NA32 caine With Clonidine Infiltration During Scalp Block in Patients
Superficial Cervical Plexus Block for Postoperative Analgesia in Undergoing Supratentorial Craniotomy
Patients Undergoing Infratentorial Surgeries and Occipital Cra- S. Purohit. SMS Medical College & Hospital, Jaipur, India.
niotomies: Background: Sympathetic stimulation associated with skull pin appli-
V. Sangai, R. Gandhe. Kokilaben Dhirubhai Ambani Hospital. Mumbai, cation and skin incision before craniotomy causes a precipitous increase
India. in hemodynamic responses. Scalp block with local anesthetic agent is
Background: In this study we compared the effectiveness of the super- effective in reducing these responses. This prospective, randomized
ficial cervical plexus block in patients undergoing infratentorial surgeries controlled double-blind study was undertaken to compare hemodynamic
and suboccipital craniotomies as compared with intravenous para- and analgesic effects of ropivacaine scalp block and ropivacaine with
cetamol and intravenous fentanyl for postoperative analgesia. clonidine scalp block in elective supratentorial craniotomies.
Methods: In this study, 40 patients scheduled for infratentorial and Methods: Sixty patients of ASA grade I and II of both sexes aged 20 to 55
suboccipital craniotomies were randomly divided into 2 groups. Group years undergoing supratentorial craniotomies were randomly divided into 2
B (received superficial cervical plexus block with inj. ropivacaine 0.5% equal groups—group A received scalp block with ropivacaine (0.5%)
20 mL bilaterally after skin closure) and group C (received intravenous 20 mL and normal saline 2 mL and group B received scalp block with
paracetamol 1 g IV just before skin closure). Postoperative pain was ropivacaine (0.5%) 20 mL and clonidine 2 mL (2 mg/kg). Anesthesia was
assessed at 30 minutes, 60 minutes, 2 hours, 4 hours, 6 hours, 8 hours, induced with propofol and rocuronium. Titrated propofol infusion was
and 12 hours using the Visual Analog Scale (VAS). Postoperative started to maintain BIS between 50 and 60 during surgery and stopped

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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

Supplement: EuroNeuro 2016
immediately after dural closure. Fentanyl 0.5 mg/kg IV was given when 20%
increase in heart rate and/or mean arterial pressure was seen. Heart rate
(HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and
mean arterial pressure (MAP) were recorded at the time of skin incision
(given 15 min after scalp block), 5, 10, 15, 30, minutes and thereafter every
30 minutes till end of surgery. Cumulative propofol and fentanyl doses
required were assessed for duration of surgery.
Results: All 60 patients completed the study. A significant difference in
HR was noticed at the time of skin incision (ATSI) till 90 minutes in
group B (ATSI, P = 0.045; 5 min, P = 0.026; 10 min, P = 0.029; 15 min,
P = 0.042; 30 min, P = 0.002; 60 min, P = 0.026; 90 min, P = 0.039)
when compared with group A. Significant fall in HR, SBP, and MAP
was noted from ATSI to 60 minutes from baseline in group B (P < 0.05).
DBP showed significant decrease from 5 minutes after skin incision till
60 minutes from baseline in group B (P < 0.05). Propofol and fentanyl
requirements were significantly lower in group B (336.87 ± 46.03 mg
and 147.8 ± 23.33 mg, respectively) compared with group A
(398.43 ± 66.6 mg and 174.4 ± 28.67 mg, respectively) (P = 0.0001 and
0.0002, respectively, for propofol and fentanyl).
Conclusions: Ropivacaine infiltration with clonidine for scalp block at-
tenuates hemodynamic responses to skin incision and decreases anes-
thetic and analgesic necessity.
EN16-NA35
L-Arginine Pathway Metabolites Predict Need for Intraoperative
Shunt During Carotid Endarterectomy
M. Tihamer*, J. Lantosw, S. Kekiz, E. Volgyi*, G. Menyheiy, P. Szabo*.
*Department of Anesthesiology and Intensive Care, University of Pecs, Hun-
gary. wDepartment of Surgical Research and Techniques, University of Pecs,
Hungary. zDepartment of Applied Chemistry, University of Debrecen, Hun-
gary. yDepartment of Vascular Surgery, University of Pecs, Hungary.
Background: The vascular tone is regulated by the L-arginine-NO
pathway. Asymmetric dimethylarginine (ADMA) inhibits NO synthesis
and is a marker of endothelial dysfunction. S100B reflects the integrity of
the blood brain barrier. Here, we tested association of L-arginine and
ADMA concentration with cerebral perfusion, blood brain barrier in-
tegrity, and surgical intervention during carotid endarterectomy. To the
analogy of central venous-arterial ratio of CO2 gap/oxygen extraction,
we assumed that elevated jugulo-arterial ratio of CO2 gap/oxygen ex-
traction indicates anaerobic cerebral metabolism.
Methods: A total of 55 patients with significant carotid stenosis were
recruited into this prospective study. All patients underwent carotid
endarterectomy under regional anesthesia. Serial blood samples were
perioperatively taken from jugular bulb and radial artery: at baseline
(T0), before (T1), and after declamping (T2), at 2 postoperative hours
(T3) and 1 day after surgery (T4). Beside blood gas analysis, concen-
tration of L-arginine, ADMA and S100B were measured.
Results: Significant positive correlation was found between baseline
ADMA and the ratio of jugulo-arterial CO2 gap/oxygen extraction at T1
and T2, respectively (P = 0.005 and 0.01, respectively). A significantly
reduced baseline L-arginine (P < 0.05) was measured in patients re-
quiring intraoperative shunt (n = 6). The critical serum level of L-argi-
nine was determined by ROC analysis (cutoff: 60.5mmol/L, P < 0.05).
Significantly higher jugular S100B (P < 0.05) was measured during re-
perfusion in patients presented with L-arginine below this threshold.
Conclusions: High jugular ADMA concentration predicts pure cerebral
perfusion indicated by elevated jugulo-arterial CO2 gap/oxygen ex-
traction. In addition, low concentration of baseline L-arginine predicts
need for intraoperative shunt. Higher jugular S100B concentration
during reperfusion was associated with lower concentration of L-argi-
nine suggesting the protective role of the NO donor L-arginine.
EN16-NA36
Investigating Renshaw Cell Circuitry in Human Neuromuscular
System
M.G. Özyurt, G. Yılmaz, M. Dursun, M. Shabsog, S. Savran, K.S.
Türker. Koc¸ University GSSE & SOM, Sariyer, Istanbul, Turkey.
Background: Among many interneurons that synapse onto motor neurons,
the Renshaw cells have been investigated in mammals, especially in cats.
S12 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
These cells are situated in the ventral horn of the vertebrate spinal cord and
provide a suitable model for studying circuits in the spinal cord. Animal
studies have suggested that these cells are inhibitory to the motor neurons
of the homonymous muscle motor neurons. However, their function in
human motor system is not so certain as conflicting results are obtained by
various investigators. In this study, we hypothesize that the activation of
the Renshaw cells by antidromically stimulated larger motor axons will
lead to an inhibition of smaller motor neurons.
Methods: The experimental procedure was approved by the Human
Ethics Committee of Koc¸ University. Surface electrodes were placed on
tibialis anterior muscle. Sterile bipolar intramuscular electrodes were
placed by a surgical needle. Subjects were asked to contract their muscles
while common peroneal nerve was stimulated with constant current
stimulator and single motor unit potentials were recorded.
Results and Discussion: As a consequence of stimulation of larger motor
axons, the motor unit activity that corresponds to the H-reflex was de-
layed by several milliseconds. The peristimulus time histogram showed
an inhibition and subsequent facilitation of motor neuron activity. As it
is stated in the hypothesis, Renshaw cells do generate a short lasting
inhibition of the motor neurons of the homonymous muscles. This in-
hibitory input seems to delay the timing of the H-reflex by several mil-
liseconds indicating that the Renshaw inhibitory and spindle excitatory
inputs arrive in the motor neurons almost simultaneously.
Conclusions: Low intensity stimulation of Ia afferents induce the H-
reflex. If the cathode position and the stimulus intensity are optimized,
the stimulus now can activate both the spindle primary (Ia) afferents and
the largest motor axons. The activity of motor axons induces an anti-
dromic activation of the Renshaw cells that then can cause an inhibition
on the ongoing activity of the motor neuron. This method can be used to
investigate the distribution and modulation of the Renshaw inputs to
various sized motor neurons in human subjects.
EN16-NA37
Cerebral Oximetry: Sensibility and Specificity in Awake Carotid
Endarterectomy
H. Meleiro, I. Correia, G. Afonso. Centro Hospitalar de São João,
Portugal.
Background: Many techniques are available for cerebral monitoring
during carotid endarterectomy (CEA). However, none is superior to
neurological clinical evaluation while performing the procedure under
cervical plexus block. Bilateral regional cerebral oxygen saturation
(rSO2) with near infrared spectroscopy (NIRS) has been used to evaluate
the adequacy of cerebral flow. This study was designed to compare the
performance of the INVOS-5100 cerebral oximeter and the clinical
neurological functions, in patients undergoing CEA under cervical
plexus block.
Methods: A retrospective analysis was conducted in patients scheduled
for CEA from October 2014 to July 2015. Awake patients (regional
anesthesia) with rSO2 monitoring during procedure were included. rSO2
values before and after internal carotid artery (ICA) clamping were
compared. A drop >20%, after carotid artery clamping, was considered
significant. Changes in rSO2 were compared with intraoperative patient
clinical status based on anesthesia and surgeon recordings. Patients
converted to general anesthesia were excluded from this study. All
analysis were calculated with software SPSS version 20.0.
Results and Discussion: A total of 38 patients were included. Five showed
a significant drop in ipsilateral rSO2 (range, 30.3% to 38.6%; mean,
33,4%): 2 of them had cerebral hypoperfusion signs, whereas the re-
maining 3 had no changes in consciousness after ICA cross-clamping
(false positive). In total, 33 patients had no significant changes of rSO2
values, 27 of them had no consciousness deterioration (true negative).
Six patients had a nonsignificant postclamping decline in rSO2 satu-
ration (range, 2.9% to 19.6%) but had cerebral hypoperfusion signs
(false negative). In this study, a total of 8 patients had changes in con-
sciousness and the median drop in rSO2 was 8.8%. INVOS-5100 sensi-
tivity was 25% and a 90% specificity in comparison to the awake testing.
Conclusions: Neurological symptoms occurred with a median drop in
rSO2 of 8.8% (range,  2.9% to 38.6%). The usefulness of rSO2 in
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
patients awake may be modest after ICA clamping. Cerebral monitoring
with INVOS-5100 has a high negative predictive value, but low positive
predictive.
EN16-NA38
The Effects of PEEP, ZEEP, and Intra-abdominal Pressure
Levels on Cerebral Oxygenation (rSO2) in the Morbidly Obese
Undergoing Sleeve Gastrectomy. Preliminary Results
I.S. Seker*, Y. Demiraran*, Z. Salihogluw, T. Umutogluz, I. Ozaydýn*,
S. Dogan*. *Duzce University Faculty of Medicine. wIstanbul University
Cerrahpasa Faculty of Medicine. zAcýbadem University Faculty of
Medicine, Turkey.
Background: Increased intra-abdominal pressure (IAP) may worsen
cerebral oxygenation by elevated intracranial pressure in morbidly obese
(MO) patients who underwent laparoscopic sleeve gastrectomy proce-
dures (LSG). Our study was designed to determine the effect of zero
(ZEEP) and 5 mm Hg positive end-expiratory pressure (5PEEP) on
cerebral oximetry levels in MO patients undergoing LSG. Second ob-
jective is to investigate the effect of IAP changes on cerebral oximetry
values (rSO2) in LSG.
Methods: After approval of ethic committee, 18 to 65 years old, ASA 2-3
status, 49 MO patients who planned SLG under general anesthesia were
included. Patients were divided into 2 groups that was ventilated with no
PEEP (group ZEEP) (n = 22) and 5 cm H2O PEEP levels (group
5PEEP) (n = 28). All patients were right-hand dominant. Cerebral oxi-
metry probes were applied to both frontal cerebral area of all patients
and the rSO2 values measured. IAP were measured transvesically in all
groups. Data were recorded as basal, after induction of anesthesia,
5 minutes before insuflation (5BI), 5 minutes after insuflation (5BA), 15,
30, 45, and 60 minutes after induction, 5 minutes before desuflation
(5BD) and 5 minutes after desuflation (5AD) time periods. Invasive
arterial pressures, cerebral oximetry values, 5 lead electrocardiography,
peripheral oxygen saturation, end-tidal carbon dioxide, peak inspiratory
pressures, and IAP, were recorded time periods in all groups. Arterial
blood samples were analyzed in the 5BI, 5AI, and 5AD periods. Anes-
thesia induction was performed with propofol, fentanyl, rocuronium,
midazolam IV and maintained with sevoflurane, air/oxygen mixture,
remifentanyl infusion, and rocuronium.
Results: There was no statistically correlation between left (P > 0.1) and
right (all P > 0.1) rSO2 values and IAP on time periods of group ZEEP.
Negative correlation was found between IAP and left (P = 0.831, 0.567,
0.860, 0.030, 0.005) rSO2 on pneumoperitoneum time in group 5PEEP.
Any statistical correlation was found between right (all P > 0.1) rSO2
values in this group. Statistical correlation was observed between bi-
lateral rSO2 values and ideal and lean body weight (IBW, LBW), body
surface area in group ZEEP (P < 0.05). Correlation observed between
IBW, LBW, and right rSO2 values in group 5PEEP, also increases of the
IAP lead to decreased rSO2 values in group 5PEEP.
Conclusions: We observed that increased PEEP and IAP may lead to
decreased rSO2 values bilaterally (especially dominant hemisphere) of
brain in LSG. Increase in the LBW may have a protective effect over
rSO2 in MO patients.
EN16-NA39
Patient Satisfaction in Ablative Intracranial Surgery for Parkinson’s
Disease
E. Pereira, A. Sampaio, S. Rêgo, J. Santiago, A. Raimundo, M.R.
Orfão. Centro Hospitalar Universitário de Coimbra, Portugal.
Background: Ablative intracranial surgery for Parkinson’s disease (PD) has
advanced to embedding electrodes into precise areas of the basal ganglia.
The anesthetist role in deep brain stimulation (DBS) is to provide adequate
operating conditions, patient comfort, and safety in order to facilitate in-
traoperative neuromonitoring for target localization. To prevent, diagnose,
and treat any adverse event during surgery are the main concerns. Our
department has developed a protocol to perform DBS, considering neuro-
surgical technique, neuromonitoring, patients’ safety, and satisfaction. The
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
anesthetic technique consists of local anesthesia in the insertion points of the
Mayfield skull clamp and incision points combined with a conscious seda-
tion. Patient satisfaction outcome is an important indicator of health care
and evaluation of the quality of services. The aim of this study is to measure
the patient satisfaction and the factors associated with it, using the Iowa
Satisfaction in Anesthesia Scale (ISAS).
Methods: Patients submitted to DBS for PD from July 2013 to October
2015 were analyzed. Patient satisfaction was measured using the 11
questions established by ISAS. The statistical analysis was performed by
SPSS (version 20.0).
Results: From July 2013 to October 2015, 15 patients were submitted to
local anesthesia combined with a conscious sedation to DBS. Analyzing the
results we obtained 87% of the patients as being ASA II and 13% ASA III
according to the physical status of ASA. The average time of surgery was 10
hours 12 minutes. Regarding the responses received from the satisfaction
questionnaire, we obtained the following results: I threw up or I felt sick
(100% completely disagree [CD]); I would want to have the same anesthetic
again (100% completely agree [CA]); I itched (100% CD); I felt relaxed
(100% CA); I felt pain (100% CD); I felt safe (100% CA); I was too cold or
hot (100% CD); I was satisfied with the anesthetic care (100% CA); I felt
pain during surgery (100% CD); I felt good (100% CA); It hurts (100%
CD). A 6.67% of patients suggested to have music therapy during surgery.
Conclusions: The patient’s feedback was very positive, as all the patients
submitted to DBS for PD using our DBS protocol were completely
satisfied. So we can continue to use this protocol in future patients
associated with music, whenever the patient wants it.
EN16-NA40
The Pharmacodynamic of Propofol During Awake Craniotomy
M. Soehle*, CF. Wolfw, M. Pristonz, A. Hoeft*, R.K. Ellerkmann*.
*Department of Anesthesiology and Intensive Care Medicine, University
of Bonn, Bonn, Germany. wDepartment of Anesthesiology and Intensive
Care Medicine, Sana Clinic Berlin-Lichtenberg, Berlin, Germany. zC3P
Analysis, Pharmacy Department, Plymouth Hospitals NHS Trust,
Plymouth, UK.
Background: During awake craniotomy, the patient’s speech center is
identified by neurological testing that requires an awake and cooperative
patient. Hence, anesthesia aims for an unconscious patient at the be-
ginning and end of surgery but an awake and responsive patient in
between. We investigated the plasma (Cpl) and effect-site (Ce) propofol
concentrations required for intraoperative return of consciousness
(ROC) and neurological testing as well as the corresponding EEG-effect.
Methods: In 13 patients, arterial Cpl were measured and Ce were esti-
mated based on the Marsh1 and Schnider2 pk/pd-models. The Bispectral
Index (BIS), Ce, and Cpl were compared during the intraoperative
awakening period at designated time points such as ROC and start of the
Boston Naming Test (BNT).
Results: At ROC, a BIS of 77 ± 7 (mean ± SD) and a Cpl of 1.2 ± 0.4 mg/
mL was measured. The Marsh model predicted a significantly (P < 0.001)
higher Ce of 2.3 ± 0.6 mg/mL as compared with the Schnider model
(Ce = 1.5 ± 0.4 mg/mL) at ROC. BNT was possible as soon as the BIS had
increased to 92 ± 6 and Cpl had decreased to 0.8 ± 0.3 mg/mL. This
translated into a time delay of 23 ± 12 minutes between ROC and BNT.
At the time point of neurological testing, Ce according to Marsh (Ce =
1.5 ± 0.7 mg/mL) was significantly (P < 0.001) higher as compared with
the Schnider model (Ce = 1.1 ± 0.5 mg/mL).
Conclusions: To perform the BNT intraoperatively, patients are required
to be wide awake with plasma propofol concentrations as low as 0.8 mg/
mL. At this neurologically crucial time point the Marsh pk/pd-model
estimates significantly higher propofol concentrations as compared with
the Schnider model.
References:
1. Marsh B, White M, Morton N, et al. Pharmacokinetic model driven
infusion of propofol in children. Br J Anaesth. 1991;67:41–48.
2. Schnider TW, Minto CF, Gambus PL, et al. The influence of method
of administration and covariates on the pharmacokinetics of propofol
in adult volunteers. Anesthesiology. 1998;88:1170–1182.
www.jnsa.com | S13
Supplement: EuroNeuro 2016
EN16-NA41
Is There an Ideal Approach for Anesthesia Management of Awake
Craniotomies?
C. Yildirim Guclu*, BC. Mecow, I. Doganw, A.Turgayw, D.Yorukogluw.
*Ankara University Faculty of Medicine Anesthesiology and ICM.
wAnkara University Faculty of Medicine, Turkey.
Background: Awake craniotomy (AC) is a “gold standard” surgical
approach for the identification and preservation of functional areas of
the brain. Various anesthetic approaches are described for the man-
agement of airway and anesthesia. One of the main challenges for the
anesthetist is to provide adequate level of anesthesia for different stages
of the procedure, without compromising patient safety. The goal of this
retrospective cohort study was to compare the different techniques and
to determine the success rate of AC cases.
Methods: In this study 62 patients undergoing awake brain tumor sur-
gery between 2008 and 2014 were evaluated. Patients’ characteristics,
anesthesia techniques, procedural data, and success rates were assessed.
Results: There was no difference between groups related to patient
characteristics, surgical procedures, and AC was successful in 93.5% of
cases. A total of 13 cases were managed with Monitored Anesthesia Care
(MAC), 5 patients with asleep-awake-asleep (AAA), and 44 patients
with asleep-awake (AA) technique. In group MAC the airway was se-
cured by an airway and in groups AAA and AA the airway was man-
aged with an LMA. Two patients in MAC group and 2 patients in AAA
group were put under general anesthesia because of desaturation and
loss of cooperation during “awake” phase, respectively.
Discussion: Two of the failed cases (from group MAC) had an oral
airway and desaturation was the reason to convert to general anesthesia.
After these 2 cases our airway management with LMA has become our
routine and we stopped using MAC technique. The other 2 failed AC
cases (from group AAA) were possibly due to over sedation and patients
could not cooperate during the awake phase of the procedure.
Conclusions: We conclude that the use of LMA is safe and an easy
alternative for the airway management of AC cases. We prefer AA
technique that enables the surgeon to do further cortical stimulation
when needed and provides better cooperation with the patient, earlier
recovery, and neurological examination.
EN16-NA42
Anesthetic Management for DBS Implantation. Experience at a
Mexican Private Setting
J. López Rodrı́guezz, A. Obregón Corona*, M. Gómez Ramı́rezw.
*Instituto Nacional de Neurologı´a y Neurocirugı´a. wInstituto Mexicano
del Seguro Social. zHospital Angeles Chihuahua, Mexico.
Background: Parkinson’s (PD) disease is the second most common
neurodegenerative disease in the world, most commonly affects people
aged over 60. PD disease is a disorder of the extrapyramidal system. The
symptoms are progressive and may become severe enough to debilitate
many patients. Deep brain stimulation (DBS) is rapidly becoming the
preferred surgical choice for treatment of advanced PD.
Case Reports: We explain the protocol for DBS implantation at our
Institution. There were included patients submitted to DBS from Jan-
uary 1, 2010 to May 31, 2014. Demographics’ and perioperative char-
acteristics of the procedures were analyzed. The patient were previously
premedicated with ranitidine (50 mg IV), ondansentron (4 mg IV), and
supplemental oxygen was provided using nasal prongs. Pulse oximetry is
monitored. Sedation was started with dexmedetomidine (DEX) 0.2 to
0.5 mg/kg/h, fentanyl 1 to 2 mg/kg/h, and a Scalp block was performed
using ropivacaine 0.75%+20 mcg DEX, then the rigid head frame halo
is placed and the patient is taken to the tomography. Upon the patient’s
arrival in the OR, standard anesthesia monitoring (EKG, NIBP, pulse
oximetry, capnography, and BIS) was applied to the patient, also the
administration of supplemental oxygen continues. We cannulate the
radial artery using a 22-G catheter to monitor IBP and for gasometric
samples. The DEX and fentanyl IV perfusions continue and propofol is
added to keep BIS values (78 to 85) or entropy (74 to 94) while the burr
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
hole is performed, after that, we stop fentanyl and propofol perfusions
while the neurological evaluations are performed. Then the same steps
are repeated for the other side. The pulse generator was implanted into
the chest wall.
Discussion: Fourteen patients in total (8 male and 6 female), ages ranging
from 31 to 62 years, all of them with PD diagnosed from 9 to 15 years at
the time of the surgery. All patients were under pharmacologic treatment
for PD, which included 2 or more of the following: carbidopa/levodopa,
rasagiline, amantadine, biperiden, pramiprexole, entacapone. Proce-
dures were performed under total intravenous anesthesia using propofol,
fentanyl, cisatracurium. In 8 patients we intubated the trachea and in 6
patients we used laryngeal mask. After the procedure was finished all the
patients were successfully extubated and taken to the postanesthesia care
unit. The average hospital stay was 4 to 6 days.
EN16-NA43
Local Anesthetic Toxicity That Developed During Deep Brain
Stimulation Operation
I.S. Seker, O. Ozlu, U. Er, S. Dikici, G. Sezen. Duzce University Faculty
of Medicine, Turkey.
Background: We presented a local anesthesia toxicity during deep brain
stimulation operation for parkinsonism.
Case Report: The patient with 15 years history of Parkinson’s disease
was on maximal medical treatment. He was 62 years old with 56 kg body
weight. Disability to perform daily life activities because of intense
dyskinesia and on-off phenomena. His medication consisted of carbi-
dopa, levodopa, and entacapone (500 mg/d), levodopa and 25 mg ben-
serazide (625 mg/d), amantadine sulphate (300 mg), and pramipeksol
dihydrochloride monohydrate (3 mg/d). Congenital single kidney with
normal renal function. Bradykinesia and rigidity were more evident at
right side. Sinus rhythm with 60 beats per minutes. Blood pressure was
130/70 mm Hg. His ejection fraction was 60% with mild-moderate aortic
valve insufficiency in echocardiographic examination. Deep brain stim-
ulation and microelectrode recording was planned under local anesthesia
(LA). LA infiltration was performed for stereotactic frame placement
bupivacaine (25 mg) and prilocaine (50 mg) mixture without epinephrine.
After computerized tomographic brain scanning, the patient was
transferred to the operating room. After the electrocardiography, in-
vasive arterial blood pressure (IBP), and bispectral index (BIS) mon-
itorization, dexmedetomidine infusion was initiated for sedation. Ring
block was performed using bupivacaine (150 mg) and prilocaine (300 mg)
mixture without epinephrine before the surgical procedure by the neu-
rosurgeon. The time interval between the ring block and field block was
approximately 1 hour. Dexmedetomidine dosage was arranged accord-
ing to BIS values (target value, 65 to 85). Twenty minutes after the ring
block, the patient was agitated without pain. In addition to dexmede-
tomidine infusion, totally 120 mg propofol at fractional boluses was
injected and then propofol infusion was initiated. Hypertension and
tachycardia were developed. Heart rate was 130 beats/min, IBP in-
creased to 220/100 mm Hg. Ventricular extrasystoles were observed
frequently. Esmolol (50 to 200 mg/kg/min) and sodium nitroprusside
(2 mg/kg/min) were initiated to control hypertension and tachycardia.
Blood pressure and heart rate decreased to basal values 60 minutes after
the ring blockage, at the end of second hour, drug infusions were
gradually ended.
Discussion: As scalp has rich vessel network, drug absorption is relatively
higher and epinephrine addition to LA for scalp anesthesia is more
important. Combination of multiple local anesthetic agents toxicity
depends on the additive dosage of agents rather than sole agents dos-
age.1 Although, total bupivacaine dosage was less than toxic dosage
2 mg/kg and prilocaine dosage was <6 mg/kg.
Learning Points: Awake cranial procedures with frame, analgesia, and
sedation necessitate careful drug choice, dosage administration, and
experienced surgical team.
Reference:
1. Rowlingson JC. Toxicity of local anesthetic additives. Reg Anesth.
1993;18:453–460.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NA44
The Effects of Intraoperative Dexmedetomidine, Propofol and
Remifentanil-based Sedation on Clinical Outcomes After Deep
Brain Stimulation (DBS) Surgery in Parkinsonian Patients: A
Retrospective Study
J. Chui, A. Rizq, I. Herrick, A. Parrent, R. Craen. University Of Western
Ontario, Canada.
Background: Deep brain stimulation (DBS) surgery requires a cooper-
ative and immobile patient to localize targeted deep brain nuclei. In-
traoperative sedation is sometimes used to facilitate surgery; however,
there are several reports of anesthetic-induced suppression of micro-
electrode recordings of the deep brain nuclei. Propofol and remifentanil
are the most commonly used agents, but dexmedetomidine is becoming
the sedative agent of choice because of its perceived benefits. However,
no studies to date have evaluated the impact of differing sedative agents
on the success of the surgery, and on patient outcomes.
Methods: We performed a retrospective study to evaluate the effect of
sedative agents on postoperative clinical outcomes at 6 months in Par-
kinsonian adult patients who underwent DBS surgery, from January
2004 to December 2014, at 1 academic center. All the data were manually
retrieved and verified before analyses. Clinical outcomes of DBS were
evaluated by a neurologist using a simplified UPDRS-III score and lev-
odopa dose equivalent (LEDD) reduction at 6 months postoperatively.
Results: We analyzed data from 121 of 124 consecutive PD patients.
Most patients (95%) had bilateral DBS electrodes implantation to
subthalamic nuclei. Three sedative regimens were used in our institute:
propofol, dexmedetomidine, and remifentanil based. We found that
patients achieved similar clinical outcomes regardless of choice of se-
dation. Intraoperative and postoperative complications were similar in
the 3 groups; with the exception that intraoperative bradycardia was
more common in the dexemedetomidine group. The need for a second
antihypertensive agent (hydralazine) to control blood pressure was most
common in the propofol group. In the regression analysis, we failed to
identify any predictors that determine the success of DBS implantation,
duration of microelectrode recordings, duration of stage I procedure,
and LEDD reduction at 6 months.
Conclusions: Our study showed that the choice of sedative agent did not
affect clinical outcomes after DBS surgery in Parkinsonian patients. It is
possible that our findings reflect the experience of the neuroanesthesia
team at our center in reducing the incidence of complications leading to
the success of surgery. Larger studies are needed to confirm our findings.
EN16-NA45
Anesthetic Management for Implantation of Deep Brain
Stimulators in Parkinson’s Disease: Remifentanil or Dexmede-
tomidine?
G. Serafini, S. Baroni, A. Marudi, A. Feletti, S. Contardi, E. Bertellini.
New Civil Hospital Sant’Agostino Estense, Italy.
Background: The anesthetic management during the implantation of a
deep brain stimulator (DBS) is very important for several reasons, but it
is still to be understood which is the best technique. Most recent studies
recommend the use of low-dose dexmedetomidine and remifentanil
along with scalp block for adequate sedation and analgesia with least
interference to neurophysiological tests. This retrospective observational
study aims at finding the best anesthetic approach between the admin-
istration of a propofol-remifentanil and a propofol-dexmedetomidine
combined sedation.
Methods: A retrospective chart review was performed on patients af-
fected to Parkinson’s disease, who underwent DBS implantation from
March 2013 to October 2015. We compared age, comorbidities, patient
comfort, and interference to the neurophysiologist tests. We compared
the Unified Parkinson’s Disease Rating Scale (UPDRS) before the op-
erating room and during sedation, but before the stimulation. Data were
analyzed using Mann-Whitney test. The anesthetic strategy was freely
chosen by the anesthetist: continuous IV infusion of propofol and re-
mifentanil (Pro-Remi) or continuous IV infusion of propofol and dex-
medetomidine (Pro-Dex). The neurophysiologists used the micro
electrode recordings patterns and the movement-related changes to lo-
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
calize the specific brain target. The neurologist evaluates each movement
change using the UPDRS scale.
Results and Discussion: Seventeen patients were included, 13 male and 4
female, mean age of 57 years. Eight of them received Pro-Dex sedation,
whereas 9 Pro-Remi sedation. Each patient felt comfortable and was
able to cooperate with the staff. The neurologists reported a decrease in
muscle tone when using the Pro-Remi sedation. The intraoperative
UPDRS evaluations differed to the preoperative a little more in the Pro-
Remi group than in the Pro-Dex group (a mean global DUPDRS of 3.0
in the Pro-Remi group vs. a 2.6 in the Pro-Dex group), but there was no
statistical significance.
Conclusions: In our study a Pro-Dex sedation seems to interfere to the
neurophysiological evaluation on a lesser scale and ensure comfort to the
patient. The sample is too small and we need further studies.
EN16-NA46
General Anesthesia for Deep Brain Stimulation in Parkinson
Disease: Our Experience
N. Garcı́a Claudio, I. Giménez Jiménez, E. Domenech Pascual, A.
López Gómez, A. Gutiérrez Martı́n, M.P. Argente Navarro. Hospital La
Fe, Valencia, Spain.
Background: Parkinson disease (PD) is one of the most common dis-
abling neurological diseases. Deep brain stimulation (DBS) has provided
remarkable benefits for the people with variety of neurological con-
ditions. The goal of study is to explain our experience with general
anesthesia in DBS for PD.
Methods: We retrospectively reviewed the digital clinical histories of 40
patients who underwent insertion of bilateral STN DBS electrodes under
general anesthesia for the treatment of advanced Parkinson disease in
our hospital. The entire surgical procedure was performed under intra-
venous general anesthesia. We record and analyze some demographic
characteristics like age, sex, comorbidities, complications with anesthetic
technique, and hospitalization days.
Results and Discussion: Between March 2012 and April 2015, 40 patients
were treated for advanced Parkinson disease under general anesthesia in
our hospital. Seventeen women and 23 men, the mean age was
58.92 ± 10.43 years. The mean of hospitalization was 7.11 ± 2.08 days,
except in 1 case who had a massive brain hemorrhage. Excellent quality
of electrophysiological recordings of the STN was obtained under gen-
eral anesthesia. General anesthesia can reduced some negative aspects of
doing this surgery with awake patients such as anxiety, back pain, and
anesthetic concerns about respiratory difficulties. The hemodynamic
management, mainly the blood pressure, is easier to control with general
anesthesia, and this decreased the possibility of complications like
bleeding.
Conclusions: General anesthesia is an alternative safe and effective
method to perform STN DBS surgery.1 Because of the lack of direct
evidence based on randomized and controlled trials, our perspective is
speculative. There is an ongoing study in our hospital aiming to validate
the advantage of general anesthesia in DBS of PD.
Reference:
1. Harries AM, Kausar J, Roberts SAG, et al. Deep brain stimulation of
the subthalamic nucleus for advanced Parkinson disease using gen-
eral anesthesia: long-term results. J Neurosurg. 2012;116:107–113.
EN16-NA47
Anesthetic Management of Awake Craniotomy for Brain Tumors:
Our Hospitals’ Experience.
I. Giménez Jiménez, N. Garcı́a Claudio, F.I. Montero Sánchez, P. Pérez
Caballero, J.M. Loro Represa, M.P. Argente Navarro. Hospital Uni-
versitari i Politècnic La Fe, Valencia, Spain.
Background: Awake craniotomy is used in deep brain stimulation pro-
cedures or in the surgical treatment of brain tumors in close vicinity to
the language or sensorimotor area.1 The consecutive awake-asleep-
awake steps can carry substantial risks like hemodynamic instability,
episodes of hypoventilation, agitation or disorientation, and interference
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Supplement: EuroNeuro 2016
with interventional test performances. We present a case series of 10
patients with brain tumors that were done with the technique awake-
asleep-awake, the anesthetic technique and complications are described.
Methods: We retrospectively reviewed the computerized clinical records
of 10 consecutive patients. We recorded some demographic character-
istics as age, sex, body mass index (BMI), comorbidities, ASA physical
status, complications with the anesthetic technique, and length of hos-
pital stay (LOS).
Results and Discussion: Five women and 5 men were included. Dates are
showed as mean (± SD). Age was 44.2 years (± 13.91), BMI 29.71 kg/m2
(± 7.13), 9 patients were ASA 2, one of them ASA 3, there were 3
hypertensive patients, the LOS was 9.55 days (± 1.42). One patient
could not be operated on due to morbid obesity, positioning, and airway
management problems. The rest of patients were operated without
complications. In all of cases, during asleep phase the management of
airway was done with laryngeal mask, total intravenous anesthesia with
propofol and remifentanyl was given. The awake-asleep-awake techni-
que offers the advantages of: greater resection extension, fewer late
neurological deficits, shorter LOS, and longer survival compared with
surgery under general anesthesia. One of the most important factors for
the success of this surgery is the adequate selection of patients, careful
explanation of the procedures, and a good psychological support.
Conclusions: The technique awake-asleep-awake for brain tumor re-
section is becoming a standard of care for lesions located within or in
close proximity to regions presumed to have language or sensorimotor
function. The wrong selection of the patients can make the surgery
impossible, as it is shown in one of our cases.
Reference:
1. Meng L, Berger MS, Gelb AW. The potential benefits of awake
craniotomy for brain tumor resection: an anesthesiologist’s per-
spective. J Neurosurg Anesthesiol. 2015;27(4):310–317.
EN16-NA48
Continuous Dexmedetomidine During Language and Motor
Mapping for Tumoral Awake Craniotomies: A Case Series
A. Martinez Simon, A. De Abajo Larriba, M. Alegre Esteban, E. Cacho
Asenjo, S. Tejada Solis, R. Diez Valle, MC. Honorato Cia. University of
Navarra Clı´nic, Spain.
Background: Awake craniotomies are frequently performed for brain
tumor resection whenever speech or motor areas are involved. This al-
lows for intraoperative speech or motor testing, and less secondary
neurological deficits. Many anesthetic techniques have been described to
achieve optimal surgical conditions and patient comfort, but there is
limited evidence to support one over others. Dexmedetomidine (DEX)
has been safely used in awake craniotomies but most publications report
stopping or reduce to the lowest dose the infusion before testing motor
or speech.
Case Report: We present a postauthorization study (CUN-DEX-2015-
01) with 10 patients who underwent awake brain tumor surgery under
continuous DEX as principal sedative agent, with adequate sedation and
without interfering with language or motor mapping. Perioperative data
collection included demographic data and basal health status, charac-
teristic of brain tumor and surgery evolution, and anesthetic manage-
ment data. A descriptive analysis of the data (median and range) was
performed using Stata 12.
Discussion: All patients received a loading dose of DEX between 0.5 and
1 mg/kg for 10 minutes. Maintenance dose (0.2 to 1.4 mg/kg/h) was kept
up to achieve a Ramsay Sedation Score of 2 during the awake phases
while ensuring patient comfort. Most tumors were large (mean volume,
38.99 [range, 15.17 to 58.31] cm3), requiring longer procedures (mean
surgery time was 392.6 [range, 325 to 501] min). During the speech and
motor testing the lowest maintenance dose of DEX was of 0.2 mg/kg/h in
4 patients; 0.4 mg/kg/h in 2; 0.6 mg/kg/h in 3 patients; and 0.8 mg/kg/h in
1. All patients cooperated adequately, and in no case DEX had to be
stopped. No propofol or benzodiazepines were used in any case. Re-
mifentanil was used in 8 of the 10 cases (range, 0.1 to 5 ng/mL) during
the initial craniotomy phase.
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Learning Point: Our experience supports the use of a DEX as sole sed-
ative agent with continuous infusion during awake brain tumor surgery.
Stop or reduce to the lowest dose of the infusion before testing is not
necessary. Doses between 0.2 and 0.8 mg/kg/h can provide adequate se-
dation and comfort without interfering with the neurological examina-
tion. Dosage can easily be adjusted to ensure patient’s comfort and
cooperation.
EN16-NA49
Regional Anesthesia and Sedation Technique With Dexmedeto-
midine for Awake Craniotomy
L. Moltó, C. Rodrı́guez, E. Vilà, J. Fernández-Candil, L. Castelltort, S.
Pacreu. Department of Anaesthesiology, Parc de Salut Mar, Barcelona,
Spain.
Background: Awake craniotomy allows to maximize lesion resection and
somatosensorial areas of the brain and to minimize the postoperative
neurological deficits.1 In our hospital, propofol infusion plus re-
mifentanil infusion was the most common option for awake craniotomy.
However, patients were sleepy that made it difficult their collaboration
during the surgery. Recently, we introduce dexmedetomidine2 (Dex), a
selective a2-adrenoceptor agonist with analgesia, sedation, and sym-
patholysis effects and without respiratory depression. We show our ex-
perience using regional anesthesia plus Dex sedation.
Methods: After approval by Ethical Committee, we evaluated during
2015, consecutively 5 patients who underwent awake craniotomy to treat
supratentorial tumors. Regional anesthesia using bupivacaine 0.25%
with epinephrine, included the blockade of the cranial nerve V and the
occipital nerves. The scalp and dura were also infiltrated. Dex infusion
was started before infiltrating, stopped before mapping, and resumed at
the beginning of dura closure. For postoperative analgesia, dexketo-
profen, paracetamol, and morphine were administered.
Results: One male and 4 females (ASA II/III) were evaluated. The fol-
lowing results are expressed as median and quartiles: age, 32 (27 to 49)
years old; weight, 60 (51 to 93) kg; length of surgery, 330 (270 to
360) min. The total bupivacaine was 140 mg. Dex infusion was ad-
ministered at a rate of 0.4 mg/kg/h at the open and closure of craniotomy
and stopped during the surgery. No side effects such as nausea, vomiting,
local anesthetic overdose, respiratory depression, hyperalgesia, or car-
diac instability were observed. One patient presented seizures. There was
a low incidence of intraoperative pain.
Conclusions: Regional anesthesia and Dex sedation provided adequate
conditions for awake craniotomy. It decreases patients’ anxiety, pain
medication needs, and level of consciousness without agitation.
References:
1. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy. Evolution
of a technique that facilitates awake neurological testing. Br J An-
aesth. 2003;90(2):161–165.
2. Bekker AY, Kaufman B, Samir H, et al. The use of dexmede-
tomidine infusion for awake craniotomy. Anesth Analg. 2001;92:
1251–1253.
EN16-NA50
Tolerance of Awake Patients During Functional Brain Mapping
L. Pariente Juste, L. Garcı́a Huete, M. Juncadella Puig, L. Contreras
López, G. Elguezabal Sangrador, A. Gabarrós Canals. Bellvitge Uni-
versitary Hospital, Barcelona, Spain.
Background: Functional brain mapping is a well-established technique to
optimize the excision of tumors involving the eloquent area. The role of
the anesthetist is key in providing adequate surgical conditions to
ensuring the patient’s capacity to interact during the neurological tests.
The objective of this study is to determine the level of comfort, analgesia,
and postintervention satisfaction of the patient.
Methods: We have studied and analyzed 30 craniotomies with functional
brain mapping performed at Bellvitge Universitary Hospital from 2012 to
2015. The patient’s comfort and postintervention satisfaction have been
evaluated with a 9-item questionnaire carried out 4 months after the surgery.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Results and Discussion: From the 30 patients studied, 17 (56%) were men
and 13 (43%) were women, with an average age of 42 (range, 19 to 67)
years. The most frequent tumor lineage was glioblastoma in 9 patients
(30%), followed by oligoastrocytoma in 7 (23%), and astrocytoma in 6
(20%). The first group, composed of 19 patients (63%), underwent an
asleep-awake-asleep technique, with propofol, remifentanil, and lar-
yngeal mask. The second group, composed of 11 patients (36%), un-
derwent an asleep-awake technique until completion of the surgery,
enabled by the patient’s tolerance. The asleep-awake-asleep procedures
were moderately longer (mean, 7.8 h) than the asleep-awake (mean,
7.2 h). Seventeen of the total number of patients (58%) showed a positive
acceptance of the proposed technique. After the procedure, acceptance
turned into satisfaction in 79% (15 patients) of the first group and 100%
(11 patients) from the second group. Four patients (21%) from the first
group felt moderate pain during surgery and 3 (27%) from the second
group felt mild pain, most of them referred as a headache. Their mem-
ories of the level of comfort were positive in all of the patients of both
groups, except one of the second group who felt uncomfortable due to
the position. All of the patients would recommend this anesthetic tech-
nique to other people with their disease.
Conclusions: Brain functional mapping using asleep-awake anesthetic
technique is positively perceived by patients. The choice of an
asleep third phase is dependent mainly on the patient’s tolerance and
also on the degree of potential complications of introducing a laryngeal
mask.
EN16-NA51
Anesthesia for Awake Craniotomy: Less is More?
I. Mladiæ Batinica*, K. Rotim*, T. Sajko*, M. Zmajevic Schonwald*, S.
Salkièeviæw. *UHC “Sisters of Mercy”. wFaculty of Humanities and
Social Sciences, Croatia.
Background: Monitored anesthesia care (MAC) becomes standard an-
esthetic technique for awake craniotomy, in case of tumor resection in
eloquent brain areas.1
Clinical Case Series: After implementation in Croatia 2 years ago, we
present our experience with 11 patients (age, 32 to 64 y; 7 male, 4 female;
ASA II). After patients were selected by a multidisciplinary team (neu-
rosurgeons, anesthesiologist, neurologist, and psychologist), they were
sedated and allowed to breathe spontaneously during the procedure. We
used target controlled infusion pumps for fine titration of remifentanil
and propofol, and for local infiltration at the site of pin insertion, skin
incision, and nerve blocks mixture of 0.5% bupivacaine and 2% lido-
caine with adrenalin. Monitoring included: electrocardiogram, invasive
and noninvasive blood pressure, pulse oximetry, respiratory rate, end-
tidal carbon dioxide, bispectral index, and hourly urinary output. Pa-
tients were stable during the operation and cooperative for motor and
language testing. There were no surgical, neither anesthesiological
complications.
Discussion: We’ve chosen MAC because avoidance of general anesthesia
prevent associated physiological disturbance, need for mechanical ven-
tilation, and utilization of anesthetics that can play a role on antitumor
immunity and tumor progression. Surgeon’s credit is an ability to in-
crease the extent of resection and survival, while preserving neurological
function. Anesthesiologist’s credit is competence to avoid a complica-
tions of general endotracheal anesthesia. That may contribute to better
outcome. Our experience shows patients’ satisfaction (evaluated by
psychologist), with optimal intraoperative working conditions for neu-
rosurgeon.
Learning Points: Anesthesiologist contribution to awake craniotomy is
essential. Crucial steps in establishment of an awake surgery is creation
of a competent neuroanesthesiologist, who are able to provide care for
awake patients, focusing on pain, sedation, hemodynamic stability,
airway management, constant perioperative support, and communica-
tion with patient.
Reference:
1. Meng L, Berger MS, Gelb AW. The potential benefits of awake
craniotomy for brain tumor resection: an anesthesiologists per-
spective. J Neurosurg Anesthesiol. 2015; 27(4):310–317.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
EN16-NA52
An Opioid-Free “Awake Throughout” Craniotomy Using Dex-
medetomidine and Nasal High Flow Oxygen in an Obese Man
With Suspected Obstructive Sleep Apnoea (OSA)
M. McGinlay, C. Kelly, B. Mullan, N. Johnston, T. Flannery. Royal
Victoria Hospital, Belfast Health and Social Care Trust, NHS, UK.
Background: Awake craniotomy allows for real-time intraoperative
speech, sensory and motor testing for tumor resection in eloquent areas
of the cortex and has been shown to improve both the efficacy and safety
of tumor resection.1 Nevertheless this technique presents several unique
challenges, particularly to the anesthetist, who is faced with an un-
protected airway and limited intraoperative access. Concerns for patient
safety have led to reluctance to perform this technique in some groups of
neurosurgical patient. The optimal anesthetic management of these pa-
tients remains unclear.2
Case Report: We describe the anesthetic dilemma of an ASA 3, 43-year-
old, 126 kg male with gastroeosphageal reflux and suspected OSA pre-
senting for an awake left frontal craniotomy for resection of a low-grade
astrocytoma. We successfully adopted a novel anesthetic approach for
an awake craniotomy using a levobupivicane based scalp nerve block
and dexmedetomodine as our sole sedative agent in conjunction with
nasal high flow oxygen therapy to provide intraoperative CPAP.1,3
Discussion: The “awake throughout” craniotomy has recently been
adopted within our institution replacing the traditional “asleep, awake,
asleep” technique allowing optimal surgical resection in patients who
would otherwise have been declined given their excess anesthetic risk.
Nasal high flow oxygen delivery is an established therapy to alleviate
upper airway obstruction in OSA. Recent evidence increasingly supports
its use within anesthetic practice.3 We found that it provided superior
respiratory support while crucially did not impede on intraoperative
speech assessment.
Learning Point: An awake craniotomy can be successfully performed in
the high-risk obese population while avoiding both airway manipulation
and opioid use.
References:
1. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy—evolution
of a technique that facilitates awake neurological testing. Br J An-
aesth. 2003:90(2):161–165.
2. Garavaglia MM, Das S, Cusimano MD, et al. Anaesthetic approach
to high-risk patients and prolonged awake craniotomy using dexme-
detomidine and scalp block. J Neurosurg Anesthesiol. 2014:26(3):
226–233.
3. Patel A, Nouraei SA. Transnasal humidified rapid-insufflation
ventilatory exchange (THRIVE): a physiological method of increas-
ing apnoea time in patients with difficult airways. Anaesthesia.
2015:70: 323–329.
NEUROINTENSIVE CARE
EN16-NI01
Agitation in Trauma ICU, Prevention and Outcome
S. Mahmood, H. Al-Thani, A. El Menyar. Trauma Surgery Department,
Trauma Intensive Care Unit, Hamad General Hospital, Doha, Qatar.
Background: Agitation is a syndrome characterized by the acute onset of
central nervous system dysfunction identified by several features in-
cluding a change or fluctuation in baseline mental status, and either
disorganized thinking or an altered level of consciousness. Agitation
occurs frequently in critically ill patients at intensive care unit (ICU).
Objectives: Although agitation is thought to be common in the ICU, it
has been poorly studied. This study aims to evaluate the incidence, risks
factors, and outcomes of agitation in ICU.
Methods: A retrospective study with waiver of consent was conducted in
one of the trauma ICU for 1 year. ICU patients were enrolled in the
study and classified based on their agitation status. The depth of seda-
tion along with the Ramsey Sedation Scale, Glasgow Coma Scale, type
of injury, and observation of vital signs were clinically evaluated.
Results: In total, 102 patients (n = 102) were enrolled during the period
of the study. Among those patients, 46 patients (n = 46) were agitated.
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Comparing the 2 groups of patient, agitated patients had higher
incidence of infection (P < 0.02) compared with the nonagitated pa-
tients. In addition, there was a significant difference type of sedation
used (P < 0.001), ventilator-free days (P < 0.001), and length of stay.
Conclusions: Agitation in ICU patients is associated with several adverse
outcomes including prolonged stay, nosocomial infections, and un-
planned extubations.
EN16-NI02
Comparison of Dexmedetomidine With Fentanyl-Midazolam for
ICU Sedation in Head Injury Patients
B. Ashish, B. Sujoy, M. Randhir, GP. Rath. Department of Neuro-
anaesthesiology, All India Institute of Medical Sciences and Associated Jai
Prakash Narain Apex Trauma Centre, New Delhi, India.
Background: Although neurointensive patients share many common
sedation goals with general intensive care unit patients, some require-
ments are unique to this population, such as maintaining adequate
cerebral perfusion pressure (CPP), while controlling intracranial pres-
sure (ICP) and mean arterial pressure. We planned this study in patients
with traumatic brain injury (TBI) to assess the effect of dexmedetomi-
dine as compared with combination of fentanyl-midazolam as a sedative
agent, in terms of time to achieve desired Richmond Agitation-Sedation
Scale (RASS) score and duration of time till RASS was maintained. Our
secondary objectives were to compare the effect of these drugs on sys-
temic hemodynamics, ICP, CPP, neurological status, and evaluation of
need for supplementary sedation.
Methods: We compared the effect of 0.2 to 0.7 mg/kg/h dexmedetomidine
infusion (group D) to a sedative infusion of fentanyl 0.2 to 1 mg/kg/h and
midazolam 0.02 to 0.07 mg/kg/h (group C) in 11 consecutive patients of
TBI admitted to neurosurgical intensive care unit in crossover alter-
nation for first 48 hours after admission, titrating sedation to the RASS.
Results: Patient demographics were well matched between the 2 groups.
Hemodynamics, heart rate, mean arterial pressure, ICP, and CPP were
maintained within (P = 0.472, 0.219, 0.328, and 0.165) and between the
groups (P = 0.096, 0.432, 0.478, 0.175, respectively). RASS score in both
the groups was comparable (P = 0.894). GCS score correlated with
RASS score in group D (r = 0.467, P = 0.021) and group C (r = 0.654,
P = 0.001). Amount and number of rescue boluses of sedation with
midazolam were similar in both the groups (n = 3, P = 0.463). No ad-
verse effects requiring rescue interventions were seen in either group.
Conclusions: Dexmedetomidine is a safe alternative to conventional
fentanyl and midazolam sedative infusion for TBI patients admitted to
neurosurgical intensive care unit. It maintains both cardiovascular as
well as cerebral dynamics, paving the way for future exploration of
dexmedetomidine for sedation for neurotrauma patients.
EN16-NI03
Retrospective Study About 211 Combat Casualties With Trau-
matic Brain Injury by Gunshot or Improvised Explosive Devices
Treated in the Spanish Military Hospital Deployed in Herat
(Afghanistan) From 2006 to 2014
R. Navarro-Suayw, C. Rodrı́guez-Morow, A. Hernández-Abadia De
Barbaraw, E. López-Soberónw, R. Tamburri-Bariainw, R. Puchades-
Rincón De Arellanow, B. González De Marcos*. *Hospital Universitario
La Princesa. wHospital Central De La Defensa Gómez Ulla, Madrid,
Spain.
Background: Over the last 10 years, conflicts in Afghanistan and Iraq
have resulted in a high numbers of casualties, some of them with blunt or
penetrating brain injuries. The aim of this study is to analyze casualties
who suffered gunshots wounds (GSW) and explosive device injuries
(IED) and were treated in the Spanish Military Hospital from 2006 to
2014.
Methods: We carried out a retrospective study of patients seen from
January 1, 2006 to December 31, 2014. The population chosen for the
study was all patients who were wounded by gunshots or by explosive
S18 | www.jnsa.com
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
devices and who were treated at Spanish Military Hospital in Herat
(Afghanistan). This study was approved by Spanish Medical Author-
ities, with NATO medical study policies.
Results and Discussion: During the period studied, 738 combat casualties
were treated at our medical facility (211 combat casualties with head
and/or neck trauma). In total, 199 (94.3%) were male and 12 (5.7%)
were female. A total of 89 (42.1%) were Afghan soldiers, 80 (37.9%)
were NATO members, and 42 (20%) were civilian. In total, 185 (87.6%)
were evacuated by helicopter to military hospital and the rest (26,
12.4%) were transferred by ground ambulance. The majority were
wounded by explosive devices (74.4%), and the rest had GSW (25.6%).
We did not see any casualties who were injured by both gunshots and
explosives. In total, 32.2% of the casualties were 25 to 29 years old. The
mortality of the casualties treated was 4.2% (N = 9 to 7 by IED and 2 by
GSW). In total, 52 (24.6%) casualties were evacuated to another military
hospital. A total of 138 (65.4%) casualties needed a surgical procedure.
A total of 108 (51.1%) casualties were admitted into the intensive care
unit. Applying the NISS, 146 (69.3%) of casualties were categorized as
minor injuries, 37 (17.5%) suffered mild injuries, and 28 (13.2%) suffered
severe injuries (25% to 89.2% by improvised explosive device and 3% to
10.8% by gunshot).
Conclusions: During the period studied, 211 combat casualties with head
and/or neck trauma were treated in the Spanish Military Hospital de-
ployed in Herat (Afghanistan). The majority (74.4%) were wounded by
explosive devices and the rest by gunshot. In total, 69.3% were cate-
gorized by NISS like minor injuries, 13.2% like mild injuries, and 13.2%
like severe injuries (89.2% of this grade by improvised explosive devices).
EN16-NI04
To Compare the Effects of 2 Different Techniques of Chest
Physiotherapy on Intracranial Pressure in Traumatic Brain Injury
Patients: A Randomized Cross Over Study
G.S. Tomar, G.P. Singh, P.K. Bithal. All India Institute of Medical
Sciences, India.
Background: The intensive care management in patients with traumatic
brain injury (TBI) is to prevent secondary brain injury by maintaining
hemodynamic, metabolic, and respiratory parameters. Chest physical
therapy (CPT) is used to promote loosening and clearing of secretions
from the airway in mechanically ventilated patients but should not be at
the cost of rise of intracranial pressure. Goal of this study is to compare
the effect of 2 different techniques of chest physiotherapy (manual chest
percussion vs. mechanical high-frequency chest wall vibrations) on in-
tracranial pressure (ICP), cerebral perfusion pressure (CPP) along with
hemodynamics and blood gas parameters in patients with traumatic
brain injury.
Methods: Forty-five adult patients with age between 18 and 75 years, of
either sex admitted to neurotrauma ICU after TBI on ventilator un-
dergoing continuous ICP monitoring, and requiring chest physiotherapy
on regular basis were included in this prospective, randomized control,
crossover study. Procedure was performed by the same trained physi-
otherapist in all the patients either using manual chest percussion with
frequencies of 100 to 120 cycles/min or mechanical chest wall vibrator
equipment with 60 Hz will be applied for a 10-minute session in each.
Trial has been registered prospectively with CTRI/2015/11/006369.
Results and Discussion: The mean values for ICP (mm Hg), MAP, CPP
(mm Hg), and HR (beats/min) before, and after CPT by mechanical or
manual method were found to be statistically (P > 0.05) and clinically
nonsignificant while during CPT with manual method, these were sig-
nificantly higher and statistically significant (P < 0.01) as compared with
mechanical method. Blood gas analysis parameters were comparable
among each group.
Conclusions: We emphasize that chest physical therapy for respiratory
care in TBI patients on ventilator can be safely commenced with
mechanical method of vibration and oscillations without any transient
rise of ICP as compared with manual method that might jeopardize
cerebral circulatory pathophysiology to further extent.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NI05
Multimodal Brain Monitoring Before and After Decompressive
Craniectomy
M. Veiga*, A. Ferreiraz, J. Silvaw, C. Diasw. *Hospital Central do
Funchal. wCentro Hospitalar de São João. z Faculdade de Medicina -
Universidade do Minho, Portugal.
Background: Traumatic brain injury (TBI) is a clinical condition of great
concern, with a very important personal/individual and social impact. In
the last 10 years, we have witnessed a decreased incidence in the devel-
oped countries and an increase in the developing countries. Because of
sedation for metabolism decrease the clinical assessment is limited.
Multimodal brain monitoring represents here a source of information
about brain hemodynamics and tissue oxygenation. Our goal was to
analyze systemic and cerebral multimodal monitoring before and after
decompressive craniectomy (DC) in severe TBI.
Methods: Retrospective observational analysis of multimodal brain mon-
itoring data of severe TBI patients with indication for DC was performed.
Nine patients followed inclusion criteria. Twelve periods of 1 hour before
DC and 12 periods of 2 hours after DC were analyzed for intracranial
pressure (ICP), cerebral perfusion pressure (CPP), arterial blood pressure
(ABP), amplitude of ICP wave (AMP), end-tidal CO2 (ETCO2), and brain
tissue oxygenation pressure (PbTO2). Secondary analysis was performed for
ICP value above 20 mm Hg (ICPd > 20), cerebral reactivity indexes (PRx
and PAx), and compliance indexes (RAP and RAC).
Results and Discussion: After DC some positive and negative alterations
occurred with statistical significance: a decrease in ICP maximum value,
ICPd > 20, CPP, ABP, HR, AMP, and RAP. RAC index was sig-
nificantly higher after surgery. DC did not influence the PbtO2, PRx, and
PAx. The EtCO2 remained constant during time. After DC, the CPP-
CPPopt was closer to zero. There was a trend for PRx to be higher after
DC, which might indicate either a derangement of pressure reactivity or
problem with PRx as a reliable indicator of pressure reactivity following
craniectomy. Furthermore no equivalent change occurred for PAx index.
Conclusions: This study analyses the changes caused by the DC re-
garding brain perfusion, oxygenation, and compensatory reserve. Fur-
ther studies are warranted to better understand brain pathophysiological
changes after DC, which might contribute to define the best indexes to
evaluate autoregulation and association with outcome.
EN16-NI06
Coagulation Profile in Patients With Traumatic Brain Injury
J.C. Gomez Builes, S. Rizoli, M. Sholzberg, K. Pavenski, A. Petropolis,
A. McFarlan, L. de Oliveira. St Michael’s Hospital, Canada.
Background: Traumatic brain injury (TBI) is often associated with co-
agulation abnormalities. Developing coagulopathy is at an increased risk
of mortality for TBI.1 To identify and treat bleeding disorders, rapid
assessment of coagulation status is decisive. However, conventional
coagulation tests are limited, as they only provide quantitative in-
formation. In contrast, thromboelastography, a point of care test, offers
quantitative and quality information of the totality of the process. Our
objective was to describe the coagulopathy profile in patients with iso-
lated TBI (iTBI) compared with TBI with severe multisystem trauma
(TBI+MST) by conventional tests and ROTEM analysis.
Methods: Retrospective study of patients with severe TBI and ROTEM
test on admission to St Michael’s Hospital from November 1, 2014 to
July 31, 2015. Demographic, clinical data, ISS and Head AIS, conven-
tional coagulation test (complete cell blood count, INR, aPTT, fibri-
nogen, EB), and ROTEM results at hospital admission were collected.
iTBI was defined as AIS head > 2 and AIS other regions <3. Coagul-
opathy was defined as one or more of: INR < 1.3, aPTT > 37 seconds,
platelet count < 100,000/mL, and/or fibrinogen <1.5 g/L; ROTEM:
EXTEM CT > 80 seconds, EXTEM CFT > 159 seconds, EXTEM
MCF < 50 mm, and FIBTEM MCF < 9 mm.
Results: In total, 150 patients with severe TBI were included. Eighty-four
patients (56%) presented isolated TBI and 66 (44%) TBI+MST. There
was no difference across the groups for age (mean, 46.3 ± 20 SD), mortality
(overall 17.3% vs. iTBI 16% vs. TBI+MST 18.1%). When compared with
iTBI, TBI+MST group had higher mean ISS (29 vs. 16), presented more
coagulopathy by standard test (22.7% vs. 13%), and by ROTEM (34.3%
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
vs. 25%), hypoperfusion (EB >  6 mE/L 27.2% vs. 11.9%), and received
more transfusions in the first 24 hours (24.2% vs. 4.7%). For patients with
coagulopathy, the most frequent abnormality was CT EXTEM > 80 sec-
onds (40/44 patients, 90.9%) and FIBTEM MCF <9 mm (18/44 patients,
40.9%) when assessed by ROTEM, and fibrinogen <1.5 g/dL (14/26 pa-
tients, 53.8%) when measured by conventional tests.
Conclusions: Coagulopathy is more frequent in patients with TBI and
multisystem trauma than in the isolated TBI group, suggesting TBI may
not by itself, cause coagulopathy. The coagulation abnormalities ob-
served in our study, support the importance of timely monitoring and
treatment of hypofibrinogenaemia (low FIBTEM and serum fibrinogen)
to assure adequate hemostasis in this population.
Reference:
1. de Oliveira Manoel AL, Neto AC, Veigas PV, et al. Traumatic brain
injury associated coagulopathy. Neurocrit Care. 2015;22:34–44.
EN16-NI07
Mapping of Cerebral Microcirculation and Histology After Head
Injury in Experimental Models
J. Bellapart Rubio*, S. Diabz, L. Gabrielianw, J. Paratz*, R. Boots*, J.
Fraserz. *Royal Brisbane And Women Hospital. wThe Adelaide School Of
Medicine. z The Prince Charles Hospital, Australia.
Background: Cerebral microcirculation after head injury is hetero-
genously distributed and temporally variable. Pericontusion regions
have restricted flow, but it is unclear how axonal injury impacts on
microcirculation. This study describes a novel head injury model that
correlates cerebral microcirculation with histopathology over 4 hours
after injury. Main endpoint is to test the hypothesis that pericontusion
microcirculation and in regions of axonal disruption is reduced when
compared with noninjured regions.
Methods: Merino sheep were instrumented using an intracardiac transeptal
injection of coded microspheres into left atrium to ensure systemic dis-
tribution. Neuromonitoring included partial tissue oxygenation and intra-
cranial pressure. Four hours after contusion, simultaneous cytometric
count and amyloid precursor staining mapped specific cerebral regions. A
mixed-effect regression model was used with flow ratios plotted at each
hour compared with baseline. A ratio below 1 represented a decrease in
flow with a positive ratio representing the contrary.
Results: Cerebral microcirculation was reduced over time at the ipsi-
lateral parietal with flow ratios being <1 compared with preinjury. In
contrast, at contralateral and ipsilateral thalamic regions flow ratios
were >1. Minimal amyloid staining was seen in all regions except for
ipsilateral thallamus and medulla.
Discussion: This study demonstrates that cerebral microcirculation is
variably distributed after head injury independently of pressure or tissue
oxygenation. Temporal reductions in cerebral microcirculation at the
ipsilateral side of the injury, medulla, contralateral parietal, and tem-
poral lobe are plausible; however, a paradoxical increase on cerebral
microcirculation at the ipsilateral temporal lobe and thalamus suggests
either perfusion mismatch or the result of collateral supplies. Amyloid
staining was maximal at areas of axonal damage, independent of the
state of microcirculation.
Conclusions: Cerebral microcirculation has spatial heterogeneity and
shows a temporal reduction 4 hours after injury in experimental models.
Amyloid staining distributes in regions where axonal damage is present
independently of microcirculation.
EN16-NI08
Etomidate Versus Midazolam for Rapid Sequence Intubation in
Severe TBI Patients
J.D. Charry, M.A. Pinzón, A.M. Cuellar, J.C. Barrios, D.R. Gurierrez,
J.H. Tejada. Universidad Surcolombiana/Hospital Universitario Hernan-
do Moncaleano Perdomo, Neiva, Colombia.
Background: Severe trauma brain injury (TBI) patients (GCS </ 8)
require emergency intubation. In this context, the use of etomidate as
sedative agent is attractive. The aim of this study is to compare the
mortality rates in TBI patients after a single dose of etomidate versus
midazolam used for emergency endotracheal intubation in a university
hospital in Colombia.
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Supplement: EuroNeuro 2016
Methods: A total of 374 severe TBI patients used tracheal intubation
between August 2011 and 2014. Recorded data were analyzed, including
patient demographics, presence of comorbidities, trauma-specific varia-
bles, length of stay in the intensive care unit (ICU), and hospital asso-
ciations between the use of etomidate versus midazolam and 28-day
mortality. Univariate analysis was performed; measures of central ten-
dency and dispersion for continuous variables were calculated. Logistic
regression was used to determine the risk of mortality in patients using
etomidate versus midazolam.
Results: A total of 374 TBI severe patients were included in this study;
165 patients received etomidate and 209 patients received midazolam.
The mean age for the etomidate group was 38.7 ± 14.4 years versus
35.7 ± 9.75 (P = 0.072). The ISS averaged for etomidate group was
16.7 ± 9.36 versus 18.7 ± 10.12 (P = 0.007). The 28-day mortality was
19.4% versus 41.2% (P < 0.001). Logistic regression was used in order
to control age, sex, GCS, ISS, and type of lesion. Midazolam was as-
sociated to a 3-fold mortality increased (OR, 2.98; 95% CI, 1.79-4.96;
P < 0.001).
Conclusions: Our results showed that the 28-day mortality was lower in
etomidate group. Etomidate is a safe and valuable alternative for en-
dotracheal intubation in severe TBI patients.
EN16-NI09
The Hyperoxic Challenge as a Surrogate to Evaluate the Regional
Cerebral Blood Flow Adequacy in Patients With Traumatic Brain
Injury. Results of a Pilot Study
G. Harutyunyan*, G. Murz, A. Sánchez-Guerreroz, F. Arikanw, G.
Mkhoyany, J. Sahuquillow. *University of Valencia (Burjassot). wVall
d’Hebron University Hospital and Universitat Autònoma de Barcelona.
zVall d’Hebron Research Institute (VHIR), Universitat Autònoma de
Barcelona, Spain. yMedical Center Erebouni, Armenia.
Background: At the microcirculatory level, the amount of oxygen (O2)
bound to hemoglobin (Hb) and the brain partial pressure of O2 (PbO2)
are in equilibrium. This equilibrium depends on the Hb affinity to O2,
which decreases when Hb is saturated with allosteric inhibitors (2.3
DPG, CO2, H+, Cl  ). Normobaric hyperoxia (NH) induces vaso-
constriction, decreases regional cerebral blood flow (rCBF), and in-
creases the Hb load with allosteric inhibitors thus raising more the PbO2.
This effect should be absent in those areas where the buffering properties
are exhausted. Our goal was to evaluate the PbO2 response after a hy-
peroxic challenge to assess the Hb buffer capacity of the rCBF.
Methods: PbO2 changes during NH test was prospectively examined in
25 patients with moderate and severe traumatic brain injury (GCS <
13). The PbO2 electrodes were placed in brain regions with various
degrees of tissue damage. The extended GOS (GOSE) was assessed 6
months after injury.
Results and Discussion: A steep PbO2 increase was observed in all cases
within a maximum 5 minutes after starting the hyperoxic challenge. This
increase (phase 1) reached a plateau in 5 cases (group A) or continued to
increase with a reduced slope after a maximum of 36 minutes in 20 cases
(group B). The duration of the first phase in the group A mainly depends
on the time of stabilization of the arterial PO2 and of the time of O2
diffusion at the tissue. The phase 1 in the group B suggests an additional
hyperoxia-induced vasoconstriction component. In the brain tissue,
metabolism of 1 mol of O2 produces 1 mol of CO2 and 1 mol of CO2 in
the erythrocytes generate 1 mol of H+. However, by releasing 1 mol of
O2, the Hb will only bind 0.6 mol H+. This physiological imbalance
together with the significant brain injury induced rCBF reduction in-
duces local acidosis and a reduced reactivity of vessels to O2 (group A).
In regions with preserved reactivity to O2 (group B), the vasoconstriction
redistributes the CBF to areas with less reactivity restoring the local
acid-base balance within a variable time, that is probably dependent of
the rCBF insufficiency as a buffer (phase 2).
Conclusions: The biochemical basis of Hb-O2 interactions in tissues
allows to use the hyperoxic-challenge as a simple maneuvre to: (1)
understand the dramatic increase of PbO2 during NH; (2) assess the
buffer reserve capacity of the rCBF; and (3) replace the concept of in-
creasing O2 delivery with the alternative concept of increasing the buffer
delivery.
S20 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NI10
Disturbed Cerebral Autoregulation, Assessed by Near Infrared
Spectroscopy, can Guide Patient-tailored Hemodynamic
Approach in Postcardiac Arrest Patients
W. Eertmans, K. Ameloot, C. Genbrugge, F. Jans, J. Dens, C. De
Deyne. Ziekenhuis Oost-Limburg, Department of Anaesthesiology, In-
tensive Care, Emergency Medicine and Pain Therapy, Genk, Belgium.
Background: Cerebral autoregulation may be disturbed in pathologic
conditions, causing a shift in the presumed lower mean arterial pressure
(MAP) threshold that still provides adequate cerebral perfusion.
Knowledge of this shift might be extremely important to safely manage
MAP. We present the possibility to monitor bedside cerebral autor-
egulation using the relationship between MAP and cerebral oxygenation
(SctO2), measured by near infrared spectroscopy.
Methods: A cerebral autoregulation index (COX) was derived from the
relationship between static MAP changes and reciprocal SctO2 changes.
This index was calculated as the moving linear correlation coefficient
between 10 seconds averaged SctO2 and MAP values over 5 minutes
moving time windows during 24 hours. As such, COX is a continuous
variable ranging from  1 to +1 that can be used as a robust marker of
autoregulation. Intact autoregulation is indicated by negative or near-
zero COX as small MAP variations will not alter SctO2 if autoregulation
is active. When autoregulation becomes impaired, COX is positive as
MAP and SctO2 correlate.
Results and Discussion: To show the usefulness of a continuous marker
of cerebral autoregulation in clinical conditions, we present data of 51
postcardiac arrest (CA) patients with continuous MAP and SctO2
monitoring during the first 24 hours of ICU stay. Cerebral autor-
egulation was classified as disturbed in 18 patients (35%). Chronic ar-
terial hypertension was more frequent in patients with disturbed
autoregulation (31% ± 47% vs. 65% ± 49%, P = 0.02). By performing
a pooled analysis for all 18 patients with disturbed autoregulation, the
overall COX predicted optimal MAP was 100 mm Hg compared with
85 mm Hg for patients with a preserved autoregulation.
Conclusions: Cerebral autoregulation is disturbed and probably right-
shifted in about one-third of post-CA patients of which a majority had
pre-CA hypertension. These patients are at risk for cerebral hypo-
perfusion when resuscitated to uniform hemodynamic targets. Our re-
sults illustrate the importance of a readily available monitoring
technique estimating bedside cerebral autoregulation.
EN16-NI11
Monitoring of Brain Oxygenation in Postcardiac Arrest Patients
During EEG-confirmed Status Epilepticus
W. Eertmans, J. Haesen, C. Genbrugge, F. Jans, J. Dens, C. De Deyne.
Ziekenhuis Oost-Limburg, Belgium.
Background: About one-third of out-of-hospital cardiac arrest patients
experience a status epilepticus (SE), associated with an increased mor-
tality. Increased cerebral metabolic demands, exceeding an increase in
cerebral perfusion, were described during SE in animal models, but no
clinical data have been reported on post-CA SE so far.1 The aim of the
study was to investigate cerebral oxygenation (SctO2), by NIRS, during
SE and to compare SctO2 in patients with SE to patients with a favor-
able post-CA EEG tracing.
Methods: With IRB approval, we prospectively applied bilateral NIRS
(Casmed ForeSight) and bilateral BIS-EEG (Covidien BIS-Vista) mon-
itoring at ICU admission in all consecutive post-CA patients, treated by
therapeutic hypothermia (331C for 24 h). SctO2 monitoring was main-
tained over a 48-hour period, divided in 3 time frames (6 to 12, 18 to 24,
and 36 to 48 h) for further analysis. Raw BIS-EEG data of all time
frames were analyzed by an experienced neurophysiologist for the
presence of slow diffuse (SD) EEG pattern or SE. We compared SctO2
values of patients with SE in one or more time frames to SctO2 values of
patients with persisting SD pattern. Mann-Whitney U test was used for
statistical analysis.
Results: Combined SctO2-EEG data of 75 post-CA patients were ana-
lyzed of which 14 patients had a SE during one or more time frames,
whereas 16 patients revealed a persisting SD EEG. Only 1 patient with
SE survived compared with 13 patients with SD EEG. No significant
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
differences in median SctO2 were observed between patients with SE and
with SD EEG rhythm during all time frames (6 to 12 h: 64% [61% to
70%] vs. 67% [63% to 69%]; 18 to 24 hours: 69% [65% to 76%] vs. 67%
[65% to 73%]; 36 to 48 hours: 72% [70% to 78%] vs. 72% [69% to
83%]). Nevertheless, in the earliest time frame a trend toward lower
SctO2 values was detected during SE. Overall, we could confirm the
already reported increase in SctO2 in both groups over the first 48 hours
post-CA.
Conclusions: This first study was not able to show significant differences
in SctO2 between patients with and without SE. Although the onset of
SE is reported to increase cellular oxygen demand, post-CA patients
might have sufficient cerebral reserve to cope with this request. However,
further research with more focus on the onset of SE, and its influence on
SctO2, could reveal more significant results.
Reference:
1. Schwartz TH. Neurovascular coupling and epilepsy: hemodynamic
markers for localizing and predicting seizure onset. Epilepsy Curr.
2007;7:91–94.
EN16-NI12
Posterior Reversible Encephalopathy Syndrome After Brain
Tumor Surgery
J. Benatar Haserfaty. Hospital Universitario Ramon y Cajal, Madrid,
Spain.
Background: The posterior reversible encephalopathy syndrome (PRES)
is a clinical-radiologic entity that manifests with decreased level of
consciousness, seizures, and visual disturbances, and radiologic as brain
edema predominantly in parieto-occipital white matter regions.
Case Report: A 55-year-old man with a history of chronic hypertension
and IV grade prostatic cancer was scheduled for brain surgery to remove a
right lobe frontal metastatic lesion. Brain tumor resection and partial
frontal craniectomy due to bone infiltration was performed, with re-
construction of bone defect with methacrylate cranioplasty. After the
surgery the patient obeyed on simple commands, with BIS values around
95, and acceptable respiratory volumes to allow safe extubation. Suddenly
the patient had a tonic-clonic left-sided seizure that lasted 5 minutes.
Propofol (200 mg) was administered to control the status and patient was
translated intubated to the ICU where a valproate (400 mg) bolus and a
continuous perfusion 15 mg/kg/d were given. Crisis were clinically con-
trolled and 6 hours later an EEG was performed showing d and spike
waves in both temporal areas. Propofol and remifentanyl were added to
control electrical epileptiform activity, a brain CT showed diffuse brain
edema with midline brain shift (> 6 mm). Intraventricular catheter was
inserted with ICPE30 mm Hg. Moderate hypercapnia, hyperosmolar
therapy lowered ICP to 18 mm Hg. During the next 4 days patient re-
mained intubated, and sedated with ICP values below 20 mm Hg, a ther-
apeutic window evidenced reappearance of clinical and EEG epileptic
activity, a new brain CT revealed bilateral temporo-parieto-occipital areas
of hypodensity with midline brain shift >6 mm. The clinical course during
the following days was slow, a neurological examination revealed left body
hemiparesis, GCS = 8 and absent swallowing reflex. Tracheostomy was
performed and finally neurological condition improved and patient regain
conscious level (GCS = 14) and a minor left arm hemiparesis. Days later
an ophthalmologic evaluation revealed bilateral cortical blindness.
Discussion: The nonspecific nature of the clinical PRES and hetero-
geneity of different radiographic patterns described require a differential
diagnosis in postoperative complicated neurosurgical patient. That is
why those dedicated to the care of neurocritical patients must know and
have a high index of suspicion of PRES not only to treat early but with
advancing knowledge, prevent it properly.
EN16-NI13
A Prospective Cohort Study on Long-term Outcome in Patients
With Severe Traumatic Brain Injury 10 to 15 Years After Trauma
E. Andersson, E. Svanborg, M. Ost, L. Csajbok, B. Nellgård. Institute of
Clinical Sciences, Gothenburg, Sweden.
Background: Brain trauma is the major cause of morbidity and mortality
in young adults. Few, if any, prospective long-term outcome studies
(> 10 y) exits after a severe TBI (sTBI, Glasgow Coma Scale <8). Thus,
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
a prospective study was initiated, 12 to 15 years posttrauma, on a well-
defined patient-cohort previously validated 1-year posttrauma. We
wanted to explore if sex or age per se influence long-term outcome. Also,
we planned to study long-term mortality versus an age-matched, sex-
matched, calendar year-matched, and area-matched control group (CG)
and then correlate them to 1-year outcome.
Methods: After ethical and next-of-kin approval the initial sTBI-patients
were included if; admitted to the ICU < 48 hours, having intracranial
monitoring, and artificial ventilation and residing in Sweden. Patients
received standardized treatment and at 1 year they were in-person in-
vestigated by a neurologist evaluating outcome (Glasgow Outcome
Scale, GOS). This patient-cohort was again investigated by a structured
validated telephone-GOS after 12 to 15 years. Mortality was found by
Death Registry. Statistical expertise evaluated whether age and sex were
risk factors for outcome and then established a large CG and correlated
patient 1-year outcome to long-term outcome versus this cohort.
Results and Discussion: A total of 95 study patients (mean, 40 y; 72%
male) were included after 29 were excluded (at 1 year, n = 22 and at 12
to 15 y, n = 7). At 1 year, 19 had died. At 12 to 15 years, 34 had died
(GOS1); 16 had severe disability (GOS3); 29 had moderate disability
(GOS4), and 16 had good recovery (GOS5). Higher age correlated to
worse outcome at both 1 year (P < 0.001) and at 12 to 15 years
(P < 0.021), whereas sex did not. We found patients both deteriorating
and improving from year 1 to 12 to 15 posttrauma. A systematic de-
crease in GOS was seen when including (P < 0.011) and excluding
(P < 0.042) the patients who died at 1 year. Kaplan-Meier plots show
that patients were alive, but with bad outcomes at 1 year (GOS, 2 to 3),
had enhanced mortality versus CG (P < 0.0001), not found in patients
with good outcomes (GOS, 4 to 5) at 1 year (P < 0.096).
Conclusions: As first research group we have prospectively found that
sTBI-patients with good outcome at 1 year have same mortality at 12 to
15 years posttrauma as the normal population. We further confirm that
higher age, but not sex is a risk factor for poor outcome. Finally, we
found individual outcome improvement over time, but also noted co-
hort-level deterioration.
EN16-NI14
S100b and Neuron Specific Enolase (NSE) For In-Hospital
Mortality Prediction. Which One is More Valuable?
V. Traskaite, A. Vilke, D. Bilskiene, G. Banevicius, A. Macas.
Lithuanian University of Health Sciences, Lithuania.
Background: Traumatic brain injury (TBI) is serious and often lethal
condition so predicting its outcomes can be really beneficial. Inves-
tigation of neuromarkers is simple but not widely used method. The aim
of this study was to compare serum S100B and Neuron Specific enolase
(NSE) values for in-hospital mortality prediction after TBI.
Methods: A prospective study took place in Anaesthesiology clinic of
Lithuanian University of Health Sciences Kaunas Clinics. Serum of 46
patients with severe TBI was investigated for neuromarkers S100B and
NSE at hospital admission and 24, 48, and 72 hours after the admission.
Outcomes were assessed and compared with specific values using non-
parametric statistical tests. All 4 measurements were obligatory for in-
clusion to the study. Level of Pr0.05 was assumed as statistically
significant. Approval of Regional bioethics committee was obtained
before study initiation.
Results: In total, 46 patients were involved in the study. The average age
was 55.33 ± 16.8 years and there was no significant difference between
women and men; however, the number of men was higher than women,
35 and 11, respectively. The median of each test was used to evaluate if
the specific value had an impact for in-hospital mortality. The medians of
S100B were 14.98 pg/mL (7.21; 67.66), 12.69 pg/mL (7.21; 66.88), 10.3 pg/
mL (7.21; 40.77), and 9.7 pg/mL (0.9; 12.69) at hospital admission, after
24, 48, and 72 hours, respectively. Only 12.69 and 10.3 pg/mL differed
statistically significantly but had no impact on increasing the risk of in-
hospital mortality. The medians of NSE were 9.72 mg/L (3.93; 21.54),
7.56 mg/L (3.99; 14.65), 6.24 mg/L (3.15; 17.23), 5.65 mg/L (3.08; 15.87) at
hospital admission, after 24, 48, and 72 hours, respectively. The values of
7.56 and 6.24 mg/L had a statistically significant difference and increased
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Supplement: EuroNeuro 2016
the risk of in-hospital mortality 4.0 and 9.35 times, respectively. The
measurement of both neuromarkers at hospital admission and after 72
hours had no significant difference, whereas the second and the third
measurements of both markers were statistically significant.
Conclusions: Both S100B and NSE can be predictors of in-hospital mor-
tality for patients with severe TBI. However, the time of neuromarkers
investigation is important as only after 24 and 48 hours the statistical sig-
nificance was found. Moreover, it can be assumed that NSE is slightly more
valuable than S100B for in-hospital mortality prediction in severe TBI.
EN16-NI15
External Validation of Rotterdam Computed Tomography Score
in the Prediction of Mortality in Severe Traumatic Brain Injury
J.D. Charry, J.H. Tejada, M.A. Pinzón, J.O. Vélez, J.H. Tovar, C.
Calvache. Universidad Surcolombiana/Hospital Universitario Hernando
Moncaleano Perdomo; Neiva, Colombia.
Background: Traumatic brain injury (TBI) is a problem of public health.
Is a disease that generates significant mortality and disability in Co-
lombia. Different calculators and prognostic models have been devel-
oped in order to establish the neurological outcome. The Rotterdam
computed tomography (CT) score was developed for prognostic pur-
poses in TBI. We aimed to examine the prognostic discrimination and
mortality prediction of the Rotterdam CT score in a cohort of trauma
patients with severe TBI in a university Hospital in Colombia.
Methods: We analyzed 127 patients with severe TBI treated in a regional
trauma center in Colombia over a 2-year period. The Bivariate and
multivariate analysis was made. The discriminatory power of the score
was assessed as the area under the receiver operating characteristic
curve. One-sample t tests, Shapiro Wilks, w2 were used to compare actual
outcomes in the cohort against predicted outcomes
Results: The median age in the validation cohort was 33 years and 84,
25% were male. The ISS median was 25, median GSC motor score was
3, the basal cisterns was closed in 46 (46%), and the midline shift >5 mm
was in 50 (36%). Six-month mortality was 29 (13%). Mortality pre-
diction by the Rotterdam CT score was 26%, P < 0.0001 (AUC, 0.825;
95% CI, 0.745-0.903).
Conclusions: The Rotterdam CT score predicted mortality at 6 months in
patients with severe head trauma in a university hospital in Colombia.
The Rotterdam CT score is useful for predicting early death and the
prognosis of patients with TBI.
EN16-NI16
Outcomes of Traumatic Brain Injury: Use the Marshall CT Score,
Rotterdam CT Score, CRASH, and IMPACT Models
J.H. Tejada, J.D. Charry, M.A. Pinzón, W.A. Tejada, J.H. Tovar, J.P.
Solano. Universidad Surcolombiana/Hospital Universitario Hernando
Moncaleano Perdomo, Neiva, Colombia.
Background: Traumatic brain injury (TBI) is a problem of public health.
Is a disease that generates significant mortality and disability in Latin
America. Different calculators and prognostic models have been devel-
oped in order to establish the neurological outcome. We aimed to test
prognostic models the Marshall CT score, Rotterdam CT score, Inter-
national Mission for Prognosis and Analysis of Clinical Trials in
Traumatic Brain Injury (IMPACT), and Corticosteroid Randomisation
after Significant Head (CRASH) Injury models for 14-day mortality,
6-month mortality, and 6-month unfavorable outcome in a cohort of
trauma patients with TBI in a university Hospital in Colombia.
Methods: We analyzed 309 patients with significant TBI treated in a
regional trauma center in Colombia over a 2-year period. The bivariate
and multivariate analysis was made. The discriminatory power of the
models was assessed as the area under the receiver operating charac-
teristic curve. One-sample t tests, Shapiro Wilks, w2 were used to com-
pare actual outcomes in the cohort against predicted outcomes
Results: The median age in the validation cohort was 32 years and 77
(67%) were male. All 4 prognostic models showed a good accuracy in
predicting outcome. In particular the IMPACT prognosis models had the
best rate of predicted unfavorable outcome (area under the receiver op-
erating characteristic curve, 0.864; 95% CI, 0.819-0.909) and mortality
S22 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
(area under the receiver operating characteristic curve, 0.902; 95% CI,
0.862-0.943) in patients with TBI.
Conclusions: All 4 prognostic models are applicable to eligible TBI pa-
tients in Colombia. The IMPACT prognosis model is the better corre-
lations than the other prognosis models. The IMPACT had more
sensibility to predict the 6-month mortality and 6-month unfavorable
outcome in patients with TBI in a university Hospital in Colombia.
EN16-NI17
Relationship Between The Bispectral Index, The Glasgow Coma
Scale, and The Intracranial Pressure in Patients With Severe
Brain Injury
H. Kang, C. Jin Park, Y. Sup Jeong, D. Hyun Baek. Chungbuk National
University Hospital, South Korea.
Background: There have been some studies suggesting that the bispectral
index (BIS) can reflect the level of consciousness in brain-injured patients,
as assessed by the Glasgow Coma Scale (GCS). However, the correlation
degrees are very wide depending on the study groups and the software
version of the BIS. Although the level of consciousness is assessed by the
GCS, changes in the intracranial pressure (ICP) can allow for early di-
agnosis of mental status alteration as it precedes clinical deterioration.
This prospective and observational study was performed with the aim of
determining if there is any correlation between these 3 commonly used
brain monitoring measures in the patients with severe brain injury.
Methods: Thirty patients with a focal neurological injury (eg, intracerebral
hematoma) or a more global injury (eg, traumatic diffuse axonal injury),
who had been admitted to the neurointensive care unit and had not re-
ceived any sedative medication for over 24 hours, were prospectively
evaluated for the GCS every hour for 5 hours by a blinded observer.
Meanwhile, an investigator noted the patient’s BIS and ICP simulta-
neously. The BIS was measured with a BIS monitor, Model A-3000 vista
(Aspect Medical Systems, Norwood) and the ICP with Spiegelberg Brain
Pressure Monitor (Spiegelberg, Germany). The correlations among the
BIS, the GCS, and the ICP were determined using Spearman rank cor-
relation coefficient and Pearson correlation coefficient, accordingly.
Results and Discussion: In spite of statistical significance (P < 0.01), the
BIS was moderately correlated with the GCS (r = 0.423) and poorly
correlated with the ICP (r = 0.212). ICP were never correlated with GCS
(r =  0.118). There was a wide range of the BIS values for any level of
the GCS and the ICP. Two reasonable explanations for this poor cor-
relation of the BIS with the ICP and the GCS with the ICP can be
proposed. First, the ICPs of patients recruited in this study were rela-
tively well maintained in the range of 8 to 13 mm Hg. Second, each value
of the ICPs had already been reflected in the BIS and the GCS.
Conclusions: Judging from the moderate correlation between the BIS and
the GCS, and wide variability, the BIS may carefully be used for as-
sessing the level of consciousness in brain-injured patients, as assessed by
the Glasgow Coma Scale (GCS).
EN16-NI18
Predicted Unfavorable Neurological Outcome is Overestimated
by The Marshall CT Score, CRASH, and IMPACT Models in
Severe TBI Patients
M.A. Pinzón, J.D. Charry, M. Falla, W.A. Tejada, J.O. Vélez, J.H.
Tejada. Universidad Surcolombiana/Hospital Universitario Hernando
Moncaleano Perdomo, Neiva, Colombia.
Background: Traumatic brain injury (TBI) is a problem of public health.
Is a disease that generates significant mortality and disability in
Colombia. Different calculators and prognostic models have been de-
veloped in order to establish the neurological outcome. We aimed to test
prognostic models (the Marshall CT score, International Mission for
Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury, and
Corticosteroid Randomisation After Significant Head Injury models) for
14-day mortality, 6-month mortality, and 6-month unfavorable outcome
in a cohort of trauma patients with TBI in a university Hospital in
Colombia.
Methods: We analyzed 127 patients with significant TBI treated in a
regional trauma center in Colombia over a 2-year period. The discrim-
inatory power of the models was assessed as the area under the receiver
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
operating characteristic curve. One-sample t tests, Shapiro Wilks, w2
were used to compare actual outcomes in the cohort against predicted
outcomes.
Results: The median age in the validation cohort was 33 years and 84,
25% was male. The ISS median was 25, median GSC motor score was 3.
Six-month mortality was 29.13%. Six-month unfavorable outcome was
37%. Mortality prediction by Marshall CT score was 52.8%, P < 0.104
(AUC, 0.585; 95% CI, 0.489-0.681), the mortality prediction by CRASH
prognosis calculator was 59.9%, P < 0.001 (AUC, 0.699; 95% CI, 0.588-
0.809) the unfavorable outcome prediction by IMPACT 80, 5%,
P < 0.048 (AUC, 0.605; 95% CI, 0.504-0.707).
Conclusions: The Marshall CT score, IMPACT and CRASH models
overestimate the adverse neurological outcome in patients with severe
head trauma in a university hospital in Colombia.
EN16-NI19
Clinical and Scanographic Factors of Early Mortality in
Traumatic Brain Injury Patients in Dijon Neurotrauma Unit
S. Mirekw, J. Darphin*, N. Opprechtw, A. Nadjiw, S. Ahow, B. Bouhe-
madw, C. Girardw. *University Edouard Herriot Hospital. wDijon Uni-
versity Hospital, France.
Background: Traumatic brain injury (TBI) remains an important global
public health problem with significant morbidity and mortality. The early
establishment of a prognosis is an important issue in order to better guide
the management and inform relatives. The Glasgow Coma Score (GCS) is
a known prognostic factor. But there are sometimes bias and the evalua-
tion of GCS is impossible when the patient is often sedated on arrival in
the ICU.1 The aim of our study was to define the clinical, biological, and
scanographic factors2 to evaluate the early mortality risk of TBI.
Methods: The study was a retrospective observational study of patients
hospitalized for TBI in the neurotrauma ICU of Dijon University Hos-
pital from January 2011 to September 2014. Excluded patients were
children under 15 years, cardiac arrest, and those not eligible for a
scanner. We collected epidemiological data, the lesion data, the man-
agement delay, the type of accident, the ICP monitoring delay and its first
value, doses of norepinephrine, biology, transfusions. The primary out-
come was mortality. A threshold of P < 0.05 was accepted as significant.
Results: A total of 355 patients were included, 3 patients were excluded
for lack of CT-scan, 9 cardiac arrest, and 18 were under 15 years old.
After analyzing data on the 325 remaining patients, significantly related
to mortality variables were age (P < 0.001), the GCS (P < 0.001), he-
moglobin (P < 0.001), PTT (P < 0.001), fibrinogen (P = 0.009), lactates
(P = 0.002), PO2/FiO2 (P = 0.038), PRBC (P = 0.006) and FFP
(P = 0.001), compression of the basal cisterns (P = 0.043), deviation of
the midline (P = 0.001), and absence of epidural hematoma (P = 0.014).
Discussion: The score of GCS is an important prognostic factor, but it
appears that it is often insufficient in itself to assess the prognosis of TBI.
It is therefore important to recognize other clinical, biological, or
imaging signs that would allow to assess more quickly the severity of
TBI. Therapy and monitoring can be adapted with these factors.
References:
1. Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of
Glasgow Coma Scale after brain trauma: change in trend over the
past ten years. J Neurol Neurosurg Psychiatry. 2004;75:161–162.
2. Gómez PA, de-la-Cruz J, Lora D, et al. Validation of a prognostic
score for early mortality in severe head injury cases. J Neurosurg.
2014;121:1314–1322.
EN16-NI20
Hemodynamic Disturbances in the Early Phase After Sub-
arachnoid Hemorrhage: Regional Cerebral Blood Flow Studied by
Bedside Xenon-Enhanced CT
H. Engquist, E. Rostami, P. Enblad. Uppsala University, Sweden.
Background: Subarachnoid hemorrhage (SAH) still causes significant mor-
tality and morbidity despite improvements in treatment of vascular aneurysms
and neurointensive care. Lots of effort has been made to elucidate the
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
mechanisms that lead to delayed cerebral ischemia. Bedside Xenon enhanced
CT (XeCT) enables repeated measurements of regional cerebral blood flow
(rCBF). The aim of our research project is to implement routine measurements
of rCBF at different stages of the clinical course after SAH. In the present
study CBF characteristics in the early phase (days 0 to 3) after SAH are
explored.
Methods: Patients diagnosed with SAH, verified by CT, and requiring
mechanical ventilation were included in the study. All patients were man-
aged according to our standardized protocol for SAH including intravenous
nimodipin and insertion of ventricular drainages to monitor ICP and drain
CSF in unconscious patients. Aneurysms were treated early with endovas-
cular embolization or surgical clipping. Patients were kept mildly hyper-
volemic if not contraindicated by intracranial mass effect or elevated ICP.
Bedside XeCT measurements were performed within day 0 to 3. Inhaled
Xenon gas is used as an inert contrast agent and repeated scans by the
bedside CT scanner are synchronized to the wash-in phase of Xenon. Scans
from 3 levels of the brain were used to calculate rCBF in the cortical tissue.
Results: Data from 58 patients (41 women, 17 men) were obtained, mean age
59 (31 to 84) years. Systemic hemodynamic parameters and ICP as well as
ventilatory parameters were stable during the measurements (CPP,
76.2 ± 13.3 mm Hg; pCO2, 5.2 ± 0.5 kPa). Median global cortical CBF was
34.7 mL/100 g/min, IQR 14.6. The differences in CBF between age groups
were small, but with a more narrow distribution among the elderly. Regional
differences in CBF were common; in 40 patients rCBF below 20 mL/100 g/
min was found in >10% of the cortical area and in 17 patients such low flow
area exceeded 30%. There were no differences in rCBF between ipsilateral and
contralateral vascular territories to the aneurysm location (MCA, 36.1 mL/
100 g/min; IQR, 22.4 and MCA, 36.0 mL/100 g/min; IQR, 20.9).
Conclusions: CBF disturbances are common in the early phase after SAH.
There was no clear pattern in the variation of global CBF. In many pa-
tients, substantial areas with low regional CBF were detected. The rCBF
disturbances did not correlate to the location of the aneurysm.
EN16-NI21
Management of Acute Aneurysmal Subarachnoid Hemorrhage at
a Regional Neurosciences Center
S. Ley*, SP. Youngw. Institute of Neurological Sciences, Queen Elizabeth
University Hospital, Glasgow, UK. *Anaesthetics ST4. wNeuroanesthesia
and Neurocritical Care Consultant, UK.
Background: Aneurysmal subarachnoid hemorrhage (aSAH) has sig-
nificant morbidity and mortality, which can be reduced by early inter-
vention. The National Confidential Enquiry into Patient Outcome and
Death (NCEPOD) “Managing the Flow” report,1 which examined the
care of aSAH patients in England, Wales, and Northern Ireland found
that only 83% of aneurysms were secured within 48 hours. It recom-
mended that weekend interventional neuroradiology (INR) services
should be expanded to improve this figure. Our neuroscience centre
(NSC) in the West of Scotland has a reduced weekend INR service. Our
aim was to see how we compared with the NCEPOD results and whether
weekend INR service was affecting our performance.
Methods: Prospective audit was undertaken from June 1 to August 2,
2015 for all patients admitted to our NSC with aSAH. Data were col-
lected on key timings and delays.
Results and Discussion: 27 patients were identified. Median age was 56
years, 78% were ASA r2, and 63% were WFNS grade 1. Twenty-five
patients had a primary isolation procedure, performed by INR in 78%
of cases. 40% had their procedure >48 hours after symptom onset. Of
these, 26% took >12 hours to present, 37% took >4 hours to be
diagnosed, and 22% waited >4 hours to be transferred out of hours.
24% had their procedure >48 hours after NSC admission (compared
with 17% in the NCEPOD report). Of these, 67% were delayed for
nonclinical reasons, of which 50% were related to decreased weekend
INR provision.
Conclusions: This audit showed patients were generally fit with low-grade
aSAH, so had most to gain from early isolation. However, there were
significant delays in both secondary and tertiary care. Half of nonclinical
delays at the NSC related to weekend INR provision. This could be
improved by extending the service, which our NSC is now considering.
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Supplement: EuroNeuro 2016
Reference:
1. Gough MJ, Goodwin APL, Shotton H, et al. Managing the flow? A
review of the care of patients who were diagnosed with an aneurysmal
subarachnoid hemorrhage. NCEPOD, 2013.
EN16-NI22
Long-Term Outcome 12-15 Years After Aneurysmal
Subarachnoid Hemorrhage (ASAH): A Prospective Cohort Study
E. Svanborg, E. Andersson, L. Csajbok, M. Ost, B. Nellgard. Institute of
Clinical Sciences, Gothenburg, Sweden.
Background: Aneurysmal subarachnoid hemorrhage (aSAH), has high
morbidity and mortality and variable incidence worldwide. Incidence
increases also with female sex, age, and heredity. Outcome has im-
proved, but few studies on long-term outcome exist. This prospective
study was initiated (12 to 15 y post-aSAH) on a well-defined patient-
cohort previously validated 1-year post-aSAH. We planned to explore if
sex, age, or Hunt and Hess grade per se influenced long-term outcome.
Also, we intended to study long-term mortality versus an age-matched,
sex-matched, and area-matched control group (CG) and then correlate
this to 1-year outcome results.
Methods: After ethical and next-of-kin approval initial aSAH-patients
were included if; admitted to the ICU < 48 hours, had a ruptured
aneurysm and residing in Sweden. Patients received standardized treat-
ment and at 1-year GOS (Glasgow Outcome Scale) was investigated by a
neurologist. The cohort was again investigated by telephone-GOS after
12 to 15 years. Mortality was found by Death Registry. Statistical ex-
pertise evaluated risk factors influence on long-term outcome. By using
Kaplan-Meier (KM) plots statistical differences in mortality of aSAH-
patients versus CG was explored, as well as correlating patient 1-year
outcome to long-term mortality and in CG.
Results and Discussion: Study-patients, n = 158 (mean, 55 y; 72% fe-
male) were included (excluded, n = 54), and were all reevaluated at 1
year. At 1 year, 23 had died. At 12 to 15 years, 55 had died (GOS1); of
the survivors 16 had poor outcome (GOS 2 to 3) and 87 had good
outcome (GOS 4 to 5). Hunt & Hess grade (P < 0.0008) correlated to
worse outcome after 12 to 15 years, whereas sex and age did not. We
found patients both deteriorating and improving from 1 year to 12 to 15
post-aSAH, but a decrease in outcome was noted when dichotomizing
patients into good (GOS 4 to 5) and bad (GOS 1 to 3) (P < 0.0002).
KM-plots show that aSAH greatly enhance mortality versus GC at 12 to
15 years (P < 0.0001). Patients with poor outcome at 1 year had higher
mortality than GC (P < 0.0001), not seen in patients with good outcome
at 1 year.
Conclusions: As first research group we have prospectively found that
aSAH-patients with good outcome at 1 year have same mortality at 12
to 15 years post-aSAH as normal population. We confirm that Hunt &
Hess grade, but not sex or age, are risk-factors for poor outcome. Fi-
nally, we found individual outcome improvement over time, but on
cohort-level a deterioration was found.
EN16-NI23
Higher Plasma M-Ficolin in Patients Developing Vasospasm and
Cerebral Ischemia After Spontaneous Subarachnoid Hemorrhage
L. Llull*, S. Thielw, Á. Cerveraz, S. Amaro*, A. Planasy, Á. Chamorro*.
*Comprehensive Stroke Center, Hospital Clinic, Barcelona, Spain. wDe-
partment of Biomedicine, Health, Aarhus University, Aarhus, Denmark.
zNeurosciences Department, Southmead Hospital, North Bristol NHS
Trust, Bristol, UK. yDepartment of Brain Ischemia and Neuro-
degeneration IIBB-CSIC, IDIBAPS, Barcelona, Spain.
Background: Spontaneous subarachnoid hemorrhage (SAH) is a highly
disabling neurological disease. A possible pathogenic role of comple-
ment system activation in SAH has been recently proposed. In the
present study, we examined the association between the development of
angiographic vasospasm and new cerebral ischemic lesions after SAH
and the plasma levels of complement associated proteins.
Methods: A total of 45 spontaneous SAH patients and 25 healthy con-
trols were included. Plasma samples were obtained at 24 hours and at 90
days after bleeding and levels of MBL, MASP-2, MASP-3, Map44, and
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
MBL were analyzed. In 19 patients with hydrocephalus and external
ventricular drainage placement, cerebrospinal fluid samples were ob-
tained at 24 hours to measure M-Ficolin levels. Neurological condition
and complications were assessed daily. Angiographic vasospasm was
evaluated using transcranial Doppler or angio-CT and was considered
symptomatic when new focal deficits were associated. New ischemic le-
sions were defined as ischemic lesions appearing in the follow-up neu-
roimaging. Functional outcome was assessed using modified Rankin
Scale at discharge and at 90 days.
Results: M-Ficolin levels (ng/mL) measured at 24 hours after bleeding
onset were associated to neurological status at admission measured using
WFNS scale (1158.48 [360.21] vs. 1654.17 [870.56], P = 0.004). M-Fi-
colin levels were higher in those patients who later developed clinical
vasospasm (1232.08 [436.17] vs. 2167.17 [1194.56], P < 0.001), angio-
graphic vasospasm (1119.44 [374.48] vs. 1514 [755.44], P = 0.031) and
new cerebral ischemia (1067.33 [325.30] vs. 1610 [766.03], P = 0.012).
Cerebrospinal fluid M-Ficolin levels were not significantly different in
patients with angiographic vasospasm, but values tended to be lower (50
[24.5 to 68] vs. 102 [30 to 131], P = 0.075). No statistically significant
differences were found in plasma concentrations of M-Ficolin between
patients and controls. However, M-Ficolin concentration was statisti-
cally higher in patients with angiographic vasospasm, symptomatic
vasospasm, and new cerebral ischemia compared with healthy controls.
Conclusions: In our sample, plasma levels of M-Ficolin were significantly
higher in SAH patients with poor clinical status on admission and in
those developing angiographic and symptomatic vasospasm and new
cerebral.
EN16-NI24
Efficacy of Stellate Ganglion Block in Cerebral Vasospasm: A
Prospective Clinical Trial
N. Samagh, NB. Panda, VK. Grover, V. Gupta, N. Bharti, R. Chhabra,
K. Jangra. Postgraduate Institute of Medical Education and Research,
India.
Background: Cerebral vasospasm is the narrowing of cerebral arteries
causing ischemia that manifests as hemiparesis, apraxia, aphasia, hemi-
anopsia, or a decrease of GCS. The sympathetic denervation by Stellate
Ganglion Block (SGB) leads to dilatation of cerebral vessels and an im-
provement in cerebral blood flow. The goals of this study were to evaluate
the efficacy of SGB to relieve vasospasm using neurological assessment,
TCD and Digital Subtraction Angiography (DSA) parameters.
Methods: Twenty patients who underwent clipping for cerebral aneurysm
and developed cerebral vasospasm later were included in the study. Blood
flow velocities were noted on TCD. Vessel diameter was measured at mid
A1segment of ACA and mid M1segment of MCA by DSA. Vasospasm
was classified as mild (< 25%), moderate (25% to 50%), or severe (> 50%)
with respect to 2D diameter. Parenchymal filling time (PFT) was calculated
as the time between initiation of contrast injection till the appearance of
parenchymal blush. Venous sinus filling time (VSFT) was calculated as the
time between initiation of contrast injection till the appearance of superior
sagittal sinus. After diagnosis of vasospasm, patients were given ultrasound
guided SGB using 10 mL of 0.5% Inj Bupivacaine on the same side of
vasospasm and confirmed by the development of Horner’s syndrome. After
30 minutes the neurological status, hemodynamic and TCD parameters
were noted. DSA was repeated to measure the vessel diameter, vasospasm
grade, PFT, and VSFT.
Results and Discussion: All patients developed Horner’s syndrome. Five
patients had neurological improvement after SGB. On TCD the peak
systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Linde-
gaard ratio (P = 0.022) significantly decreased after SGB. The mean vessel
diameter measured at the mid A1 segment of ACA (P = 0.002) and mid
M1 segment of MCA (P = 0.003) increased significantly after SGB. The
mean PFT and mean VSFT decreased after SGB (P = 0.163/0.104).
Conclusions: We conclude that SGB causes clinical improvement in few
patients. Improvement has been seen in blood flow velocities on TCD
and vessel diameter on DSA of the large blood vessels after SGB. There
are no significant changes in PFT and VSFT indicating lack of impact on
cerebral microvasculature that might lead to this clinic-angiographic
dissociation.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NI25
Cardiogenic Subarachnoid Bleed: A Case Report
I. Ghosh, D. Ghoshdastidar, A.M. Rangarajan. Institute of Neuro-
sciences, Kolkata, West Bengal, India.
Background: Ruptured mycotic aneurysms account for approximately
5% of the neurological complications of infective endocarditis.1 Rarely,
a ruptured mycotic aneurysm can be the first manifestation of infective
endocarditis and is associated with an 80% mortality rate.2 A case of
SAH with infective endocarditis undergoing successful multidisciplinary
management is reported.
Case Report: A 41-year-old man presented with a sudden onset of
vomiting, followed by loss of consciousness. Soon after admission the
patient developed severe respiratory distress and bilateral coarse crep-
itation on auscultation. EKG showed sinus tachycardia with features of
left ventricular hypertrophy. He was immediately intubated and put on
mechanical ventilation. Urgent chest x-ray showed features of pulmo-
nary edema and was administered diuretics. CT scan showed SAH and
IVH. Simultaneous CT-angiography demonstrated left posterior cere-
bral artery aneurysm. Echocardiography revealed severe aortic regur-
gitation along with vegetation on the aortic cusps. Diagnosis of infective
endocarditis was made provisionally and started on appropriate anti-
biotics after sending blood for culture. Once stabilized was taken up for
definitive treatment. Cerebral angiogram revealed a mycotic aneurysm
of posterior cerebral artery that was embolized. He improved over the
next few days and was discharged being neurologically intact. One
month after discharge he underwent aortic valve replacement and thus
attained complete recovery.
Discussion: The overall prevalence of hemorrhage in CNS involvement
of infective endocarditis is 3% to 7%. Subarachnoid hemorrhage or
subdural hematoma is rare. The incidence of clinically diagnosed in-
tracranial mycotic aneurysms in patients with infective endocarditis is
approximately 2%. Our case depicts successful management of a rare
but fatal disorder through interdisciplinary collaboration.
Learning Points: Hemorrhagic stroke is a complication of infectious
endocarditis. Urgent echocardiography is mandatory in all patients with
subarachnoid bleed to rule out underlying cardiac pathology.
References:
1. Pruit AA, Rubin RH, Karchmer AW, et al. Neurologic complications
of bacterial endocarditis. Medicine. 1978;57: 329–343.
2. Bohmfalk GL, Story JL, Wissinger JP, et al. Bacterial intra-
cranial aneurysms. J Neurosurg. 1978;48:369–382.
EN16-NI26
Optic Nerve Sheath Diameter Evaluated by Transorbital Sonog-
raphy in Healthy Volunteers From Pakistan
A.M. Ali, M. Hashmi, A. Hussain. Aga Khan University Hospital,
Pakistan.
Background: Raised intracranial pressure (ICP) is a common manifes-
tation of severe brain injury. Rapid diagnosis and timely intervention is
required to prevent secondary brain damage and death. Measurement of
optic nerve sheath diameter (ONSD) by ultrasound is increasingly used
as a marker to detect raised ICP. Knowledge of normal ONSD in a
healthy population is essential to interpret this measurement. Our aim
was to evaluate normal optic nerve sheath diameter in healthy volunteers
in Pakistan.
Methods: This was a prospective, observational study in which 100
healthy volunteers of Pakistani origin, aged above 18 years were re-
cruited in the study. The ultrasound probe was placed on the superior
and lateral aspect of the orbit against the upper eyelid with the eye
closed. For each subject, the primary investigator performed 3 meas-
urements on each eye. The measurements of each eye were then averaged
to yield a mean ONSD.
Results: The median ONSD of right eye was 4.84 mm and 95% of in-
dividuals had mean ONSD in the range of 4.84 to 4.97 mm, whereas the
median ONSD of left eye was 4.86 mm and 95% of individuals had a
mean ONSD in the range of 4.85 to 4.96 mm. There was no difference
among the 3 repeated measures of ONSD in each eye. There was no
relationship between ONSD with age, sex, and measurement taken be-
tween left and right eyes.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
Conclusions: 95% of study sample have an ONSD <4.82 mm. ONSD
>4.82 mm in this population should be considered abnormal and may
reflect raised intracranial pressure.
EN16-NI27
Pulsatility Index and Resistive Index Measured by Transcranial
Doppler and Optic Nerve Sheath Diameter Measured by
Ultrasonography Correlates With Opening Intraventricular
Intracranial Pressure
N. Kaloria, N.B. Panda, S. Sahu, H. Bhagat, V.K. Grover, R. Chhabra,
S. Dhandapani. Postgraduate Institute Of Medical Education And Re-
search, Chandigarh, India.
Background: Various noninvasive methods have been used to estimate
intracranial pressure (ICP), out of which Pulsatility Index (PI) and
Resistive Index (RI) by Transcranial Doppler (TCD) and optic nerve
sheath diameter (ONSD) by ultrasonography (USG) have correlated
well with ICP. Increase in ICP leads to decrease in diastolic velocity and
mean velocity in major intracranial vessels resulting in increased PI and
RI. Raised ICP also increases the ONSD as it is the direct continuation
of duramater. Our study endeavours to find out the correlation of TCD
derived indices (PI and RI) and the ultrasonographic ONSD with the
opening cerebrospinal fluid pressure measured by a direct intra-
ventricular catheter.
Methods: A prospective, observational, double-blinded study was con-
ducted on 36 patients aged 8 to 65 years with clinical features of raised
ICP posted for endoscopic third ventriculostomy or ventriculoperitoneal
shunt surgery. The TCD derived indices measured by MCA flow velocity
through the temporal window preoperatively and mean ONSD meas-
ured by USG both preoperatively and intraoperatively. The opening ICP
was derived from direct catheterization of lateral ventricles. Pearson
correlation test was used to correlate PI, RI, and ONSD with ICP and
also to find the correlation of preoperative ONSD with intraoperative
ONSD values. A ROC curve was drawn to find a cutoff value of PI, RI,
and ONSD to predict an ICP of 20 mm Hg.
Results and Discussion: The opening intraventricular ICP values ranged
from 9 to 44 mm Hg. PI and RI has a significant correlation with ICP
(r = 0.678, P = 0.000 and r = 0.580, P = 0.000, respectively). There was
also significant correlation of both preoperative and intraoperative
ONSD with ICP (r = 0.497, P = 0.002 and r = 0.450, P = 0.006, re-
spectively) and preoperative ONSD significantly correlated with intra-
operative ONSD (r = 0.924, P = 0.000). An ICP of Z20 mm of Hg was
predicted by a PI of 0.92 and RI of 0.58 with similar sensitivity of 73.7%
and specificity of 70.6% (area under ROC curve, 0.807 and 0.811;
P = 0.002 and 0.001, respectively), whereas a mean ONSD of 5.9 mm
with sensitivity of 63.2% and specificity of 76.5% predicted ICP
Z20 mm of Hg (area under ROC curve, 0.737; P = 0.015).
Conclusions: Both TCD derived PI, RI, and the ONSD measured by
USG correlates well with opening intraventricular ICP. Hence both
modalities can be used to diagnose intracranial hypertension and guide
ICP reduction therapy as an alternate to invasive ICP monitoring.
EN16-NI28
Measurement of Optic Nerve Sheath Diameter to Find its
Correlation With Raised Intracranial Pressure in Neurocritical
Patients
D. Lahkar*, M. Dasw, H. Sapra*. *Department of Neuroanaesthesia and
Neurocritical Care, Medanta the Medicity Gurgaon, India. wAnaesthesia
and ICU, Khoula Hospital, Muscat, Oman.
Background: Optic nerve sheath diameter (ONSD) measurement by
bedside ocular ultrasound have been shown to correlate with clinical and
radiologic signs and symptoms of increased intracranial pressure (ICP)
in majority of studies reported till date. Our aim was to calculate the
ONSD by ultrasound imaging and correlating it to (1) CT features of
raised ICP, (2) GCS, and (3) ICP measured by invasive technique when
available.
Methods: A total of 100 patients admitted to the neurocritical care
unit were enrolled in this prospective, observational study. Binocular
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Supplement: EuroNeuro 2016
ultrasound ONSD were calculated. GCS and ICP values in patients with
ICP monitoring device (if present),during the examination period were
also recorded. Ultrasound examination were preceded or followed by
half an hour of CT examination. A mean ONSD of >5.0 mm were
considered abnormal in our study.
Results: Association analysis revealed a statistically significant agree-
ment between the measured ONSD when compared with CT head
findings (P = 0.021 and 85% agreement) and GCS findings (P = 0.228
and 51% agreement). In 8 of 100 patients who had invasive mon-
itors,ONSD were found to be raised in 7 of these patients although only
5 patients had ICP readings >15 mm, considered to be the threshold for
active intervention of active reduction if ICP.
Conclusions: ONSD measurement can prove to be a very useful adjunct
in monitoring ICP in conjunction with invasive monitoring whenever
available. It can also be a very useful tool in scenarios where invasive
monitoring is not feasible and CT is delayed/not available, in at least
doing a rapid assessment of ICP.
EN16-NI29
Guillain-Barré Syndrome: A Clinical Evaluation and Comparison
With Current Literature
F. De Burghgraeve*, C. Vandycke*, L. Vanopdenboschw, M.
Bourgeois*. *Department of Anesthesia and Critical Care, Ziekenhuis AZ
Sint-Jan, Brugge, Belgium. wDepartment of Neurology, Ziekenhuis AZ
Sint-Jan, Brugge, Belgium.
Background: Guillain-Barré syndrome (GBS) or acute inflammatory
demyelinating polyneuropathy is a postinfectious autoimmune disorder
that affects the peripheral nerve system, leading to paraesthesia and
muscle weakness. The weakness can progress to complete paralysis with
respiratory insufficiency and need for mechanical ventilation. Auto-
nomic dysfunction is present in 70% of the cases. Diagnosis is based on
clinical examination, of cerebrospinal fluid analysis and neuro-
physiological testing. Therapy includes supportive care and specific
treatment with intravenous immunoglobulin or plasma exchange.
Methods: We retrospectively studied all patients diagnosed with GBS
and admitted to our hospital between January 2001 and December 2014.
All patients were evaluated for age, sex, history of infection in the past
weeks before the start of GBS, presence of autonomic dysfunction, need
for intensive care, need for ventilation, and the treatment that was given.
These data were compared with the current literature.
Results: We identified 57 patients. Two patients had incomplete data.
Five patients were subsequently diagnosed with chronic inflammatory
demyelinating polyneuropathy. The male/female ratio was 30:20. The
median age of at diagnosis was 58 years with an interquartile range of
26. A total of 27 patients (54%) had a brief history of infection in the 4
weeks preceding the diagnosis of GBS. In total, 38 patients (76%) re-
ceived immunoglobulins, 1 patient (2%) received plasma exchange be-
cause of a poor response to immunoglobulins. In total, 37 patients
(74%) were admitted to the intensive care unit and 11 patients (22%)
needed invasive ventilation. Four patients (8%) showed life-threatening
autonomic dysfunction.
Discussion: Most of our data corresponded well with the current liter-
ature on GBS. Only the occurrence of autonomic dysfunction was dif-
ferent. This presumably is due to the different definition we used for this
dysfunction. In this study we only screened for major and life-threat-
ening autonomic dysfunctions. Mild dysfunctions were not detected in
our data collection.
EN16-NI30
A Fulminant Case of Acute Disseminated Encephalomyelitis
(ADEM) in an Adult
X. Chen. Cambridge University Hospitals/Khoo Teck Puat Hospital, UK/
China.
Background: Acute disseminated encephalomyelitis (ADEM) is a rare
immune-mediated inflammatory demyelinating condition predominantly
affecting the white matter of the brain and spinal cord.1 We report a case
of fulminant ADEM in an adult who had refractory intracranial hy-
pertension despite decompressive craniectomy.
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Case Report: A 32-year-old lady presented with acute urinary retention
and lower limb weakness after a 2-week history of diarrhea. A lumbar
puncture and magnetic resonance imaging lumbar spine were performed
which were unremarkable. The differential diagnoses were ADEM and
meningoencephalitis. The next day she was found to be unresponsive,
was intubated and admitted to the Neuro-Critical Care Unit. Urgent
cranial CT performed was normal but she was started on pulsed IV
methylprednisolone on the presumptive diagnosis of ADEM. A repeat
CT was performed the next morning that showed patchy low attenuation
in supratentorial white matter, whereas magnetic resonance imaging of
head/spine showed florid brain and spinal cord white matter lesions,
consistent with ADEM. Over the next 2 days, she had intermittent pu-
pillary dilation needing hypertonic saline. An ICP bolt was inserted. She
was started on plasma exchange. With constantly spiking ICPs, she was
placed on stage 4 ICP protocol (sedated, paralysed, cooled to hypo-
thermia) and an EVD was placed. Repeat CT showed progression of
lesions and brain swelling. Despite maximal medical therapy and EVD,
she had refractory intracranial hypertension and decompressive bi-
frontal craniectomy was performed. On her repeat scans, there was
progressive edema of brain extending to brainstem, transtentorial her-
niation of temporal lobes, severe compression of midbrain, and ex-
tracranial herniation of frontal lobes through the craniectomy defect.
The prognosis was deemed to be poor and discussion was made with her
family. Further treatment was not in her best interests and consensus
was made to withdraw treatment.
Discussion: Decompressive craniectomy has been reported to be life
saving in a few severe cases of ADEM.2 Our patient rapidly deteriorated
despite maximal medical and surgical therapy. Future research about the
severe form of this disease is needed.
References:
1. Ketelslegers IA, Visser IE, Neuteboom RF, et al. Disease course and
outcome of acute disseminated encephalomyelitis is more severe in
adults than in children. Mult Scler. 2011;17:441–448.
2. Ahmed AI, Eynon CA, Kinton L, et al. Decompressive craniectomy
for acute disseminated encephalomyelitis. Neurocrit Care. 2010;13(3),
393–395.
EN16-NI31
Predictors of Perioperative Hyperglicemia and its Effect on
Neurological Outcome in Aneurysmal Subarachnoid Hemorrhage
N.B. Panda, S. Koyyana, N. Bharti, N. Singla. PGIMER Chandigarh,
India.
Background: Hyperglycemia is common in patients with aneurysmal
subarachnoid and is associated with delayed cerebral ischemia and cer-
ebral infarction resulting in poor outcome. General anesthesia adds
further stress and worsens hyperglycemia. We planned to assess preva-
lence, predictors of perioperative hyperglycemia, and its effect on out-
come of such patients.
Methods: A prospective observational study was carried out in 150 adult
patients with the diagnosis of aneurysmal subarachnoid hemorrhage
posted for clipping of aneurysm. Blood sugar levels at admission, in-
traoperative, and postoperative period was assessed. RBS > 160 mg/dL
was considered as hyperglycemia and RBS > 200 mg/dL was considered
as severe hyperglycemia. Persistent hyperglycemia was defined as
hyperglycemia during any 2 of 3 study periods (preoperative, intra-
operative, and postoperative periods) where a transient hyperglycemia
was defined as hyperglycemia during any 1 study period. Predictors of
hyperglycemia and its effects on outcome of the patient measured by
number of ICU and hospital days, GOS and mortality at 1 and 3 months
after discharge were assessed.
Results and Discussion: Two patients were excluded due to incomplete
data and statistical analysis was carried out in 148 patients. Prevalence
of perioperative hyperglycemia and severe hyperglycemia was 75.7%
and 27%. Prevalence of persistent hyperglycemia and persistent severe
hyperglycemia was 37.83% and 7.43%. The predictors of hyperglycemia
in patients with aneurysmal SAH were identified by multivariate logistic
regression. History of DM, high RBS at admission, high MAP at ad-
mission, longer duration surgery, and anesthesia were predictors of
perioperative and persistent hyperglycemia. Perioperative hyperglycemia
were associated with increased ICU days (Pr0.007), hospital days
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
(Pr0.038), and poor GOS at 1 and 3 months after discharge. At 3
months follow-up 47.5% patients with perioperative severe hyper-
glycemia and 54.54% patients with persistent severe hyperglycemia had
poor outcome (GOS 1 to 3). Patients with transient hyperglycemia was
not associated with poor outcome whereas transient severe hyper-
glycemia (P = 0.002) was associated with poor outcome
Conclusion: Hyperglycemia is a potentially modifiable risk factor, which
is significantly associated with poor outcome after aneurysmal SAH.
EN16-NI32
Dysphagia Lusoria as a Rare Cause of Aspiration Pneumonia
With Respiratory Failure in a Stroke Patient
V. Spatenková, J. Jedlicka. Neurocenter, Neurointensive Care Unit, Re-
gional Hospital, Liberec, Czech Republic.
Background: Dysphagia is a risk factor of aspiration pneumonia and
acute respiratory failure (ARF) in stroke patients. We present a first case
report of dysphagia lusoria as a cause of aspiration pneumonia with
ARF in a stroke patient.
Case Report: A 67-year-old female patient was admitted to the stroke
unit with a minor left intracerebral hemorrhage in the left basal ganglia
of about 3.05 cm3 causing a phatic disorder and right hemiparesis. On
admission she had Glasgow Coma Scale 15 and negative screening test
for dysphagia. Sixteen hours after admission to the stroke unit, dysp-
noea suddenly occurred, with a decrease of SpO2 (72%), blood pressure
160/80 mm Hg, and body temperature 36.81C. X-ray of the lungs showed
a broad disfigured shadow of the anterior mediastinum on the basis of
the lusoria artery and aspiration pneumonia. Dysphagia lusoria was
confirmed by the spiral computed tomography angiography. The patient
was intubated and kept on mechanical ventilation. For lasting dyspha-
gia, tracheostomy was performed and the patient was successfully
weaned on 12 days. Intermittent dysphagia appeared on the targeted
questionnaire given by the family, but it had never been evaluated by a
physician.
Conclusions: One aim of neurocritical care is a prevention of pneumonia
for a risk of ARF. Dysphagia lusoria could be a rare cause of aspiration
pneumonia in a stroke patient.
EN16-NI33
Anti-NMDA Limbic Encephalitis: A Case of Secondary Epilepsy
F. Pereira*, S. Pedrosaz, H. Martinsz, C. Diasw.*Centro Hospitalar do
Porto. wCentro Hospitalar de São João. zCentro Hospitalar Baixo
Vouga, Portugal.
Background: Limbic encephalitis (LE) is characterized by memory loss,
confusion, seizures, and psychological disturbances.1 Anti-NMDAr
antibodies were found in serum and CSF of patients with LE. We report
a case of an 18-year-old girl with acquired epilepsy caused anti-NMDA
LE.
Case Report: An 18-year-old girl with a history of autoimmune thyroi-
ditis and epilepsy (unmedicated and asymptomatic since age 6), had a
generalized seizure with prolonged postictal period. Cerebral CT was
normal and she was medicated with carbamazepine. On the 2 following
weeks she presented with behavior changes, emotional lability, slowed
speech, and catatonic posture. Carbamazepine was substituted with
levetiracetam and mirtazapine was associated, with no improvement. By
the end of the second week she had several seizures and second cerebral
CT showed discrete prominence of the right temporal horn. She was
admitted to the Neurology ward but due to rapid development of
nonconvulsive status epilepticus with dysautonomia she was transferred
to the ICU for vital functions support and continuous EEG monitoring.
Cerebral magnetic resonance imaging was normal. Anti-NMDA anti-
bodies in CSF and plasma were positive confirming the diagnosis of
autoimmune LE. She started first-line treatment with IV corticosteroid
followed by IV immunoglobulin cycle. As status epilepticus and dys-
autonomia persisted she was submitted to second-line im-
munosuppression with IV cyclophosphamide and rituximab. After pelvic
sonography, CT and PET scans, ovarian teratoma was excluded. There
was a favorable neurological evolution in the ICU with adequate control
of seizures; however, humor lability and slowed speech persisted.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
Discussion: The frequency of LE is unknown and more than half of the
cases described have a paraneoplastic association.2,3 Ovarian teratomas
are observed in 50% to 60% of young women with anti-NMDA ence-
phalitis.1,2 However, in this case there was no primum cause identi-
fication. High diagnostic suspicion and knowledge of this type of
neurological pathology, which courses with psychiatric and epileptic
manifestations, it is of great importance.
Learning Points: Clinicians must have a high diagnostic suspicion when
approaching this type of neurological pathology. Immunosuppression
therapy has an important role in the autoimmune control. The prognosis
of LE relates to the identification of the primum cause.
References:
1. Miya K, Takahashi Y, Mori H. Anti-NMDAR autoimmune ence
phalitis. Brain Dev. 2014;36:645–652.
2. Dalmau J, Tüzün E, Wu HY, et al. Paraneoplastic anti-N-methyl-D-
aspartate receptor encephalitis associated with ovarian teratoma. Ann
Neurol. 2007;61:25–36.
3. Schmiedeskamp M, Cariga P, Ranta A. Anti-NMDA-receptor auto
immune encephalitis without neoplasm: a rare condition? N Z Med J.
2010;123:67–71.
EN16-NI34
Bacterial Meningitis Secondary to Postoperative Thigh Abscess:
A Case Report
R. O’Connor Emmett. Bronson Battle Creek Hospital, Battle Creek, MI, USA.
Background: Central nervous system dysfunction in patients with systemic
lupus erythematosus is highly variable. A literature review found no cases
of meningitis disseminated from a postoperative hip wound abscess.
Case Report: B.H. is a 59-year-old woman who presented to the emer-
gency department with fever and confusion. She resides in a nursing home.
She presented with a temperature of 102.4 and was confused with some
posturing of her hands. CT of head showed no acute bleeding. Magnetic
resonance imaging revealed no acute findings. Lumbar puncture was not
possible in the initial phase of her care as her INR was 3.4. There is no
report of cough, nausea, or vomiting per the nursing home. No immediate
family was present to interview. The patient was obtunded and could not
give an accurate history. Chart review uncovered an open reduction in-
ternal fixation of her left hip 2 months before this admission. Documents
from the nursing home revealed a significant history, including but not
limited to systemic lupus erythematosus, atrial fibrillation, cerebral vas-
cular accident without deficits, mitral valve repair. Her medications in-
cluded plaquenil, cellcept, and coumadin. Laboratory data showed and
INR of 3.4, C-reactive protein level 343, white blood cell count 9.8, and
creatinine of 3.3. Upon physical examination a warm, erythematous area
over her left lateral thigh was noted. CT scan revealed an abscess. Given
her immune compromised state and neurological examination, it was de-
cided to treat for potential meningitis. She was given dexamethasone fol-
lowed by vancomycin, rocephin, and acyclovir. She was admitted to the
intensive care unit for fluid resuscitation, neuromonitoring, and supportive
care while correcting her INR with fresh frozen plasma. An EEG was
performed upon admission and showed encephalopathy of indeterminate
cause. The following day a lumbar puncture was performed which revealed
yellow hazy fluid. Total protein count 382, glucose 33, total nucleated cells
1119, red blood cells 69. Gram stain showed Gram-positive cocci in pairs.
The other tests for fungal and viral causes were negative and the acyclovir
was stopped. Streptococcus pneumoniae cultures returned from the abscess
and blood were susceptible to rocephin. The vancomycin was stopped. Her
mental status improved dramatically over the next several days, and her
creatinine returned to baseline. She made a remarkable recovery over the
course of her hospitalization.
Discussion: As neurointensivists, our responsibility to patient care is to
consider the entire spectrum of disease processes. Although this patient
appeared as many do with central nervous system sequela of severe sepsis,
she suffers from immunosuppression and therefore requires a complete
workup to include a radiographic imaging, and EEG and if warranted
sampling of the cerebral spinal fluid. Immunocompromised patients are at
increased risk for meningitis over the general population. Her presentation
was complicated by the obvious source of infection in her leg and could
have explained her symptoms, but without full workup the management
could have been minimized to debridement, fluids and an incomplete an-
tibiotic course, causing increased morbidity and potentially death.
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EN16-NI35
Management of Cerebrospinal Fluid Fistulae: A Retrospective
Analysis With Lumbar Drainage
S. Nunes*, C. Diasw, S. Freitas*. *Hospital Central do Funchal.
wHospital São João, Portugal.
Background: Cerebrospinal fluid (CSF) fistulae result from abnormal
communication between the CSF and the skin due to meningeal dural
and arachnoid laceration. These fistulae occur more frequently after
trauma or surgery but they can also occur spontaneously without an
identifiable cause. Continuous subarachnoid lumbar drainage has been
suggested as an alternative to conservative (bed rest with the head of the
bed elevated) and surgical methods in treating and preventing their oc-
currence. The aim of this study was to retrospectively analyze the ex-
perience at a neurocritical unit care (NCCU) with lumbar drainages
(LDs) over a period of 5 years, and assess the efficacy and safety of LD
in the management of CSF fistulae.
Methods: A retrospective observational study was conducted in a 10-bed
NCCU. All the patients with LD admitted to the NCCU between April
2010 and June 2015 (n = 45) were analyzed. Data were obtained with
review of paper and electronic medical records. Statistical analysis was
performed using IBM SPSS Statistics 19: Independent samples and w2
tests.
Results and Discussion: Patients were predominantly male (62%) with
mean age 46.89 (± 17.45) years. Indications for LD were: clinical evi-
dence of CSF fistulae (14 nasal and 3 cutaneous leaks), refractory in-
tracranial hypertension (1), normal pressure hydrocephalus (1) and
prophylactic LD during the perioperative period of spinal or skull base
surgery (19). The mean time of LD was 5.2 (± 1.3) days. The rate of CSF
fistulae resolution with LD was 58.8%. Ten patients (21.3%) developed
CSF leak after LD removal. Seven of these patients had CSF fistulae
recurrence and 3 had no previous documented fistulae, but this result
had no statistical significance (P = 0.231). Complications related with
LD were either mechanical or infectious, and occurred in 20% of pa-
tients: meningitis (4, 8.9%), catheter obstruction or fracture (3, 6.7%),
nerve root irritation (1, 2.2%), and pneumocephalus (1, 2.2%). The
meningitis rate was 1.8/100 days of LD and all patients with meningitis
had previous nasal CSF leaks, which may contribute to the appearance
of this complication. Except for meningitis that resolved with antibiotics,
all other complications reverted with catheter removal, and there were
no deaths or permanent injury associated with LD.
Conclusions: LD is effective as an alternative management of CSF leaks,
and is a technique with low rate of complications or permanent damage.
EN16-NI36
Role of Levetiracetam in Neurocritical Patients With Non-
convulsive Seizure
S. Kung*,w. *Division of Neurosurgery, Department of Surgery, Kaoh-
siung Medical University Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan. wGraduate Institute of Medicine, College of Medi-
cine, Kaohsiung Medical University, Kaohsiung, Taiwan.
Background: The role of levetiracetam in the neurocritical patients with
nonconvulsive seizure (NCS) are not known. In recent decade, the
emerging role of continuous electroencephalography (cEEG) monitoring
in neurocritical care unit discloses significant number of cases with NCS.
This study was to evaluate the incidence of NCS in neurocritical care
unit and the efficacy of levetiracetam relative to other antiepileptic drugs
in NCS.
Methods: A retrospective study was conducted, we identified all patients
(N = 63) under cEEG monitoring >24 hours in our neurosurgical in-
tensive care unit, from March 2013 to April 2014.
Results: The mean age of the patients was 54.7 years. The male to female
ratio were 36 to 27. The most common diagnosis was severe head injury
(39.6%), cerebral vascular malformation (15.8%), intracranial neoplasm
(9.5%), stroke (9.5%), and other etiology (25.6%). The incidence of all
types of seizure was 41.2% (N = 26). Among all the seizures, the in-
cidence of NCS was 69.2% (18/26). The efficacy of levetiracetam mon-
otherapy in the NCS was 55.5% (10/18), bitherapy with phenytoin was
27.8% (5/18), and bitherapy with valproate acid was 16.7% (3/18).
S28 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Conclusions: In this study, the incidence of the NCS was concurred with
other published results. The efficacy of levetiracetam in the NCS espe-
cially as a single antiepileptic drug is validated.
NEUROMONITORING
EN16-NM01
BIS VISTA Bilateral Monitoring System (BVM): Make the Most
of Your Money
J.T. Herrera, A. Álvarez, I. Bilbao, M. Hernández, F. Iturri, A. Mar-
tı́nez. Hospital Universitario de Cruces, Barakaldo, Spain.
Background: Intraoperative seizures (IS) may induce cerebral and sys-
temic acidosis, increased intracranial pressure, and cause cerebral ede-
ma.1 Early diagnosis is essential to prevent the development of brain
lesions during surgery. IS under general anesthesia are rare but may be
masked by neuromuscular blockade. Unexplained tachycardia, hyper-
tension, increased end-tidal CO2, and decreased SjO2 are suspicious signs
of IS, a diagnosis that only EEG can confirm.
Case Report: We report 3 cases of IS in neurosurgical procedures, 2
craniotomies for removal of brain tumors and a surgical drainage of an
acute subdural hematoma. Diagnosis was made through the Bilateral
Monitoring System (BVM). We describe changes in the 4-channel EEG,
Density Spectral Array and the Asymmetry Indicator along with asso-
ciated changes in hemodynamics and in continuous SjO2.
Discussion: Bispectral index (BIS) displays processed data based on the
EEG and is commonly used to monitor depth of anesthesia.2 BIS is not
designed nor validated for the diagnosis of seizures as its values are
significantly affected by abnormalities in the EEG.3 Therefore, previous
published data about BIS changes during seizures are limited and con-
troversial.4 BVM enhances the anesthesiologist capabilities of intra-
operative diagnosis of the brain state, as it monitors parameters that can
alert of both global and interhemispheric changes. Given the higher cost
of the BVM compared with the BIS monitor, its acquisition should be
pondered considering the clinical activity we engage in.
References:
1. Perks A, Chakravarti S, Manninen P. Preoperative anxiety in neuro-
surgical patients. J Neurosurg Anesthesiol. 2009;21(2):127–130.
2. Sigl JC, Chamoun NG. An introduction to bispectral analysis for the
electroencephalogram. J Clin Monit. 1994;10(6):392–404.
3. Ogawa S, Okutani R, Nakada K, et al. Spike-monitoring of anesthesia
for corpus callosotomy using bilateral bispectral index. Anesthesia.
2009;64(7):776–780.
4. Iturri Clavero F, Tamayo Medel G, de Orte Sancho K, et al. Use of
BIS VISTAt bilateral monitor for diagnosis of intraoperative seiz-
ures, a case report. Rev Esp Anestesiol Reanim. 2015;62:590–595.
EN16-NM02
Density Spectral Array of BIS VISTA Monitoring System in
Epilepsy Surgery With Intraoperative Electrocorticography
L. Bosch, L. Castelltort, M. Lamora, E. Lopez, J. Fernández-Candil, S.
Pacreu. Department of Anaesthesiology. Parc de Salut Mar, Barcelona,
Spain.
Background: Anesthesiologists use sedative drugs, opioids, hypnotics,
and neuromuscular blocking agents to induce and maintain general
anesthesia, monitoring cardiovascular, respiratory, and EEG parameters
all along the procedure. The Bilateral Bispectral Index (BIS) was de-
signed to allow the user to record and display 4 channels of EEG; 2 from
each side of the brain. This monitor equally shows changes in the power
spectrum distribution through the Density Spectral Array (DSA).1
Asymmetry (ASYM) is a processed variable indicating the percentage of
EEG power present in left or right hemispheres with respect to total (left
and right) EEG power.2 In our case BIS was used to observe changes in
DSA, during the anesthetic-surgical procedure.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Case Report: A 51-year-old man underwent left amygdalohippo-
campectomy 3 years ago for drug resistant epilepsy. However, he con-
tinued with epileptic crisis and he was scheduled for left temporal
lobectomy with intraoperative electrocorticography (ECoG). On enter-
ing the operating room, electrocardiogram, noninvasive blood pressure,
and pulse oximetry were monitored. Bilateral BIS electrode strip was
placed on the front temporal position according to the International 10-
20 system of electrode placement. Anesthesia was maintained with sev-
oflurane (MAC 0.5) and infusions of remifentanyl (0.06 mg/kg/min) and
dexmedetomidine (0.5 mg/kg/h) to keep BIS values within 45 to 60 range.
Rocuronium was also administered (0.3 mg/kg/h). During surgery, an
asymmetry was detected related to the left hemisphere, where the epi-
leptogenic focus was located. This asymmetry was a consequence of a
power increase in low frequency (0.1 to 4 Hz) and alpha bands (8 to
12 Hz). Before performing the intraoperative ECoG, sevoflurane and
remifentanyl infusion rates were slowed resulting in light anesthesia,
which caused a decrease of power in low frequency and alpha bands,
more visible in the right side. When the surgery finished, sevoflurane was
increased (MAC 0.6) and the effect of “fill-in” of sevoflurane on the
spectrogram appeared, increasing the power on the left hemisphere.
Unlike DSA, the BIS trend did not reflect differences between 2 hemi-
spheres. The patient was extubated in the operating room and trans-
ferred to the recovery room. She was discharged from hospital 2 days
later.
Discussion: This case provides novel evidence to support the clinical
utility of DSA in monitoring depth of anesthesia and sedation. As de-
scribed by Purdon, every anesthetic has its own spectrogram.2
Reference:
1. Hernández-Hernández MA, Fernández-Torre JL, Ruiz-Ruiz A, et al.
Utilidad de la matriz de densidad espectral del sistema de ı́ndice
biespectral bilateral en la monitorización del status epilepticus no
convulsivo [Usefulness of the bispectral index system density spectral
array in monitoring non-convulsive status epilepticus]. Med Intensiva.
2014, May;38(4):265–267.
2. Purdon PL, Sampson A, Pavone KJ, et al. Clinical Electro
encephalography for Anesthesiologists: Part I: Background and Basic
Signatures. Anesthesiology. 2015;123:937–960.
EN16-NM03
Changes in Density Spectral Array of BIS VISTA Monitoring
System With the Administration of Etomidate and Propofol
E. López, L. Castelltort, M. Lamora, L. Bosch, J. Fernández Candil, S.
Pacreu. Department of Anaesthesiology, Parc de Salut Mar, Barcelona,
Spain.
Background: Anesthetics act at different molecular targets and neural
circuits to produce distinct brain states visible in the electroencephalo-
gram (EEG). Bilateral bispectral index display the unprocessed EEG and
the spectrogram through the density spectral array (DSA).1 The spec-
trogram shows the frequency decomposition of the EEG segment for all
the frequencies in a given range with changes in the dosing of the an-
esthetics and/or the intensity of arousal-provoking stimuli. We present 2
cases where we observed changes in DSA, during the anesthetic-surgical
procedure.
Case Reports: A 71-year-old woman with arterial hypertension was
scheduled for a total shoulder arthroplasty. At the operating room, the
electrocardiogram, noninvasive blood pressure, and pulse oximetry were
monitored. Bilateral BIS single montage sensor was placed on the
forehead according to the International 10-20 system of electrode
placement. Anesthesia was maintained with sevoflurane (MAC 0.7) and
remifentanyl infusion (0.05 mg/kg/min) to keep BIS values within 45 to
60 range. During the surgery we administered a bolus of etomidate
(16 mg) and we observed disappearance of low frequency (0.1 to 4 Hz)
and alpha bands (8 to 12 Hz). A 77-year-old woman with arterial hy-
pertension was scheduled for transsphenoidal hypophysectomy. Similar
intraoperative monitoring and anesthetic maintenance was used. Within
surgery we administered 2 boluses of etomidate (14 and 16 mg) and we
observed disappearance of alpha bands but persistence of low frequency
bands. However, when we administered an additional propofol bolus
(100 mg), alpha bands disappeared and slow and delta oscillations
maintained on the spectrogram.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
Discussion: Several investigators showed that different anesthetics have
different electroencephalogram patterns visible in the spectrogram.2 The
administration of boluses deepened the anesthetic level abolishing alpha
oscillations.
References:
1. Hernández-Hernández MA, Fernández-Torre JL, Ruiz-Ruiz A, et al.
Utilidad de la matriz de densidad espectral del sistema de ı́ndice
biespectral bilateral en la monitorización del status epilepticus no
convulsivo [Usefulness of the bispectral index system density spectral
array in monitoring non-convulsive status epilepticus]. Med Intensiva.
2014, May;38(4):265–267.
2. Purdon PL, Sampson A, Pavone KJ, et al. Clinical Electro
encephalography for Anesthesiologists: Part I: Background and Basic
Signatures. Anesthesiology. 2015;123:937–960.
EN16-NM04
Density Spectral Array of BIS VISTA Monitoring System During
Wada Study
C. Rodrı́guez, S. Pacreu, L. Moltó, E. Vilà, R. Rocamora, J. Fernández-
Candil. Department of Anaesthesiology, Parc de Salut Mar, Barcelona,
Spain.
Background: Amobarbital is a very short-acting barbiturate, which is
injected in an internal carotid to perform Wada test for patients eligible
for surgery treatment. Using density spectral array (DSA) of bispectral
index (BIS) VISTA Monitoring System (BVMS), we observed alpha
oscillations in frontal areas, a characteristic event of general anesthesia
known as “anteriorization”.1 To confirm these findings, we initiated a
retrospective study analyzing the EEG recordings with 10-20 system.
The aim of the study was to compare percentage of alpha power between
occipital and frontal areas and differences between both hemispheres
when amobarbital was injected.
Method: Six patients undergoing intracarotid amobarbital (IA) injection
were included in the study. The EEG was recorded during 5 stages: (A)
Epoch 1: baseline EEG, awake patient; (B) Epoch 2: left or right anes-
thetized hemisphere (ill hemisphere); (C) Epoch 3: washout period; (D)
Epoch 4: right or left anesthetized hemisphere (healthy hemisphere). For
each EEG channel the mean alpha absolute power was calculated ob-
taining a single value for each Epoch. To assess significantly difference
between alpha power for each study brain zone and each epoch we used
the Wilcoxon signed-rank test.
Results: After the administration of barbiturate, there was an increase of
alpha oscillations more evident in occipital than anterior area and es-
pecially in healthy brain. A slight increase of alpha power was observed
in the anesthetized brain.
Discussion: DSA of BIS showed that the administration of IA in 1
hemisphere produced low frequency and alpha oscillations in the EEG
of occipital and frontal hemispheres more evident in healthy brain, but
patients did not lose the consciousness. The presence of this EEG pattern
could be due to some cross-flow of the amobarbital and to an altered
connectivity in the nonanesthetized hemisphere produced by a transient
functional disconnection from the injected hemisphere.2
References:
1. Purdon P, Sampson A, Pavone KJ, et al. Clinical electro
encephalography for anesthesiologists. Anesthesiology. 2015;123:937–960.
2. Douw L, Baayen JC, Klein M et al. Functional connectivity in the
brain before and during intra-arterial amobarbital injection (Wada
test). Neuroimage. 2009;46:584–588.
EN16-NM05
Comparing 2 EEG-based Indices of Anesthesia: qCON and
qNOX Fall and Rise Times During Loss and Recovery of Con-
sciousness
PL. Gambus*, U. Meliaw, E. Weber Jensenw. *Department of Anesthesia,
Hospital Clı´nic, Barcelona, Spain. wR&D Department, Quantium Medi-
cal, Barcelona, Spain.
Background: An important issue with the current hypnotic effect and
pain/nociception monitors is the separation between the hypnotic and the
analgesic effects. In this context, the behavior of 2 electroencephalogram
www.jnsa.com | S29
Supplement: EuroNeuro 2016 J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016

(EEG)-based indices are compared by measuring their fall and rise times Results:
after drug induction and during recovery of consciousness.
Methods: Data were recorded from 140 patients scheduled for general an-
esthesia with a combination of propofol and remifentanyl. The qCON 2000 TABLE 1. Classifiers Performances
monitor (Quantium Medical, Barcelona, Spain) was used to calculate the Classification accuracy (%)
qCON and qNOX.1 The responses of the 2 indices to the changes of hypnotic
and analgesic concentrations were analyzed by calculating their fall and rise y 1 0.1 1 0.1 1 0.1
times at the beginning and at the end of the surgery. The fall times were Training size (%) 80 50 30
defined as the difference between the start of propofol or remifentanyl infusion This Work 90 96 91 95 89 95
and the time when qCON and qNOX reached a value under 65. The rise DCFMMN 85 91 83 86 80 88
times were defined as the difference between the time of recovery of con- Training time (TThisWork/TDCFM)
sciousness and the times when qCON and qNOX reached a value above 85.
Results and Discussion: The qCON reached 65 in median (25th; 75th y 1 0.1 1 0.1 1 0.1
percentile) at 198.0 (114.0; 245.0) s after anesthesia induction, whereas the Training size (%) 80 50 30
qNOX fall time was significantly longer (P < 0.05): 249.0 (189.0; 322.0) s. 1 0.8 0.9 0.7 1 0.7
At the end of the surgery, the qNOX started to increase to 85 at 5.0 (44.0;
46.0) s after recovery, whereas the qCON at 88.0 ( 151.0; 40.0) s
(P < 0.05). The statistical differences between the qCON and qNOX fall
TABLE 2. TBI Patient Recording Diagnosis
times might be associated with the different effects that hypnotic and an-
algesic agents induced to EEG signals. Hence, after anesthesia induction, Diagnosis accuracy (%)
loss of consciousness is achieved before adequate analgesia, according to
the rate of change of qCON and qNOX. During recovery, the probability y 1 0.5 0.1
of response to noxious stimuli (assessed by the qNOX) increases before the This Work 99 99 100
patient recovered consciousness as assessed by the qCON. DCFMMN 97 99 100
Conclusions: The indices qCON and qNOX were able to detect differ-
ences between the times of actions of hypnotic and analgesic agents. The
qCON showed faster decrease during induction, whereas the qNOX
FMMN complexity controlled by y [0 1].
showed a faster increase during recovery.
Acknowledgement: The qNOX was based on an idea from the Depart-
ment of Anaesthesia Hospital CLINIC de Barcelona (Spain) funded by
Conclusions: We propose a classifier for the real time categorization of
grant PS09/01209 and has been developed in collaboration with Quan-
cerebral status of TBI patients. These results suggest a potential for
tium Medical.
good, fast, and accurate classification. Further clinical validation is
Reference:
warranted.
1 Jensen EW, Valencia JF, López A, et al. Monitoring hypnotic effect
and nociception with two EEG–derived indices, qCON and qNOX,
during general anaesthesia. Acta Anaesthesiol Scand. 2014;58(8),
933–941. EN16-NM07
Heart Rate Variability and Delayed Cerebral Ischemia
P. Löwhagen Hendén, S. Naredi. Department of Anaesthesiology and
Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg,
EN16-NM06
Sweden.
Real Time Diagnostic of Cerebral Status in Traumatic Brain Background: Delayed cerebral ischemia (DCI) is a feared complication
Injury Using Neuro-fuzzy Networks after subarachnoid hemorrhage (SAH). The diagnosis is often delayed
G. Emeriaudw, S. Fartoumi*,w, M. Sawan*. *Polystim Neurotechnology due to limitations in monitoring facilities. Heart rate variability (HRV)
Laboratory, Department of Electrical Engineering, Polytechnique Mon- has been reported as a promising adjunct tool to detect DCI after SAH.
treal, Québec, Canada. wPediatric Intensive Care Unit, CHU Sainte- The goal of the study was to investigate whether HRV can be used to
Justine, Universite´ de Montréal, Quebe´c, Canada. detect DCI development in SAH patients.
Background: Severe traumatic brain injury (sTBI) is the main cause of Methods: Data are presented from a prospective study including con-
mortality in teenagers. In intensive care unit (ICU), sTBI must be treated secutive SAH patients admitted to our Neuro Intensive Unit (NICU)
quickly to reduce risks of sequelae. sTBI is a complex condition and from June 2015 to 2016. Patients are continuously monitored with HRV,
accurate decisions can be missed. Decision support systems have proved sampled at 1000 Hz, for 10 days. Patients with arrhythmias, pacemaker,
to be useful assisting doctors when processing big amount of data in and previous intracerebral processes are excluded. DCI is defined as:
ICUs. Diagnosis of patient’s brain state is essential to provide person- neurological deterioration (not explained by other causes), TCD veloc-
alized treatments. We present preliminary results of cerebral status di- ities >2 m/s or verified vasospasm/ischemia/infarction (by angiography,
agnosis using a hyperboxes-based neural networks. CT-scan, or magnetic resonance imaging).Until November 2015, 45
Methods: We have implemented an incremental learning fuzzy min-max patients are included. Five of 45 patients have developed DCI. For
neural networks (FMMNs) classifier for real-time applications that adjust comparison of HRV values and patterns between patients with and
its parameters online. The proposed algorithm computes weight for each without DCI, 5 patients without DCI are used as controls. HRV is
input variable, reducing computational cost when dealing with overlaps analyzed off-line 3 times a day (6 AM, 2 PM, and 10 PM) for 10 days (TP,
from hyperboxes of different classes. The FMMN categories for the cere- LF, HF, LF/HF, RMSSD, SDNN).
bral status include: under control, at risk of ischemia, hyperaemia, and/or Results and Discussion: HRV values and patterns did not significantly
moderate or severe intracranial hypertension. In this preliminary study, we differ between patients with DCI and patients without DCI during the
used 1740 samples of TBI recordings (median, 70 min) as data set (intra- first 10 days after SAH, but there is a trend toward lower TP, LF, HF
cranial pressure, brain tissue O2 pressure, and difference between target and values for the first 5 days in the DCI group. P-values are nonsignificant
actual cerebral perfusion pressure) and tested the accuracy and computa- in 2-way ANOVA for all parameters (Table and Fig.). Analysis of HRV
tion time of our algorithm compared with a similar classifier, the data-core in association with ICU variables as sedatives, vasoactive drugs, and
based FMMN (DCFMMN). We also used 2 complete patient recordings as ventilator treatment will be done for the whole cohort, aiming for >100
training sets and tested diagnosis accuracy using a different patient re- included patients.
cording. Specialists analyzed the data set recordings and their diagnoses Conclusion: HRV may be an adjunct monitoring for DCI development,
were used as targets for classification. but the use could be limited due to ICU management variables.

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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NM08
Assessment of Heart Rate Variability at Different Propofol Effect
Site Concentrations in Patients With Supratentorial Tumors
M. Radhakrishnan*, M. Mittalw, G.S. Umamaheswara Rao*, Ka-
vyashree. *Department of Neuroanaesthesia, National Institute of Mental
Health and NeuroSciences, Bengaluru, Karnataka, India. wConsultant,
Fortis hospital, Mohali, Punjab, India.
Background: Literature suggests autonomic dysfunction in patients with
intracranial space occupying lesions. The complex interaction between
general anesthetics, ANS, and intracranial tumors with raised ICP has
not been extensively studied.
Objective: To evaluate the cardiac autonomic function (heart rate vari-
ability) in patients undergoing surgery for supratentorial tumors at
baseline and at different effect site concentrations of propofol during
induction of anesthesia and compare with those in patients undergoing
noncranial surgeries.
Methods: Consecutive adult patients undergoing surgeries for supra-
tentorial tumor (study group) and brachial plexus injury (control group)
were recruited. ECG was recorded for 5 minutes at 3 time points—before
propofol induction, at propofol effect site concentrations (Ce) of 2 and
4 mg/mL.
Results: Forty-five patients were recruited, 24 in the study group and 21
in the control group. With increasing propofol ce, heart rate increased
significantly in the control group (P < 0.05). HRV variables in both the
groups changed the same way in response to the increasing concen-
trations of propofol (Table 1).
Conclusions: Following propofol administration, HRV measurements
were significantly different at baseline between the 2 groups but the
changes following propofol administration were similar between the 2
groups. Funding: The equipment used for ECG data collection was
purchased through a project funded by SERB-DST, Government of
India.
TABLE 1. Between Group Comparison of HRV Parameters at different
Propofol Ce
Craniotomy B Plexus
Base 2 lg/ 4 lg/ Base 2 lg/ 4 lg/
Line mL mL line mL mL P Interaction
Mean 778 ± 818 ± 812 ± 879 ± 843 ± 793 ± 0.529 0.505
RR 120 153 151 176 139 117
(ms)
LF/HF 2.3 ± 1.1 ± 1.4 ± 1.2 ± 1.2 ± 1.4 ± 0.708 0.103
2.2 1.5 1.5 1.1 1.1 1.2
EN16-NM09
Direct Motor-evoked Potentials and Cortical Mapping Using the
NIM Nerve Monitoring System: A Case Report
B. Suparna*, H. Faizalw, H. Mattheww, C. Jason C*. *Department of
Anesthesia & Perioperative Medicine. wDepartment of Clinical Neuro-
logical Sciences (Neurosurgery), Western University, London, Ontario,
Canada.
Background: Motor-evoked potentials (MEPs) are commonly used to
prevent neurological injury when operating in close proximity to the
motor cortex or corticospinal pathway. We report a novel application of
the NIM (Medtronics@NIM response 3.0) for intraoperative MEP
monitoring.
Case Report: A 69-year-old female patient presented with a 4-month
history of progressive left hemiparesis secondary to a large meningioma
in the right posterior frontal lobe that abutted and compressed the
motor cortex. Motor cortical mapping and MEPs were indicated. At our
institute, the NIM is readily available. We were interested in evaluating
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
the effectiveness of the NIM for performing intraoperative MEPs and
cortical mapping. The patient was anesthetized and maintained on total
intravenous anesthetics. Compound muscle action potential of abductor
pollicis brevis, brachioradialis, and biceps on the right side were moni-
tored. After the craniotomy and cortical exposure were complete, we
began with the Ojemann (monopolar) stimulator for direct cortical (dc)
stimulation (pulse frequency = 60 Hz, pulse width = 500 ms, inter-
stimulus width = 2 ms, starting current = 2 mA). Tonic movement of the
left hand was observed at 7 mA. The cortical motor hand area was
delineated. As the total charge delivered by Ojemann stimulator (Pen-
field technique) is much higher than the standard dc-MEP (Taniguchi
method) and the NIM, we switched to use the monopolar nerve stim-
ulator probe of NIM for subsequent direct cortical stimulation. The
compound muscle action potential response of right abductor pollicis
brevis was subsequently elicited using the NIM stimulating probe (pulse
width = 250 s, train frequency = 7 pulses/s, current = 20 mA). There
were no intraoperative complications and the motor function of the
patient was preserved after the surgery.
Discussion: In this case, we successfully used the NIM system to elicit dc-
MEP under general anesthesia. The advantages of using this system
include a simple set up, neurosurgeon familiarity, wide availability, and
lower cost. Stimulating patterns for dc-MEP with the NIM system are
comparable to other methods, but effective stimulation parameters may
vary among different technologies.1 We conclude that the NIM system is
a feasible and potentially more accessible alternative for dc-MEP and
cortical mapping.
Reference:
1. Landazuri P, Eccher M.Simultaneous direct cortical motor evoked
potential monitoring and subcortical mapping for motor pathway
preservation during brain tumor surgery: is it useful? J Clin Neuro-
physiol. 2013; Dec;30(6):623–625.
EN16-NM10
An Anesthesiologist’s Cognitive Aid for the Resolution of Crisis in
Intraoperative Neurophysiological Monitoring: an Imperative
Need
F. Echeverri Gonzalez. Clinica Comfamiliar Risaralda and Hospital San
Jorge de Pereira, Colombia.
Background: In neurosurgeries where Intraoperative Neurophysiological
Monitoring (IONM) is used wide range of crises may occur and the
attenuation or loss of the signal is one of them. How could any anes-
thesiologist correctly act during this crisis? Probably, if he had a cog-
nitive aid for this situation in his operating room, his performance would
be better. The objective of this paper is to present a cognitive aid for the
anesthesiologist who is facing the loss or attenuation of the signal during
IONM.
Methods: A nonsystematic review of the literature of scientific articles
presenting a cognitive aid (algorithm or Checklist) for this kind of crisis
was made. After analyzing the existing ones, an adaptation was per-
formed.
Results: Five articles presenting cognitive aids for resolution of crisis
were obtained. These cognitive aids were analyzed using the Cognitive
Aids in Medicine Assessment Tool (CMAT) and then a new one were
designed.
Discussion: The presence of cognitive aids is essential in infrequent an-
esthesias crisis. Then, the existence of one of them for crisis during the
IONM is imperative. However, they are not exempt from controversy.
They cannot replace clinical judgment. The advantages of this cognitive
aid are: First, it is exclusive to the anesthesiologist and second is more
didactic than others. The main weakness is that it has not been tested in
a clinical setting. So, this work will be finished when the cognitive aid
will be evaluated in a simulation trial.
Conclusions: Present a cognitive aid for the anesthesiologist that you can
use when faced with the loss of signal in IONM during neurosurgery.
www.jnsa.com | S31
Supplement: EuroNeuro 2016
FIGURE 1: Cognitive aid flow chart.
EN16-NM11
Predicting Unconsciousness After Propofol Administration:
qCON, BIS and the Power in the Alpha Band Frequency
J. Fernández-Candilw, S. Pacreuw, E. Vilàw, L. Moltów, C. Rodrı́guez-
Cosmenw, P. Gambús*. *Hospital Clı´nic de Barcelona. wParc de Salut
Mar, Barcelona, Spain.
Background: It is not clear which is the exact moment of loss of con-
sciousness (LOC) after administration of propofol. The EEG spectro-
gram allows exploring LOC assessed by the increase in power in the
alpha band as well as “anteriorization” consisting of a shift in alpha
activity from parietal to frontal areas. The goal of the study is to eval-
uate changes of different somatic or EEG-derived indicators of LOC
with respect to changes in the alpha band during slow induction of
general anesthesia with propofol.
Methods: After IRB approval and written informed consent 8 female
patients undergoing surgery for breast cancer under general anesthesia
were included. The qCON monitor (Quantium Medical, Spain) and BIS
VISTA TM bilateral sensors (Medtronics Inc.) were positioned, both
frontal and parietal. Propofol was administered by TCI (Schnider
model). The effect site target was 2.5 mg/mL. When the patient showed
signs of LOC, alfentanil and rocuronium were administered to facilitate
intubation. Raw EEG was analyzed offline to estimate the averaged
frontal (FAAP) and parietal (PAAP) alpha absolute power over win-
dows of 1 minute at the following clinical endpoints: before starting
propofol infusion, before loss of verbal command (LVC), between LVC
and loss of eyelash reflex (LER), after LER and intubation. Besides, to
test the ability of qCON and BIS to predict unconsciousness based on
the values of FAAP, Pk value has been used.
Results and Discussion: FAAP and PAAP increased since start of pro-
pofol infusion. After LER, PAAP decreased and shifted to frontal
cortex. Pk for qCON and BIS to predict FAAP were 0.85 (0.06) and 0.79
(0.06), respectively. As demonstrated previously, a shift in power in the
alpha frequency band from parietal to frontal LOC is observed.1 qCON
and BIS values decreased when propofol effects started. Both indicators
exhibit a high ability to predict FAAP according to their Pk value.
qCON and BIS can be considered as good predictors of FAAP as well as
of unconsciousness when propofol is used.
Conclusions: FAAP, qCON, and BIS changes are in good correlation
and prediction ability with anteriorization and clinical signs of uncon-
sciousness. Monitors combining a graphical display of alpha frequency
and quantitative indicators of hypnotic effect will help predicting the
phenomenon of LOC under general anesthesia.
Acknowledgements: The authors thank J. Fontanet and E. Jensen for the
EEG analysis.
S32 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Reference:
1. Purdon PL, Pierce ET, Mukamel EA, et al. Electroencephalogram
signatures of loss and recovery of consciousness from propofol. Proc
Natl Acad Sci U S A. 2013;110:E1142–E1151.
EN16-NM12
Reappraisal of the Reference Levels for the Energy Metabolites in
the Normal Brain
Á. Sánchez-Guerrero*, G. Mur-Bonet*, L. Castro*, D. Gándara*, A.
Reyw, J. Sahuquillow. *Vall d’Hebron Research Institute (VHIR). wVall
d’Hebron University Hospital, Barcelona, Spain.
Background: Cerebral microdialysis is widely used in many neurocritical
care units. Reference intervals for brain energy metabolites originate
from studies in animals, other organs or from the application of mi-
crodialysis in epileptic or posterior fossa lesion patients. The goal of this
study was to establish the reference range for analytes involved in energy
metabolism (glucose, lactate, and pyruvate) by using the extrapolation to
zero flow methodology in anesthetized patients and by constant perfu-
sion at 0.3 mL/min in awake patients.
Methods: A CMA-71 probe was implanted during surgery in patients
with posterior fossa or supratentorial lesions. The perfusion flow rate
was varied randomly between the following rates: 0.1, 0.3, 0.6, 1.2, and
2.4 mL/min. Microdialysis samples were collected hourly for the 0.1 mL/
min flow rate and every 30 minutes otherwise. Within 24 hours after
surgery, the perfusion was resumed at a constant 0.3 mL/min in fully
awake patients; samples were collected hourly. All samples were imme-
diately analyzed with the ISCUS Flex analyzer. The metabolite con-
centrations at a theoretical flow rate of 0 mL/min were calculated using
the extrapolation to zero flow methodology.
Results and Discussion: Fifteen patients were included (5 males) with a
median age of 43 (range, 21 to 69 y). The median (minimum-maximum)
values for chemical markers obtained through the extrapolation to zero
flow methodology were 1.4 (0.9 to 4.8) mmol/L for glucose, 1.6 (0.9 to
5.2) mmol/L for lactate, and 65.8 (44.3 to 207.3) mmol/L for pyruvate.
The concentrations determined at a perfusion flow rate of 0.3 mL/min in
the awake patient were 1.7 (0.3 to 3.0) mmol/L for glucose, 3.3 (1.6 to
5.6) mmol/L for lactate and 153.0 (85.0 to 192.0) mmol/L for pyruvate.
Conclusions: The extrapolation to zero flow method was applied in a
cohort of patients to estimate the brain parenchymal concentrations of
energy metabolites. Our findings question the normal thresholds rou-
tinely used at the bedside and prompt the review of the definition of
metabolic disturbances in neurocritical patients.
EN16-NM13
The Effectiveness of Brain PAD (BP) Within a Controlled Pro-
phylactic Normothermia Strategy in 2 Neurosurgical Procedures
F. Iturri, J. González-Uriarte, A. González-Uriarte, JT. Herrera, A.
Álvarez, A. Martı́nez. Hospital Universitario de Cruces, Barakaldo, Spain.
Background: We describe the successful use of BP within a controlled
prophylactic normothermia (CPN) strategy to minimize injury asso-
ciated with surgery in 2 neurosurgical procedures.
Case Reports: Our CPN strategy starts by increasing intraoperative core
temperature (T) to <36.51C. Measures are applied every 30 minutes if
there is an increase in T, or if the decrease is not higher than 0.11C
during said interval. The sequence includes: decreasing intraoperative
blanket T to 321C; 1 g (IV) acetaminophen administration; medium flow
lung ventilation instead of minimal flow; placing the Brain PAD (BP)
without interrupting surgery. When BP was placed during the first
procedure (emergency clipping of left middle cerebral artery aneurysm)
T dropped 0.51C every hour, changing from a maximum of 37.31C to
36.21C within 120 minutes. T continued to decrease, but the decrease
slowed down with time until it reached 351C during transfer to critical
care unit. In the second procedure (scheduled posterior fossa craniotomy
for excision of metastasis) the decrease in temperature was similar,
changing from 37.41C to 36.41C within 120 minutes. The decrease in T
slowed down, but it continued to decrease until it reached 36.21C within
the next 60 minutes. However, we could only place a part of the device in
this procedure, since the posterior fossa was involved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Discussion: Intraoperative hyperthermia requires early diagnosis and
treatment.1 The efficacy of induced intraoperative hypothermia as a
neuroprotective strategy during neurosurgical procedures has not been
proven.2 CPN not only reduces fever, but also keeps T strictly under
36.51C, induced in such an early manner, and during the whole acute
phase of neurological injury.3 Endovascular and surface cooling systems
using gel pads have shown their efficacy and viability at inducing and
maintaining normothermia, whereas conventional temperature control
measures such as NSAIDs and cooling blankets are not enough to
prevent fever.3
Learning Points: The CPN strategy is a measure to prevent secondary
neurological injury. BP is more effective than the rest of physical or
pharmacological measures in our CPN plan. BP does not require an
initial investment. It is easy to place, even during cranial surgery.
References:
1. El Beheiry H. Protecting the brain during neurosurgical procedures:
strategies that can work. Curr Opin Anaesthesiol. 2012;25:548-55.
2. Galvin IM, Levy R, Boyd JG, et al. Cooling for cerebral protection
during brain surgery. Cochrane Database Syst Rev. 2015;1:CD006638.
3. Broessner G, Fischer M, Pfausler B, et al. Controlled prophylactic
normothermia. Crit Care. 2012;16(suppl 2):A–10.
EN16-NM14
Zero-Heat-Flux Cutaneous Thermometer for Core Temperature
Measurements in Extreme Situations
M. Vendrell Jordà, M. Lacambra Basil, E. Bassas Parga, M. José Bernat
Álvarez, J. Fernanz Antón, L. Gil Gomez, E. Pujol Rosa. Consorci
Sanitari Integral, Hospital Sant Joan Despı´ Moise`s Broggi, Spain.
Background: Temperature control is important not only during surgery,
but also in the specific neurological setting. In traumatic brain injury, or
for neurological protection after cardiac arrest, a strict, relatively fre-
quent core temperature (CT) control is important, as large changes can
happen in short periods of time, and the prevention of hyperthermia is
essential.1,2 CT probes may be esophageal, tympanic, or placed within
central veins; with pulmonary artery catheter as the gold standard.
The Zero-Heat-Flux (ZHF) Cutaneous Thermometer (3 M Spot On)
allows for CT measurements obtained from a probe placed upon the skin
surface.3 Cytoreductive surgery combined with hyperthermic intra-
peritoneal chemotherapy (CRS/HIPEC) provides for an excellent setting
to evaluate extreme temperature changes. During CRS, CT may quickly
fall to <341C, whereas during the HIPEC phase, peritoneal cavity
temperature is raised to 42.51C, with the consequent hyperthermia. We
aim to correlate CT measurements as obtained from the ZHF ther-
mometer to those obtained from a midesophageal probe (MEP) in the
setting large temperature changes that is CRS+HIPEC surgery.
Methods: Patients undergoing CRS/HIPEC from July to October 2015
were included. Simultaneous measurements of CT data obtained from a
MEP and a ZHF probe placed above the right supracilliary arch were
registered every 15 minutes during CRS and final review, and every
5 minutes during HIPEC phase. Lin concordance correlation coefficient
and Bland-Altman were used to assess agreement.
Results: A total of 31 consecutive patients were recorded (13 M/18 F).
Age (mean [IQR]) was 59.94 [53 to 68]. BMI was 27.1 (23.23 to 30.3).
There were 25 ASA II and 6 ASA III patients. The (mean ± SD) du-
ration of CRS, HIPEC, and review phases was 240 ± 93.27,
42.58 ± 15.05, and 46.45 ± 18.76 minutes, respectively. In all phases,
Lin’s concordance correlation was substantial (rc 0.78, 0.76, and 0.86,
respectively). Bland-Altman showed slightly increased values from MEP
as compared with ZHF during CRS (0.15 ± 0.31C), HIPEC
(0.19 ± 0.451C), and review phases (0.11 ± 0.291C), with <10% of the
values being Z0.51C.
Conclusions: ZHF is a reliable, noninvasive measurement probe for
strict, frequent CT control in the setting of quick temperature changes as
is CRS/HIPEC surgery. This measurement method could be of help in
other settings where such a strict temperature control is needed.
References:
1. Provencio JJ, Badjatia N. Participants in the International Multi-
disciplinary Consensus Conference on Multimodality Monitoring.
Monitoring inflammation (including fever) in acute brain injury.
Neurocrit Care. 2014;21 (Suppl 2):S177–S186.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
2. Chandrasekaran PN, Dezfulian C, Polderman KH. What is the right
temperature to cool post-cardiac arrest patients? Crit Care. 2015;19:
406.
3. Eshraghi Y, Nasr V, Parra-Sanchez I, et al. An evaluation of a zero-
heat-flux cutaneous thermometer in cardiac surgical patients. Anesth
Analg. 2014;119:543–549.
EN16-NM15
Continuous Cerebral Saturation Monitoring During Therapeutic
Hypothermia in Out-of-Hospital Cardiac Arrest Patients
W. Eertmans, C. Genbrugge, I. Meex, J. Dens, F. Jans, C. De Deyne.
Ziekenhuis Oost-Limburg, Genk, Belgium.
Background: Regardless of the recent advances in cardiopulmonary re-
suscitation and postresuscitation care, most patients who die during
their hospital stay after out-of-hospital cardiac arrest (OHCA) decease
due to postanoxic neurological injury. Near infrared spectroscopy
(NIRS) provides information on frontal brain oxygenation by measuring
the regional cerebral oxygen saturation (SctO2). The aim of the study
was to monitor SctO2 for 48 hours in OHCA patients during targeted
temperature management.
Methods: A prospective, observational study was performed during
therapeutic hypothermia (TH; 24 h at 331C, followed by rewarming at
0.31C/h over 12 h) in 107 successfully resuscitated OHCA patients. SctO2
was continuously monitored with NIRS for 48 hours using the FORE-
SIGHT (CAS Medical systems, Branford, CT). The Cerebral Perfor-
mance Category (CPC) scale was used to define patient’s outcome at 180
days after the cardiac arrest (CA), where CPC 1 to 2 and CPC 3 to 5
represented a good and poor neurological outcome, respectively. Stu-
dent t tests were performed as appropriate. To define an outcome related
threshold of SctO2, the area of the SctO2 curve below predefined SctO2
thresholds was calculated and analyzed by univariate logistic regression.
Results and Discussion: Although 57 patients (53%) died, 50 patients
(47%) survived with a good neurological outcome. In the survivors, the
mean SctO2 at ICU admission was 64% ± 7% compared with
66% ± 6% in the nonsurvivors (P = 0.18). After initiation of TH, a
mean decrease was observed in both survivors (3% ± 12%) and non-
survivors (5% ± 6%) (P = 0.43). This was followed by a progressive
increase in both groups toward baseline values. Outcome prediction by
the area under a preset SctO2 threshold revealed that a longer duration
below SctO2 values of 64% was associated with a poor neurological
outcome (OR, 0.98; 95% CI, 0.97-0.99; P = 0.04).
Conclusions: Therapeutic hypothermia at 331C after OHCA is accom-
panied by fluctuations in the balance between oxygen delivery and
supply to the brain as reflected by the observed SctO2 changes. More-
over, patients who spend more time below a SctO2 of 64% have a
worsened outcome at 180 days post-CA.
EN16-NM16
Changes in Hourly Serum Lactate Levels in Postcardiac Arrest
Patients Treated With Therapeutic Hypothermia at 331C
H. Stragier, W. Eertmans, C. Genbrugge, F. Jans, J. Dens, C. De Deyne.
Ziekenhuis Oost-Limburg, Belgium.
Background: Despite improved care of patients resuscitated from cardiac
arrest, mortality and incidence of poor neurological outcome remains
high. Current evidence supports a clear association between initial serum
lactate and mortality, with higher initial serum lactate levels reflecting a
longer interval of ineffective circulation and a more severe postcardiac
arrest syndrome. The present study analyzed hourly changes in serum
lactate in post-CA patients treated with therapeutic hypothermia (TH)
(331C).
Methods: A prospective observational study was performed in 108 pa-
tients, resuscitated from out-of-hospital cardiac arrest (OHCA) of pre-
sumed cardiac cause. In all patients, a strict post-CA management
protocol was applied.1 Following admission at the ICU hourly serum
lactate analysis was performed during the first 36 hours. All patients
were treated with TH (331C) during 24 hours, followed by 12 hours of
rewarming (0.31C/h). Primary outcome was mortality at 180 days and
neurological functionality (CPC score).
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Supplement: EuroNeuro 2016
Results: Mortality rate at 180 days was 53.7%, while all survivors were
classified as CPC 1 to 2. At every time point during first 36 hours post-
CA, we found a significant difference between serum lactate levels in
survivors versus nonsurvivors. More specifically, lactate levels were
significantly lower in survivors compared with nonsurvivors on admis-
sion to ICU (T0), at the end of TH (T24) and after rewarming (T36) (T0:
5.63 mmol/L [4.40 to 6.87] vs. 7.55 mmol/L [6.46 to 8.64], P = 0.022; T24:
1.93 mmol/L [1.56 to 2.30] vs. 2.96 mmol/L [2.38 to 3.54], P = 0.005; T36:
1.52 mmol/L [1.32 to 1.73] vs. 2.52 mmol/L [1.97 to 3.08], P = 0.002).
During the first hour both survivors and nonsurvivors had a lactate
reduction of approximately 20%. During the 36 hours, we found no
significant difference in serum lactate clearance. In survivors, 68% of the
patients cleared lactate to a normal level (< 2.2 mmol/L) within 24 hours
(vs. 55.35% in nonsurvivors).
Conclusions: Not only initial levels of serum lactate, but all hourly serum
lactate values during TH and rewarming phase are strong predictors of
mortality in post-CA patients. Our results reveal that applying TH at
331C, we found abnormal lactate levels at 24 hours post-CA in still one-
third of survivors.
Reference:
1. Ameloot K, Meex I, Genbrugge C, et al. Hemodynamic targets during
therapeutic hypothermia after cardiac arrest: A prospective ob-
servational study. Resuscitation. 2015;91:56–62.
EN16-NM17
Extracellular Glutamate is Significantly Elevated in the Hippo-
campus of Awake-Behaving Aged Fisher-344 Rats Compared
With Young Rats Following Craniotomy
M. Humeidan*, S. Bergese*, V. Davisw, G. Gerhardtw. *The Ohio State
University Wexner Medical Center. wUniversity of Kentucky Center for
Microelectrode Technology, USA.
Background: Post-operative cognitive disorders (POCD) are a frequent and
costly complication of surgery. Advancing age is consistently demonstrated
as a risk factor for POCD. Glutamate is the predominant excitatory neu-
rotransmitter in the central nervous system, and excess glutamate (ex-
citotoxicity) is linked to multiple nervous system pathologies. Glutamate
may be implicated in POCD as a result of dysregulation secondary to aging,
or due to surgical inflammation or ischemia in the hippocampus, the brain
region responsible for learning and memory. The studies presented here
investigate postoperative regulation of hippocampal extracellular glutamate
of neuronal origin in a rat model of human aging.1–5
Methods: Following craniotomy under isoflurane anesthesia, we used
chronically implanted microelectrode arrays in the hippocampus of Fischer
344 rats to measure in vivo extracellular glutamate in real-time. Starting at
a minimum of 48 hours postcraniotomy, in vivo extracellular basal glu-
tamate levels were measured in unanesthetized rats and compared across
age groups (young 3 to 6 mo old, late-middle aged 18 mo, aged 24 mo).
Results: Older rats had significantly elevated postoperative extracellular
glutamate levels in the hippocampus compared with young rats (mean ±
SEM, 8.4 ± 1.1 vs 16.7 ± 3.2 mM, n = 38, P < 0.05). Isoflurane anesthesia
had no effect on extracellular glutamate neurotransmission in the hippo-
campus (mean ± SEM, iso 16.5 ± 4.0 mM, awake 16.3 ± 4.1 mM, n = 15).
Conclusions: Aging animals demonstrate postoperative dysregulation of
glutamate neurotransmission in the hippocampus, which could be im-
portant to development of POCD by an excitotoxic mechanism. Iso-
flurane does not appear to acutely cause changes in glutamate
regulation. We hope to incorporate behavioral assessments into future
studies to correlate glutamate levels with cognitive performance post-
operatively.
References:
1. Pomerleau F, Day BK, Huettl P, et al. Real time in vivo measures of
L-glutamate in the rat central nervous system using ceramic-based
multisite microelectrode arrays. Ann N Y Acad Sci. 2003;1003:
454–457.
2. Warner DS. Perioperative neuroprotection: are we asking the right
questions? Anesth Analg. 2004;98:563–565.
3. Mitchell SJ, Merry AF, Frampton C, et al. Cerebral protection by
lidocaine during cardiac operations: a follow-up study. Ann Thorac
Surg. 2009;87:820–825.
S34 | www.jnsa.com
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
4. Bilotta F, Gelb AW, Stazi E, et al. Pharmacological perioperative
brain neuroprotection: a qualitative review of randomized clinical
trials. Br J Anaesth. 2013;110:S1 i113–S1 i120.
5. Lin TY, Chung CY, Lu CW, et al. Local anesthetics inhibit glutamate
release from rat cerebral cortex synaptosomes. Synapse. 2013;67:568–579.
EN16-NM18
Intraoperative Cerebral Oxygen Saturation and BIS Reduction
may be Associated With Postoperative Delirium and Cognitive
Dysfunction Following Cardiac Surgery
E.M. Aldana, J.L. Valverde, I. Bellido. Department of Anesthesiology.
Hospital Vithas Xanit Internacional. Benalmádena, Spain.
Background: Determination of intraoperative cerebral oxygen saturation
(rSO2) by means of near-infrared spectroscopy cerebral/somatic oxi-
meter (INVOS) allows a noninvasive assessment of the cerebral oxygen
delivery and demand ratio in the frontal cortex region. Intraoperative
rSO2 measurement may have prognostic relevance thus it reflects cere-
bral and systemic oxygen balance during cardiac surgery and allows us
to monitor the adequacy of cerebral perfusion. Intraoperative rSO2 and
depth of anesthesia, measured by Bispectral Index (BIS) may be related
to various causes of morbidity-mortality after cardiac surgery in the
elderly including postoperative cognitive dysfunction and neuro-
psychological dysfunction. Delirium is an acute change in cognition and
concentration that complicates the postoperative course of 10% to 40%
of cardiothoracic surgical patients. The aim of this study was to examine
whether cerebral frontal cortex O2 desaturation and depth of anesthesia
may be related with the development of delirium symptoms and the
incidence of cognitive function’s decline after cardiac surgery.
Methods: A prospective, longitudinal study in II-IV ASA class patients
scheduled for cardiac surgery and undergoing intravenous general an-
esthesia with remifentanil plus propofol was done. Clinical and surgical
parameters, cardiopulmonary function, intraoperative cerebral oxygen
saturation (rSO2), and BIS were continuously recorded and corrected
throughout the surgery. Time is divided into 7 parts. Delirium is
measured by the use of CAM ICU test after surgery. Standardized test
measuring capacity of attention, language, verbal and visual memory,
visual-spatial orientation, executive, psychomotor and motor capacity,
and independence in daily life and the perception of the patient of their
psychological situation were used to assessed the cognitive function
before and 7 days after surgery.
Results and Discussion: Patients (n = 44, 77% male, aged 60 y), scheduled
to coronary (36.4%), aortic valve replacement (18.2%), mitral valve re-
placement (13.6%), coronary plus valve replacement (13.6%), and other
(18.2%) surgeries, on pump 98.4% were enrolled. Patients with rSO2 re-
duction higher than 10% and BIS values under 28 also showed post-
operative delirium and 7 days after surgery, a significant deficit (P < 0.05),
namely vocabulary remembering, and at the executive function.
Conclusions: Reduction of rSO2 and BIS during cardiac surgery was re-
lated with delirium and cognitive dysfunction following cardiac surgery.
EN16-NM19
Alzheimer-Connected CSF-Neuromarkers Tau and Beta-Amyloid
can Prospectively Predict Mortality in Patients With Acute Hip
Fracture
R. Dutkiewicz*, Z. Henrikw, K. Blennoww, B. Nellgård*. *Inst of Clin-
ical Sciences. wInst of Clinical Neurosciences, Sweden.
Background: Patients with acute hip fracture (AHF) have high post-
trauma mortality rate (10% at 30 d; 25% at 1 y). AHF-patients are old
(> 80 y; 2/3 female) and >50% have multiple diseases, (ASA III-IV).
Age (above 85 y), male sex, and ASA > III are independent risk factors
for mortality. Retrospective studies have shown that Alzheimer’s disease
(AD) also is a risk factor for mortality in AHF patients, but this has
prospectively not been studied. Biochemical Neuromarkers (BNM) in
the cephalous spinal fluid (CSF), enhanced Tau and decreased Beta-
amyloid 1-42 (BA1-42), have been demonstrated to strongly correlate to
AD and is now 1 criterion for AD diagnosis. We wanted to prospective
explore if CSF-Tau and CSF-AB1-42 correlate to mortality at 3 months
and at 1 year in AHF-patients.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Methods: After ethical and patient/next-of-kin approval, AHF patients
were included if having an AHF and receiving a spinal anesthesia.
Lumbar puncture was performed with a spinal needle (24 G). Before the
injection of local anesthetic 4 mL of CSF was collected and then frozen
in aliquots. CSF-Tau and CSF-BA1-42 was analyzed with sandwich
ELISA technique. Mortality was found by Death Registry. Statistical
expertise utilized univariable logistic regression analyses correlating CSF
concentrations of Tau and BA1-42 to 3 months and 1 year mortality.
Estimated probability plots of death was made for BA1-42.
Results and Discussion: Totally, n = 151 AHF patients were included
(average age, 80 y; 71% female). At 3 months postoperatively, 21 (16%) of
the patients had died, and at 1 year 23% had died. Both at 3 months
(P < 0.04) and at 1 year (P < 0.0023) low CSF-BA1-42 concen-
tration correlated to increased mortality. Enhanced CSF-Tau at 1 year
correlated to increased mortality (P < 0.04), but not at 3 months. Esti-
mated probability plots of death for BA1-42 demonstrate that AHF pa-
tients with very low values (< 300 pg/mL) had a probability of dying at 1
year of 50%, whereas those with high values (> 1000 pg/mL) had only 5%
probability. Similar values for 3 months were 25% and 5%, respectively.
Conclusions: In this prospective outcome study in AHF-patients we have
for the first time shown a correlation of AD-connected BNM’s to mor-
tality at both 3 months (Beta-amyloid 1-42) and 1-year (Tau and Beta-
amyloid 1-42) posttrauma. Dementia seems to be a risk factor in this
patient-cohort, a notion that may have substantial clinical applications.
EN16-NM20
Does Off-Pump Technique for Coronary Revascularization Have
Lower Incidence of Neurological Complications?
O. Torres*, P. Carmonaw, E. Mateo*, N. Almenara*, J. De Andrés*.
*Anesthesiology Department, General University Hospital. wHospital “La
Fe”, Valencia, Spain.
Background: The goal of all surgical procedures is to perform the tech-
nique with minimal morbidity and mortality. On-pump coronary artery
bypass graft (ONCABG) continues to be the gold standard to achieve
these goals in coronary revascularization. Part of the morbidity related
to CABG is caused by the cardiopulmonary bypass, prompting the off-
pump coronary artery bypass graft (OPCABG).1,2
Objective: We aim to describe our experience in ONCABG versus OP-
CABG surgery comparing postoperative neurological outcomes and 30-
day and long-term mortality after 20 years in a single experienced center in
which 40% of coronary revascularization is performed under OPCABG.
Methods: This is a retrospective, observational cohort study of prospectively
collected data from consecutive patients who underwent isolated CABG at
the Hospital General of Valencia from January 1993 to June 2013. The data
collection was extracted from our database (PalexData, Barcelona, Spain).
The resulting base sample contained detailed clinical information on 3097
patients. In order to reduce the effects of treatment selection bias and potential
confounding factors, we used a propensity score matching analysis. Patients
with concomitant cardiac procedures, carotid endarterectomy, or cardiac re-
operations were excluded. Neurological complications were defined as stroke,
transient ischemic attack, and psychomotor agitation. In-hospital and long-
term mortality were also registered.
Results: After propensity score 1004 pairs of patients were matched. The
neurological complications were more frequent in the ONCABG versus
OPCABG group with significant differences (39 [3.9%] vs. 22 [2.2%],
respectively, P = 0.03). There was no significant differences between the
ONCABG and the OPCABG group in hospital mortality (2.8% vs.
3.8%, P = 0.210) and all causes mortality during the period of study
(12.3% vs. 12.9%, P < 0.42).
Conclusions: Our study suggests that both coronary revascularization
techniques are safe options in terms of neurological morbidity and
mortality.
References:
1. Murzi M, Caputo M, Aresu G, et al. On-pump and off-pump coro
nary artery bypass grafting in patients with left main stem disease: a
propensity score analysis. J Thorac Cardiovasc Surg. 2012;143(6):
1382–1388.
2. Rodrigues AJ, Evora PR, Tubino PV. On-pump versus off-pump
coronary artery bypass graft surgery: what do the evidence show?
Rev Bras Cir Cardiovasc. 2013;28(4):531–537.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
EN16-NM21
Propofol Versus Sevoflurane Anesthesia: Effect on Cognitive
Functions and Electrophysiological Findings
J. Kletecka*, I. Holeckovaw, P. Brenkusz, J. Pouska*, J. Benes*, I.
Chytra*. Departments of *Anesthesiology and Intensive Care. wNeur-
osurgery. zNeurology, The University Hospital in Plzen, Czech Republic.
Background: Postoperative cognitive dysfunction (POCD) is diagnosed
in up to 40% patients after anesthesia. Causative role of anesthetic
toxicity remains unclear. Using clinical tests no clear-cut differences have
been observed between anesthetics so far. Aim of this trial was to
compare incidence of POCD diagnosed by battery of psychometric tests
and changes in auditory event-related potentials (ERPs) after propofol
and sevoflurane anesthesia.
Methods: Sixty patients undergoing lumbar discectomy were pro-
spectively randomized to receive sevoflurane (SEVO) or propofol
(PROP) based anesthesia. Depth of anesthesia was controlled with BIS.
Preoperatively and on days 1, 7, and 40 after surgery modified ISPOCD
test battery and ERPs (N1, P3a, and P3b waves) were performed. POCD
was defined as a decline of >1 SD in 3 or more tests.
Results and Discussion: In 47 patients (78%; 22 in PROP and 25 in
SEVO group) all selected tests were performed and used for the evalu-
ation. POCD was present in 28%, 15%, and 11% of patients on days 1,
7, and 40 with no intergroup difference. Among psychometric tests the
most significant decline against baseline was observed in Categorical
Verbal Fluency scores congruently in both groups on days 1 and 7
(SEVO: 21 ± 1 vs. 15 ± 1 and 16 ± 1; PROP 23 ± 1 vs. 17 ± 1 and
19 ± 1; all P < 0.01) with full recovery on day 40. Transient deterio-
rations in other tests were observed as well. In SEVO group, ERPs
analysis showed significant increase of N1 and P3b latencies on days 1
and 7 and decrease of P3b amplitude on the day 1. Decrease of P3a
amplitude was observed in both groups on day 7 lasting till the day 40.
However, no association of POCD positivity and ERP changes was
found.
Conclusions: In our study, sevoflurane and propofol anesthesia was as-
sociated with similar incidence of POCD (mainly decline in executive
cognitive functions). Prolonged ERP changes were more significant after
sevoflurane anesthesia. They seem not to have any correlation with the
decline registered with psychometric tests and represent subclinical
changes.
Acknowledgement: Supported by Charles University research fund
PRVOUK P36.
EN16-NM22
Systematic Review of Regional Cerebral Oxygen Saturation
Changes Using Near Infrared Spectroscopy During Neurosurgical
Spine Operations in Prone Position and our First Experience
S. Murniece*,w, B. Mamaja*,w, A. Skudre*, J. Stepanovs*,w. *Departe-
ment of Anaesthesiology, Riga East University hospital, Latvia. wRiga
Stradins University, Latvia, Letonia.
Background: Near infrared spectroscopy (NIRS) mainly used in cardiac
surgery, has lately gained its actuality in other fields. Maintained ad-
equate cerebral oxygenation during operation prevents complications
like cognitive dysfunction, stroke, and organ failure. Neurosurgery is a
complex medical field covering a wide range of operations not only on
brain but also on spine.
Methods: A systematic review was undertaken to determine whether
operations on spine in prone position impact cerebral oxygenation using
NIRS devices intraoperatively. Relevant publications were found using
the PubMed database. In total, 309 articles were found. All the articles
were screened for eligibility. Only 3 articles met all the criteria.
Results: Fuchs et al1 in his study included 48 patients for lumbar dis-
cectomy. Results reveal that there were no significant changes in rScO2
from baseline values during supine with head left/right, prone, sitting
position after 1, 3, 5 minutes in anesthetized and awake volunteers.
Deiner et al2 included 205 patients (above 68 y). A total of 63 patients
underwent spinal surgery in prone position, 142—major surgery in su-
pine position. Results showed that mild desaturation is 2.3 times more
likely for patients in prone position. Andersen et al3 had 52 patients
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Supplement: EuroNeuro 2016
undergoing spinal surgery in prone position hypothesing that head ro-
tation >45 degrees would affect rScO2. Conclusion is made that the
neutral head position is recommended for prone patients.
Discussion: As there are only 3 articles reviewed no significant results can
be made. All the studies have left an open field to investigate the relation
to postoperative period. We have had 8 patients so far. Our results
showed no significant changes in rScO2 from baseline values during
change from supine to prone and backwards, a close relation to NIBP
measurements, no changes in MMSE after surgery, no incidence of
stroke, organ dysfunction, and no patients were admitted to ICU.
Conclusions: Patients undergoing spinal surgery are at risk to altered
cerebral saturation because of the circulatory changes during prone
position as well as bleeding risk. Only a couple of studies have been
made and more investigations have to be performed.
References:
1. Fuchs G, Schwarz G, Kulier A, et al. The influence of positioning on
spectroscopic measurements of brain oxygenation. J Neurosurg An-
esthesiol. 2000;12:75–80.
2. Deiner S, Chu I, Mahanian M, et al. Prone position is associated with
mild cerebral oxygen desaturation in elderly surgical patients. PLoS
One. 2014;9:e106387.
3. Andersen JD, Baake G, Wiis JT, et al. Effect of head rotation during
surgery in the prone position on regional cerebral oxygen saturation:
A prospective controlled study. Eur J Anaesthesiol. 2014;31:98–103.
EN16-NM23
Cerebral Hemodynamic Response to an Orthostatic Challenge in
Severe Obstructive Sleep Apnea Patients Before and After 2
Years of Continuous Positive Air Pressure Therapy
C. Gregori Plaw, T. Durduranz, A. Fortuna Gutiérrez*. *Hospital de la
Santa Creu i Sant Pau. wICFO-Institut de Cie`ncies Fotòniques, The Barce-
lona Institute of Science and Technology. zICFO-Institut de Cie`ncies Fotò-
niques, The Barcelona Institute of Science and Technology/Institució
Catalana de Recerca i Estudis Avanc¸ats (ICREA), Barcelona, Spain.
Background: In obstructive sleep apnea (OSA) syndrome, breathing is
repeatedly interrupted during sleep because of upper airway obstruction.
Left untreated, OSA may lead to high blood pressure, congestive heart
failure, heart attack, and ischemic stroke. Cerebral autoregulation
(CAR) is the ability of the brain to keep a constant perfusion and thus
protect the brain. CAR is aided by cerebral vasoreactivity (CVR), the
ability of the cerebral arterioles to vasoconstrict/vasodilate in response
to stimuli. One of the hypothesis associated to the increased risk of
stroke in OSA patients is related to impairment or alteration of CVR
and/or CAR. Continuous positive air pressure (CPAP) is the most
common therapy for severe OSA patients. CPAP improves cognitive
function, mood, and sleepiness after few weeks from the therapy start,
but it is not clear if CVR and CAR are improved or restored.
Methods: We have developed a diffuse correlation spectroscopy (DCS)
system to follow orthostatic challenge induced microvascular blood flow
Figure: A, 0 to 30 degrees head-of-bed. B and C, 30 degrees back to 0 degrees.
S36 | www.jnsa.com
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
changes in the frontal lobes during a head-of-bed (HOB) challenge (from
0 to 30 to 0 to 20 to  8 to 0 degrees). HOB induces changes in the
cerebral blood blow, whereas a healthy CAR and CVR should coun-
teract for these changes. We performed a large study (n = 81 subjects) of
OSA patients and controls where OSA patients, before CPAP therapy
start, and a control group were measured. After 2.1 (mean) years of
continuous CPAP therapy, 14 severe OSA patients and part of control
group (no CPAP), have been measured again.
Results and Discussion: (1) There is no difference between OSA severe
and control pre-CPAP and post-CPAP groups (panel A) over an equal
time period from 0 (baseline) to 30 degrees of HOB, as in our previous
study. (2) Both pre-CPAP and post-CPAP OSA groups (panel A) show a
larger variability, different clinical characteristics may account for these
differences. (3) After coming back to baseline position (panel B), only
severe pre-CPAP therapy group is significantly different (*) from the
baseline while the rest, recover as expected. (4) From (panel C) we could
say that 1.7 years of CPAP therapy have altered the response. Clinical
data revealed that OSA patients indeed had a significant clinical im-
provement.
Conclusions: This suggests that DCS together with a HOB challenge
could be used to check the still damaged or restored CAR and CVR in
OSA patients during CPAP.
NEUROSURGERY, OUTCOME, AND
POSTOPERATIVE COMPLICATIONS
EN16-NS01
Surgical Meningioma Resection: Retrospective Analysis of 65
Patients
M.H. Machado Lima, M. Fernandes, A.F. Ribeiro, A. Eufrásio, J.
Gonc¸alves, R. Orfão. Centro Hospitalar Universitário Coimbra, CHUC,
Portugal.
Background: Meningiomas are the most common benign tumors of the
brain and the incidence ranges around 25% of all brain tumors. They
arise from the arachnoid cells that have a poliblastic feature, resulting in
different histologic subtype which WHO divided into 3 categories: be-
nign (I), atypical (II), and malignant (III). Approximately 90% of the
intracranial meningiomas are supratentorial and the most common lo-
cations are the convexity, parasagittal, and sphenoid ridge.1,2
The aim of this study is to characterize the population that underwent
surgical meningioma resection in our hospital during 2013.
Methods: A retrospective study was carried out by analyzing the clinical
data of consecutive patients who underwent meningioma resection in
our hospital from January to December 2013. A descriptive analysis was
performed to determine demographic data, coexistent disease, clinical
symptoms, tumor location, histologic classification, complications, and
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
mortality rate. Continuous variables were reported as median (inter-
quartile range [IQR]).
Results and Discussion: Sixty-five patients were analyzed, 16 males
(24.62%) and 49 females (75.38%) with a median age of 64 years (IQR, 22).
The most common coexistent diseases were hypertension (40 patients),
dyslipidaemia (20), and diabetes mellitus (18). Headache, visual symp-
toms, and paresis were the most frequent clinical symptoms. Forty-four
patients underwent an elective surgery (67.69%) and 21 were operated
on an urgent basis (32.31%). Most of the meningiomas were intracranial
(92.30%) with prevalence in the convexity (30.77%), parasagittal
(15.38%), and sphenoid (21.54%), with a frequency of benign menin-
gioma (grade I) of 75.38%, which meets the data in the literature. Our
series showed an overall in-hospital mortality of 6.15% and a compli-
cations rate of 20% that was similar to the reported in literature.
Conclusions: Recent evidence has suggested acceptable outcomes fol-
lowing intracranial meningioma resection, although the risks of com-
plications necessitate careful consideration when deciding to operate on.
Risk factor analysis emphasized the importance of considering pre-
operative status and comorbidities during patient selection. Future re-
search should address the causes and prevention of complications.
References:
1. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of
meningioma. J Neurooncol. 2010;99:307–314.
2. Patil CG, Veeravagu A, Lad SP, et al. Craniotomy for resection of
meningioma in the elderly: a multicentre, prospective analysis from
the National Surgical Quality Improvement Program. J Neurol
Neurosurg Psychiatry. 2010;81:502–505.
EN16-NS02
The Role of American Society of Anesthesiologists Scores in
Predicting Meningioma Resection Outcome
M. Fernandes, H. Lima, A. Ribeiro, A. Eufrásio, R. Órfão. Anaes-
thesiology Department of Centro Hospitalar e Universitário de Coimbra,
CHUC, Coimbra, Portugal.
Background: Preoperative risk scores are designed to guide patient
management providing a method to predict operative outcome. Several
risk scores are used in neurosurgery but studies on their clinical relevance
are scarce.1,2 The American Society of Anesthesiologists (ASA) Physical
Status Classification system is the most well-known preoperative risk
evaluation used for surgical patients worldwide. The predicting risk of the
ASA classification has not been established in cranial neurosurgery and
no customized risk scores exist. This study aims to evaluate the impact of
ASA score in hospital outcome after meningioma resection.
Materials and Methods: A retrospective study of patients undergoing
surgical meningioma resection at Centro Hospitalar e Universitário de
Coimbra—CHUC, between January and December 2013. We collected
all data regarding sex, age, ASA, size of tumor, mortality rate, compli-
cations, and days of hospitalization. Statistical analysis was performed
using SPSSv20.0. The test used for parametric variables was Student t
test and for nonparametric variables was Mann-Whitney.
Results and Discussion: Overall, 65 patients were included, 16 males
(24.62%) and 49 females (75.38%). The median age of patients ASA I/II
was 61 years (IQR, 23.5) and ASA III/IV 69 years (IQR, 8). Average size
of the tumor in patients ASA I/II was 41.8 mm (IQR, 16.3) and in
patients with ASA III/IV 55.8 mm (IQR, 14.9).
Four patients died (6.15% in-hospital mortality rate) and 13 patients (20%)
had complications, of these, 8 cases were infections. The median days of
hospitalization were 12 (IQR, 10). The statistical analysis did not show any
significant association between ASA classification, mortality rate, infectious
complications, and days of hospitalization (P > 0.05). However, it dem-
onstrated that patients ASA III/IV were significantly related to a higher
average tumor size (P = 0.016) and older age (P = 0.011).
Conclusions: ASA classification correlates significantly with age and size of
tumor. It is a further preoperative clinical variable that can be incorporated
into future risk prediction tools but large prospective studies are needed to
validate the use of the reviewed risk score in meningioma resection.
References:
1. Reponen E, Tuominen H, Korja M. Evidence for the use of
preoperative risk assessment scores in elective cranial neurosurgery: a
systematic review of the literature. Anesth Analg. 2014;119:420–432.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
2. Fu KM, Smith JS, Polly DW Jr, et al; Scoliosis Research Society
Morbidity and Mortality Committee. Correlation of higher pre-
operative American Society of Anesthesiology grade and increased
morbidity and mortality rates in patients undergoing spine surgery.
J Neurosurg Spine. 2011;14:470–474.
EN16-NS03
Tumor of the Posterior Fossa With Lesion of Cranial Base Pairs
After Surgery. Is it a Frequent Complication?
Y. Dominguez Dı́az, E. Guerra Hernández, Z. Hussein Dib González, P.
Aguado Garcı́a, A. Rodrı́guez Pérez. Hospital Universitario de Gran
Canaria Doctor Negrı´n, Spain.
Background: Surgery of the posterior fossa presents an elevated rate of
postoperative morbidity/mortality.
Case Report: A 52-year-old woman was admitted to the hospital with
unsteady gait, diplopia, and left anisocoria. She was diagnosed with a left
cerebellopontine angle tumor and underwent a programmed suboccipital
craniotomy and tumor resection. Anesthesia was given with TIVA. Neu-
rophysiological monitoring was done. Surgery was carried out in a prone
position. There was evidence of a lesion in the facial nerve that had to be
resected. After the intervention, the patient was admitted to the Post-
surgical Critical Care Unit, intubated. A control cranial CT showed
postsurgical changes. The orotracheal tube was removed without incident.
A neurological examination revealed affectation of VI, VII, and XII left
cranial pairs with left hemiparesis. At 48 hours after the intervention due to
dysphagia and decreased cough and gag reflexes with poor management of
secretions, a tracheotomy protection was performed a week after surgery.
Discussion: Postoperative nausea and vomiting are the most frequent
complications, followed by tongue and/or airway edema and the affectation
of cranial pairs VII and VIII. Sitting position has a better postoperative
preservation of cranial nerves than in a prone position. Lesions of base
cranial nerves are more frequent with large tumors. Its deficit causes
changes in phonation, swallowing, and inability to protect the airway
against aspiration. Dysphagia and dysarthria can cause loss of control or
airway permeability forcing a decision to extubate in a Critical Care Unit
or, in severe cases, performing a tracheotomy, at least temporarily.
Learning Points: Infratentorial surgery presents specific complications such
as pneumoencephalus, cerebellar mutism, and dysfunction of the cranial pairs.
Postoperative dysfunction of cranial pairs after surgery of the posterior fossa
can include from pair II to pair XII. Injury of base cranial nerves can force a
decision to do a temporary or definitive tracheotomy to preserve the airway.
EN16-NS04
Anesthestic Implications of Aminolevulinic Acid Protoporphyrin
IX Fluorescence Guided Resection of Gliomas
S. Solanki Lal, S. Solanki, M. Desai. Tata Memorial Centre, Mumbai,
India.
Background: Aminolevulinic acid protoporphyrin IX (ALA) fluo-
rescence-guided resection of gliomas is a novel approach to improve the
extent of tumor resection. Intraoperative tumor fluorescence provided
by 5-ALA assists surgeons in identifying the true tumor margin, con-
sequently increasing the extent of the resection.1
Methods: This is a retrospective analysis of prospectively collected data
and includes malignant glioma (WHO grade III and IV) excision in ASA
I and II patients for glioma excision surgeries from January 2013 to
October 2015. Intraoperative and postoperative hemodynamic parame-
ters were noted and biochemical investigations of day before surgery,
postoperative day 0, 1, 7, and 14 were noted. Usage of vasopressors in
perioperative period and photosensitivity and thermal injury was noted.
Results: A total of 35 patients were included; No patient had any pho-
tosensitivity or thermal burn, mean mephentermine used was 9 mg. Four
patients had raised LFT’s on 14th day after surgery. Two patients had
pain in the abdomen. There was leukocytosis in 30 patients after 24
hours of administration.
Conclusions: Using ALA for resection of gliomas is safe with due pre-
cautions. Meticulous care is required in 24 hours postoperative period to
avoid phototoxicity. UV light emitting should be avoided in operating
room as well as recovery room.
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Supplement: EuroNeuro 2016
Reference:
1. Tsugu A, Ishizaka H, Mizokami Y, et al. Impact of the combination of
5-aminolevulinic acid-induced fluorescence with intraoperative magnetic
resonance imaging-guided surgery for glioma. World Neurosurg. 2011;
76:120–127.
EN16-NS05
Length of ICU Stay, Morbidity, and Mortality in Neurocritical
Unit After Brain Tumor Surgery
J. Benatar Haserfaty. Hospital Universitario Ramon y Cajal, Spain.
Background: This study evaluate the association between preoperative and
postoperative variables and the extended need for intensive care monitoring
(> 1 d) and the morbidity and mortality of surgery of brain tumor patient
during their stay in the NeuroIntensive Care Unit (NICU).
Methods: Retrospective chart review of 317 consecutive postoperative
brain tumor surgical patients admitted to a NICU within a 3-year period
(2010 to 2012).
Results: Sixty-eight patients (21.5%) with a length of stay (LOS) > 1 day,
named group L, in the NICU were compared with 249 patients (78.5%)
with a LOS < 1 day, named group C. The univariate association between
preoperative and postoperative factors was assessed with LOS. There were
no significant differences in demographics, physical status as classified by
the American Society of Anesthesiologists (ASA), the pathologic charac-
teristics and radiologic tumor severity index between groups L and C.
Tracheal intubation was needed in 29 patients (42.6%) of group L at some
point after surgery. Thirteen patients (19.1%) of group L had systemic and
regional complications simultaneously.
Conclusions: There is a significant fraction of patients with a LOS > 1
day in the NICU after brain tumor surgery. Both the need of tracheal
intubation and the ventilatory support and the onset of systemic and
regional complications can determine LOS > 1 day.
EN16-NS06
Assessment of Postoperative Psychological Outcomes Associated
With Awake Craniotomy facilitated by a Dexmedetomidine-based
Anesthetic Protocol
J.C. Gomez Builes, M. Garavaglia, A. Rigamonti, G. Hare, D. Sunit, C.
Adriana. St Michael’s Hospital, UK.
Background: An awake craniotomy (AC) may be an exceptionally
stressful experience for patients. Team coordination and patient’s ability
to cooperate during the tests are key factors for success. Psychological
consequences (pain, anxiety, etc.) after awake craniotomy has been re-
ported. Milian et al, studied posttraumatic stress disorder in patients
after AC, and they found that 44% of the patients had experienced
either repetitive distressing recollections or dreams related to the awake
surgery. Our objective is to document the incidence and persistence of
PTSD in patients undergoing awake craniotomy performed with an
anesthetic technique based on dexmedetomidine and scalp nerve blocks.
Methods: Observational study in patients undergoing AC for tumor
resection under sedation with dexmedetomidine and scalp blocks. Pre-
vious to the surgery depression was assessed by Patient Health Ques-
tionnaire 9 (PHQ-9). After the AC, PTSD inventory questionnaire1 was
sent by mail at 3 and 6 months, and patients were asked to return it by
mail. According to the DSM-IV, PTSD is characterized by symptoms
like reexperiencing (Criterion B), avoidance (Criterion C), and physio-
logical hyperarousal (Criterion D) after a traumatic experience (Crite-
rion A). These must be present for >1 month (Criterion E) and cause
occupational or social impairment (Criterion F).
Results: Eight patients participated in the study. Six of the 8 (75%) and 4
of the 8 (50%) completed 3 and 6 months follow-up, respectively. In
total, 62.5% were males and 37.5% females, age was 44.4 ± 17.2 years
(mean, SD). Tumor location was predominantly frontal (57.1%), in the
right hemisphere (75%), WHO glioma grade IV (37.5%), III (25%), and
M1 (25%); surgery length was 215.7 ± 40.3 minutes (mean, SD). Pre-
operatively, 71.4% (5/8) presented a mild major depressive disorder ac-
cording to the PHQ-9 scale. PTSD: None of the patients had
reexperienced, nor persistent avoidance of stimuli associated with the
AC. Persistent symptoms of increased arousal occurred in 12.5% of the
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
patients. Weight loss was reported by 50% of the patients, and 25%
reported changes in the appetite.
Conclusions: Patients undergoing awake craniotomy surgery under se-
dation with dexmedetomidine had a low frequency of psychological
symptoms, despite the high frequency of mild depression preoperatively.
Multidisciplinary management to detect preoperative depression may
improve the patient care.
Reference:
1. Milian M, Luerding R, Ploppa A, et al. “Imagine your neighbor mows
the lawn”: a pilot study of psychological sequelae due to awake cra-
niotomy: clinical article. J Neurosurg. 2013;118:1288–1295.
EN16-NS07
Failed Awake Craniotomy: Judicious Patient’s Selection is
Essential
A. López Gómez, P. Ferrer Tárrega, M. Echeverri Vélez, L. Martı́nez
Ferreiro, MS. Matoses Jaén, P. Argente Navarro. Hospital Universitario
La Fe, Spain.
Background: Awake craniotomy is an established procedure for the re-
section of intra-axial lesions adjacent to or within eloquent brain re-
gions. To ensure a successful awake craniotomy, several prerequisites
should be met. Judicious patient selection is essential for precise map-
ping and reliable continuous monitoring. Preoperative preparation is
essential in achieving patient cooperation, and a specialized team is
needed to manage the scenario for optimal complications avoidance.1,2
Case Report: We report a case of a 36-year-old woman scheduled for
awake craniotomy due to a recurrent tumor within an eloquent brain
region. BMI 43.5. Mallampatti test: I. Five years before a Cormack and
Lehane: I was reported. As a predictor of difficult mask ventilation: class
III obesity. During depositioning of the patient a bad perfusion was
detected in the recumbent upper limb. Ventilation with the laryngeal
mask was impossible and surgery was not performed.
Learning Points: The management of awake craniotomy is challenging.
The success of this procedure depends on multidisciplinary team and
competent operating room personnel apart from a cooperative patient.
The first step is a careful and rigorous patient selection. We must un-
derstand that all factors that alter the patient’s ventilation will deterio-
rate the conditions of the surgical field, although an obese patient is a
relative contraindication, we should be very strict with the selection in
each specific case
References:
1. Nossek E, Matot I, Shahar T, et al. Failed awake craniotomy: a
retrospective analysis in 424 patients undergoing craniotomy for brain
tumor. J Neurosurg. 2013;118:243–249.
2. Rath GP, Mahajan C, Bithal PK. Anaesthesia for awake craniotomy.
J Neuroanaesthesiol Crit Care 2014;1:173–177.
EN16-NS08
Perioperative Complications of Deep Brain Stimulation Surgery
C.A. Focaccio, L. Valencia, A. Rodrı́guez-Pérez, T. Sarmiento, A.
Ramos, F. Robaina. Hospital Universitario de Gran Canaria Doctor
Negrin, Spain.
Background: Deep brain stimulation (DBS) is a neurosurgical procedure
that provides relief to patients with a variety of movement and other
neurological disorders that do not respond to medication. The primary
objective of this study was to evaluate perioperative complications in
DBS. As a secondary objective, partial or total withdrawal of specific
drugs after surgery was assessed.
Methods: A retrospective, observational study was carried out. All pa-
tients who had undergone DBS in our hospital between 2005 and 2014
were included. Patients were selected from the follow-up database of the
Chronic Pain and Functional Neurosurgery Unit. Demographics, years
of follow-up, duration of disease, indications and duration of surgery,
perioperative complications, ICU and hospital length of stay were all
collected. Partial or total withdrawal of anti-Parkinson’s drugs at 1, 6,
and 12 months after surgery were also recorded. The variables were
analyzed by SPSS software. The results are shown in percentages and
means ± SD.
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Results and Discussion: Forty-seven patients were included with an
average age of 60.6 ± 8.6 years. The sex distribution was 53.2% males
and 46.8% females. The duration of disease until surgery was
12.52 ± 4.83 years. The main indication for surgery was refractoriness to
treatment (59.6%) followed by dystonia caused by levodopa (34%). The
duration of surgery was 473.9 ± 112 minutes. The most frequent intra-
operative complication was high blood pressure (BP) (> 30% from
baseline) in 48.9% of the patients. Low BP (< 30% from baseline),
decreased level of consciousness, lack of cooperation, and anxiety was
found in 4.3%. As described, our most frequent postoperative compli-
cation was high BP in 21.3%. Other complications were anxiety syn-
drome in 8.5%, low BP, decreased level of consciousness, epileptic crises,
infection of the surgical wound, and generalized tremors in 4.3%. The
ICU and hospital length of stay was 1.18 ± 0.16 and 15.15 ± 6.68 days,
respectively. After 1 month, it was possible to decrease medication in
40.4% of the patients and withdraw it in 27.7%. In 38% of these pa-
tients, it was necessary to reinitiate treatment at 1 year. Finally, medi-
cation could be decreased in 40.4% and completely withdrawn in 4.3%.
Conclusions: Perioperative high BP with fear for risk of brain hemor-
rhage was the most common complication. Monitored anesthesia care
along with tight BP control could reduce serious adverse outcomes in
DBS surgery patients. In more than half of the patients, it was possible
to withdraw the medication partially at 1 year. However, complete re-
moval was possible only in a small percentage.
EN16-NS09
Symptomatic Intracranial Hemorrhagic Complications of Deep
Brain Stimulation for Parkinson’s disease
J. Benatar-Haserfaty, D. Meléndez Salinas, A.L. Sierra Tamayo. Hos-
pital Universitario Ramón y Cajal de Madrid, Spain.
Background: Intracranial hemorrhage (ICH) is an infrequent but po-
tentially devastating complication of deep brain stimulation (DBS)
surgery. This study analyzed the number of cases and risk factors for
ICH in a large series of DBS in patients with advanced Parkinson’s
disease.
Methods: Three hundred forty-three cases with advanced Parkinson’s
disease and scheduled for DBS between January 2006 and May 2015
were included in this study. All cases were assisted by a dedicated neu-
rophysiologist who performed the microelectrode recording (MER).
Postoperative CT was performed only in symptomatic patients. Sta-
tistical correlation analysis of risk factors for ICH was performed by
stepwise logistic regression. Explanatory variables were patient age, sex,
blood pressure, and drugs used to treat Hypertension.
Results: Postoperative symptomatic ICH occurred in 9 cases (2.6%).
Hypertension, sex, and age were not significant factors contributing to
symptomatic ICH (P < 0.05). Four of the 9 ICH cases (1.2%) resulted in
focal neurological deficits. Length of Intensive Care Unit stay was 1 day
(median) and increased for patients with symptomatic ICH (median
values of 1 to 68 d).
Conclusions: This study failed to reveal any association between age, sex,
previous hypertension, and ICH. The small number of hemorrhages
made it impossible to perform a meaningful statistical analysis. Many
functional neurosurgery teams use MER to “refine” the surgical inter-
vention, and there is no doubt that MER is an important research tool.
Nevertheless, evidence that MER is superior to a meticulous image-
guided approach in terms of clinical outcome is lacking.
EN16-NS10
Active Surveillance of Health Care Associated Infection in Neu-
rosurgical Patients
S. Mohapatra*, R. Agarwal*, G. Prasad Rathw, D. Guptaz, A. Kapil*.
*Department of Microbiology. wDepartment of Neuroanesthesiology &
Critical Care. zDepartment of Neurosurgery, All India Institute of Med-
ical Sciences, New Delhi, India.
Background: Health care associated infections (HCAI) are frequently
observed in neurosurgical patients. There is scarcity of data with regard
to the incidence and burden of nosocomial infection (NI) in this patient
population.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
Methods: A prospective surveillance of 4 months duration was carried
out on all neurosurgical patients admitted to a tertiary-care center of
India. HCAIs were identified using the National Healthcare Safety
Network definitions of the CDC. Data pertaining to the demographic
characteristics, diagnosis, underlying diseases, invasive procedures,
HCAI, isolated micro-organisms, and their antibiotic susceptibilities was
collected from the medical record of the patients. The site-specific rate of
NI and the ratios of device utilization were calculated.
Results: A total of 328 patients with 4054 patient-days were analyzed for
HCAI. Twenty-three NIs were identified in 22 patients. The overall rate
of NI was 7.01% and 5.67 per 1000 patient-days. The mean age of the
patients was 41.3 years (range, 1 to 67). Catheter-associated urinary tract
infection (CA-UTI) was the most common (82.6%) infection noticed
followed by ventilator-associated pneumonia (VAP, 4.34%). The CA-
UTI rate was 23.05 per 1000 urinary catheter-days. VAP rate was 1.69
per 1000 ventilator-days. None of the patient had central line–associated
blood stream infection. The ratios of utilization for urinary catheter,
central line, and ventilator were 0.20, 0.06, and 0.15, respectively. K.
pneumoniae (41.2%) was the commonest organism responsible for CA-
UTI followed by E. coli (35.3%), Pseudomonas spp (17.6%), and P.
vulgaris (5.89%). All the isolates (100%) were found to be multidrug
resistant.
Conclusions: This study generates a baseline data for the device-asso-
ciated infections, which will further help monitoring its trend and anti-
microbial resistance pattern. Moreover, this study will help formulating
the antibiotic policy in terms of prophylaxis and preventive measures,
which may reduce the morbidity and mortality in neurosurgical patients.
EN16-NS11
Incidence of Surgical Wound Infections in Patients Undergoing
Craniotomy During the Period 2007 to 2014
E. Vilà Barriuso, J.L. Fernández Candil, L. Moltó Garcı́a, C. Rodrı́guez
Cosmen, M. Sadurnı́ Sardà, S. Pacreu Terradas, C. Garcı́a Bernedo.
Parc de Salut Mar, Barcelona, Spain.
Background: The overall incidence of surgical infection in patients un-
dergoing craniotomy is around 5%. Infection rate in our hospital was
much higher (14% in 2007 and 12.5% in 2008), for this reason a mul-
tidisciplinary working group was created.
Objective: The aim of this study was to determine the incidence of no-
socomial infection in elective craniotomies (January 2007 to December
2015) and to analyze the effectiveness of our therapeutic measures in-
troduced in order to reduce the number of surgical wound infections.
Methods: All patients undergoing elective craniotomy were followed up
to 30 days after surgery. During these years several measures were im-
plemented: (1) epidemiological study of infections; (2) culturing samples
from surgical instruments from the sterilization room; (3) limiting the
amount of people inside the operating room (OR) and the door open-
ings; and avoiding surgical staff shifts’ change; (4) creating a pre-
operative, intraoperative, and postoperative checklist; (5) providing
place outside the OR for storage of surgical material; (6) changing the
antiseptic skin wash and head surface shaving; (7) changing the pro-
phylactic antibiotic; (8) using only a specific OR for neurosurgery.
Results: The incidence of wound infection was highly variable: 2009
(5.9%), 2010 (16.7%), 2011 (7.4%), 2012 (9.4%), 2013 (8.7%), and 2014
(3.5%). A total of 221 procedures were analyzed between 2012 and 2013.
We found a total of 20 postoperative wound infections. We obtained 15
bacterial isolations: S. aureus (4), S. epidermidis (1), S. pyogenes (1), S.
agalactiae (1), Acinetobacter baumannii (1), Klebsiella pneumoniae BLEE
(2), Klebsiella (1), Bacteroides (1), Enterobacter cloacae (2), E. coli
(1).These findings showed that 53% of the isolated pathogens were
Gram-negative bacteria that were not covered with the empirical anti-
biotic prophylaxis made with cefazolin and in 2014 was replaced for
cefuroxime. After these changes the rate of infection along 2014 was
3.5%, 4 of the 114 craniotomies were infected and 2 Gram-positive cocci
were identified.
Conclusions: Knowledge of the infections local microbiology is essential
to guide both prophylaxis and empirical antibiotic therapy. The multi-
disciplinary approach of the surgical wound infections helps to enhance
the results.
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EN16-NS12
Incidence and Predictors of Postoperative Pulmonary Complica-
tions in Patients Undergoing Craniotomy and Excision of Poste-
rior Fossa Tumors
S.K. Dube, B. Hooda, R.S. Chouhan, G.P. Rath, P.K. Bithal. Depart-
ment of Neuroanaesthesiology & Critical Care, AIIMS, New Delhi, India.
Background: Postoperative pulmonary complications (POPCs) are re-
ported in 5% to 10% of all surgical patients. Infratentorial neurosurgical
procedures are at high risk for the development of POPC that prolongs
patient stay in the intensive care unit (ICU) and hospital with substantial
perioperative morbidity and mortality. We carried out a retrospective
study to evaluate the incidence and predictors of POPC in adults who
underwent surgery for posterior fossa tumors, and to find out its impact
on length of hospital stay and neurological outcome.
Methods: Medical records of patients in between the age groups of 18 to
65 years who underwent elective surgery for posterior fossa tumors during
the period from January 2011 to December 2012 were reviewed. Patients
on mechanical ventilation, preoperatively, and those who underwent
emergent surgery were excluded. Data with regard to preoperative factors
such as ASA physical status, comorbidities, history of smoking, sleep
apnoea, respiratory symptoms and chronic lung disease, lower cranial
nerve (LCN) palsy, and low level of consciousness; intraoperative com-
plications such as hemodynamic alterations suggestive of brain stem or
cranial nerve handling, brain bulge, blood loss, and transfusion; and
postoperative variables like duration of mechanical ventilation, trache-
ostomy, POPCs, length of ICU and hospital stay, condition of the patient
at-discharge, and cause of in-hospital mortality were collected. POPC was
defined as presence of atelectasis, trachea-bronchitis, pneumonia, bron-
chospasm, respiratory failure, reintubation, and weaning failure.
Results: Case files of 288 patients who fulfilled the study criteria were
analyzed; POPCs observed in 35 patients (12.1%). On univariate analysis,
the risk factors were found to be preoperative LCN involvement, ASA
physical status higher than 2, intraoperative blood loss in excess of
1400 mL, massive transfusion, prolonged duration of surgery (> 300 min),
postoperative LCN palsy, low level of consciousness, need for reexplora-
tion, prolonged ventilation (> 48 h), placement of nasogastric tube, post-
operative blood transfusion, tracheostomy, and prolonged ICU stay
(> 3 d). On multivariate logistic regression analysis, postoperative blood
transfusion, LCN palsy, prolonged ICU stay, and tracheostomy were
found to be the independent predictors for the occurrence of POPCs.
Conclusions: An incidence of 12.1% of POPC was observed following
infratentorial tumor surgery. The predictors for the occurrence of POPC
were postoperative blood transfusion, LCN palsy, prolonged ICU stay,
and tracheostomy.
EN16-NS13
The Clot Thickens. An Audit of Thromboprophylaxis in Neuro-
surgery
A.J. Watts. Kings College Hospital, UK.
Background: Post neurosurgery there is a high rate of venous throm-
boembolism complication resulting in significant morbidity, mortality,
and cost. The use of thromboprophylaxis in surgery has been demon-
strated to improve survival outcomes and is now recommended by NICE
& SIGN. In May 2014, 80% of respondents to a survey at Kings College
Hospital felt there ought to be a local guideline about administration
timings. Venous thromboembolism guidelines had been implemented in
February 2013 and renewed in July 2014.
Methods: We conducted a retrospective audit, against local guideline, of
thrompoprohylaxis (LMWH) prescription in all neurosurgical cases be-
tween July 14 and 28, 2014. We collated data on prescription, admin-
istration timing, VTE assessment, and the prescriber. Finally, we
conducted a survey to assess prescriber’s knowledge of the local guideline.
Results: Data from 137 patients was acquired and after exclusion criteria
applied, data from 103 patients was analyzed. A total of 85 were elective
and 70 had postoperative LMWH prescribed. All had VTE assessment
completed and recorded. In total, 60% of the cranial surgery group had
LMWH prescribed, mainly for day 1 postoperation, prescribed by the
neurosurgeon. Those who had not, were appropriately omitted as per
protocol because they were low risk. In total, 80% of the elective spinal
group had LMWH prescribed, mainly by the neurosurgeons. In keeping
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
with national guidelines the majority of patients had their LMWH day 1
postoperatively, yet no one had their LMWH within 6 hours as per local
guideline. On our repeat survey (n = 17) less than one-third of Neuro-
surgical theater practitioners were aware of a local guideline and of
them, less than half implemented it.
Conclusions: Our hospitals current performance meets national guidelines
in that low-risk bleeding patients are not receiving LMWH if appropriate
and meets local guideline in that 78% of elective cases are being prescribed
LMWH timely and 56% administered within 24 hours. Nonelective pre-
scriptions depend on individual case assessment yet there is non-
compliance with local guideline of 6 hours postemergency spinal LMWH,
although administered within 24 hours as per national guideline. There is
a heavy weighting toward neurosurgical prescription and ongoing un-
awareness/lack of uptake of local guideline, despite previous calls for such
guidance. Clarification of the acceptability of the combined VTE docu-
ment to neurosurgery is required and if so, training in its implementation.
EN16-NS14
Comparison of the Efficacy of Oral Oxycodone and Oral Codeine
in the Treatment of Postcraniotomy Pain
M. Lim, RM. Lee, CT. Chong, B. Lim. Tan Tock Seng Hospital,
Singapore.
Background: Postcraniotomy pain has been reported to be moderate to
severe. Management of postcraniotomy pain is inadequate in many
cases, yet is limited by the side effects of opioids. Codeine has been the
mainstay of treatment of postcraniotomy pain in our institution, due to
its safer side effect profile when compared with more potent opioids.
However, its effectiveness may be limited due to the need to be deme-
thylated before it has any analgesic effect and this process is subject to
interindividual variability.
Objective: Our primary objective was to determine if there is a difference
in the mean pain VAS scores in the oxycodone and codeine groups at 24
hours. Secondary objectives were to compare pain VAS scores at 48 and
72 hours and to compare the incidence of excessive sedation, depression
of respiratory rate, and GCS.
Methods: A randomized, double blinded controlled trial was used to
evaluate the efficacy of oral oxycodone versus oral codeine. Forty pa-
tients were randomized to the control group of codeine (n = 20) or the
experimental group receiving oxycodone (n = 20), in addition to regular
oral paracetamol for both groups of patients. Analgesia was to be ad-
ministered according to a strict protocol. Patients were reviewed by
blinded assessors closely in the first day and then subsequently once a
day at the 48 and 72-hour postoperatively.
Results: A total of 36 patients were analyzed (4 patients dropped out due
to postsurgical complications). The mean pain scores at 24 hours was
1.85 ± 1.60 and 2.78 ± 1.92 (P = 0.110) in the codeine and oxycodone
group, respectively. There were also no statistically significant difference
in the sedation scores, respiratory rate, and GCS scores.
Discussion: Oral oxycodone is as effective as oral codeine in the man-
agement of postcraniotomy pain. Our local population also seemingly
has very mild pain after a craniotomy (mean pain VAS scores 1 to 3), as
compared with what was reported in the literature. One deduction that
can be made is that compared with the western population, our pop-
ulation probably has minimal genetic variability in the ability to me-
tabolise codeine. Our population may all be efficient metabolisers, thus
allowing codeine to be as effective as oxycodone. Also, as our patients
generally had mild pain, codeine may also be adequate analgesia. As
there is no difference in adverse, oxycodone may also be as safe as
codeine, in bioequivalent doses. Hence, oxycodone can be considered as
an effective alternative to codeine.
EN16-NS15
Outcomes in Carotid Endarterectomy in a Portuguese Tertiary
Care Hospital
I. Correia, H. Meleiro, G. Afonso. Centro Hospitalar de São João,
Portugal.
Background: Carotid endarterectomy (CEA) is the standard treatment of
carotid stenosis for symptomatic and asymptomatic patients. Indications
and outcomes of CEA are based in clinical multicentre trials, where
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
patients and hospitals included were highly selected. The purpose of the
study is to describe patient’s characteristics, anesthesia and surgical
techniques, including short-term outcome in our institution.
Methods: A retrospective study was conducted in patients scheduled for CEA
between October 2014 and July 2015. Data were obtained from electronic
clinical charts. Variables included: demographic data, anesthesia and surgical
technique, postoperative complications, and hospital stay. Exclusion criteria:
simultaneous CEA and cardiac surgery. All analysis were calculated with
SPSS 20.0. P-value < 0.05 was considered to be statistically significant.
Results: Of 104 patients, a total of 89 patients were included, 100% ASA III,
83% (n = 74) were men, median ages of 69 (Q1, 62; Q3). In total, 47%
(n = 42) of the patients were symptomatic. A total of 93% (n = 83) were
submitted to deep and superficial cervical plexus block (DSCPB) and 7%
(n = 6) to general anesthesia. Four patients with DSCPB were converted to
general anesthesia, 2 for poor cooperation and 2 for changes in consciousness.
Conventional CEA was performed in 88% of the patients (76% with patch-
closure technique and 12% with direct suture). Eversion CEA was performed
in 12% of the patients. Surgery last a median of 118 minutes (Q1, 87; Q3, 130)
and cross-clamp lasts 37 minutes (Q1, 29; Q3, 50). In 4% carotid shunt was
done. Postoperative complications: death 2% (n = 2). Neurological compli-
cations: stroke 4% (n = 4), cranial nerve dysfunction 4% (n = 4), intra-
operative consciousness deterioration 13% (n = 12). Non-neurological
complications: hypertension 38 (n = 43%), myocardial infarction 1% (n = 1),
pneumonia 1% (n = 1), cervical hematoma 13% (n = 12). Hospital stay:
Intermediate Care Unit (median 1 day [Q1, 1; Q3, 1], ward 2 [Q1, 1; Q3, 4]).
Conclusions: CEA was performed in accordance with international
standards although a significant morbidity complicating this procedure
occurred in our institution. A prospective study should determine risk
factors of these complications.
EN16-NS16
Vascular Rupture During Surgery of Herniated Lumbar Disk
E. Guerra Hernández, Z. Hussein Dib González, P. Aguado Garcı́a, R.
Fariña Castro, L. Grosso, T. Sarmiento, A. Rodrı́guez Pérez. Hospital
Universitario de Gran Canaria Doctor Negrı´n, Spain.
Background: Lumbar discectomy is a frequent surgical procedure with good
functional results and a low incidence of severe surgical complications.
Case Report: A 42-year-old man with lumbosciatica, secondary to a L4-
L5 herniated disk was scheduled for surgical treatment. A L4-L5 lam-
inectomy was performed and the herniated disk was removed. While
manipulating the disk, the patient began to bleed and experience arterial
hypotension. After the dissection of the hernia, the bleeding increased
accompanied by arterial hypotension and refractory tachycardia to
vasopressors. A vascular injury was suspected, so the patient was placed
in a supine position, an emergency laparotomy was carried out and
vascular surgeon detected a rupture of the iliac artery and laceration of
the iliac vein. After surgery, the patient was taken to postsurgical critical
care unit and discharged from these at 48 hours without sequelae.
Discussion: The main complications of laminectomy—discectomy surgery are
vascular injuries, followed by visceral injuries. Vascular injuries are the most
serious intraoperative complications with an incidence of 0.01% to 0.17% of
patients with a mortality of 15% to 61%. Early detection is fundamental for
the survival of the patient. The diagnostic method of choice is angio-CT or
abdominopelvic CT without contrast. In the case of hemodynamic instability
and signs of severity an emergency exploratory laparotomy and immediate
consultation with general and vascular surgeons are recommended.
Learning Points: Vascular complications after disk surgery are rare, but
serious. They should be suspected, diagnosed, and treated early to pre-
vent the patient’s death. The most frequent vascular injury is to the iliac
artery followed by the cava or iliac vein. It is recommended to always be
in contact with a vascular or general surgeon if assistance is needed.
EN16-NS17
Duty of Candour: Honesty When Things go Wrong
S.W. Holly Chamarette. The National Hospital for Neurology and Neu-
rosurgery, London, UK.
Background: The Care Quality Commission has put in place a require-
ment for health care providers to be open with patients and apologise
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Supplement: EuroNeuro 2016
when things go wrong. This duty applied in the UK from November
2014. The aim of the legislation is to ensure that patients are told about
patient safety incidents that affect them. The process starts once a Datix
form is submitted. If moderate or greater harm has occurred the incident
handler will inform the patient’s Consultant. The Consultant should
have a conversation with the patient, an open discussion about what
happened, an apology, and agreement about what will happen next,
including whether the patient wishes to be kept informed of any findings
and what will be done to prevent someone else being harmed. The aim of
the study was to see if targets involving Duty of Candour are being met.
Methods: Data from March to October 2015 was gathered from the
Quality and Safety Team. We looked at neurosurgery within Queen
Square, to see how many incidents had been reported on Datix and
whether or not they complied with the Duty of Candour process.
Results: 94.7% compliant with Duty of Candour. However, only 24% of
“returns to theatre” were reported during that same time frame (of 29
cases, 22 had no Datix reports).
Category of Harm Moderate Severe Contributed to Death Total
Incidents reported 9 6 4 19
Compliant with DoC 9 5 4 18
Discussion: Although the compliance with Duty of Candour is sig-
nificant, under reporting of unexpected returns to theater means that we
are only looking at the tip of the iceberg. This requirement is a difficult
culture change for surgeons. A reluctance to engage in this process may
relate to the perception that reporting is onerous or may have further
personal consequences.
Conclusions: Duty of Candour represents a substantial administrative and
cultural change that will take time to fully embed as people learn how to
reconcile incidents with the definitions of harm. It is posible to comply with
the Duty of Candour process; however, this can only be achieved if Datix
forms are submitted. We must encourage surgeons to lead the pathway to a
learning culture by recognizing the requirement to report errors and be
open and honest with their patients when things go wrong.
Reference:
Care Quality Commission. 2015. http://www.cqc.org.uk/content/
regulation-20-duty-candour.
EN16-NS18
Postoperative Requirements After Elective Craniotomies
M. Fontanals Caravaca, E. Carrero, R. Valero, J. Tercero, P. Hurtado,
N. Fàbregas. Hospital Clı´nic de Barcelona, Spain.
Background: There are no formal criteria for postoperative care of pa-
tients undergoing elective craniotomies.1 In our institution, overnight
monitoring in the intensive care unit (ICU) is the protocol for most
patients. The goal of this study is to identify which group of patients
could benefit of not requiring overnight ICU care.
Methods: An observational study was carried out for 6 months including
all consecutive elective craniotomies. Demographic data, type of surgery,
postoperative level of care: ICU or Post-Anesthesia Care Unit (PACU),
risk factors2 and complications (Clavien-Dindo classification)3 during
the first 48 hours were analyzed. The incidence of complications ac-
cording to postoperative level of care and risk factors were studied.
Results and Discussion: Eighty-six patients (age 18 to 84 y, 52% female)
were included. ICU group: 74 patients, PACU group: 12 patients. Sur-
geries in PACU group were: biopsy (n = 1), neuroendoscopy (n = 1),
epilepsy surgery (n = 2), deep brain stimulation surgery (n = 3), and
pituitary surgery (n = 5). Complications were registered in 23/86 pa-
tients, all in the ICU group: grade 1 = 11, grade 2 = 5, grade 3b = 7,
grade 4 = 0, and grade 5 = 0. Twenty-four (89%) patients in the ICU
group did not present complications nor risk factors: pituitary surgery
(n = 7), supratentorial tumor resection (n = 7), epilepsy surgery (n = 5),
neuroendoscopy (n = 2), vascular surgery (n = 2), and deep brain
stimulation surgery (n = 1) (Fig. 1). In ICU group patients presenting
risk factors were 47 (64%), from those 27 (57%) did not present com-
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FIGURE 1: Complications according to unit of admission, risk factors, and type of surgery.
plications, majoritary patients under supratentorial surgery 9 of 13
(69%) and posterior fossa 16 of 24 (66%).
Conclusions: First, PACU admission criteria was optimal. Second, patients
admitted in the ICU, without risk factors, have low probability to present
postoperative complications. Patients scheduled for Supratentorial Surgery
without risk factors could benefit of not requiring overnight monitoring in
the ICU. More research is needed for proper selection of patients.
References:
1. Hanak BW, Walcott BP, Nahed BV, et al. Postoperative intensive care
unit requirements after elective craniotomy. World Neurosurg. 2014;
81:165–172.
2. Wanderer JP, Anderson-Dam J, Levine W, et al. Development and
validation of an intraoperative predictive model for unplanned
postoperative intensive care. Anesthesiology. 2013;119:516–524.
3. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo
classification of surgical complications: five-year experience. Ann
Surg. 2009;250:187–196.
EN16-NS19
National Survey on Postoperative Circuits After Neurosurgical
Procedures in Spain
N. Saiz-Sapena, R. Valero, E.J. Carrero, F. Iturri, on behalf of Section
of Neurosciences of the Sociedad Española de Anestesiologı´a y Rean-
imación. Section of Neurosciences of the Sociedad Española de Anes-
tesiologı´a y Reanimación (SEDAR), Spain.
Background: To know organizational aspects of hospital circuits in the
postoperative care of patients undergoing neurosurgical procedures in Spain.
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Methods: A national survey carried out between June and October 2014
by the Section of Neurosciences of the SEDAR (Spanish Society of
Anesthesia and Critical Care) on the peroperative treatment of the
neurosurgical patient. The survey questioned about the existence of a
postoperative monitoring protocol, the responsible of its design, and the
factors that were considered for its preparation; It also questioned about
postoperative destination of the patient, who decides destination, and
which types of wards were available for neurosurgical patients according
to the procedure they have undergone. Participants were enquired about
the type of unit depending on the type of surgery, which specialist
(neurosurgeon, anesthesiologist, intensivist, others) is responsible for
postoperative treatment, availability of specialized nurses for the post-
operative care of the neurosurgical patient, availability of neurosurgical
assessment protocols, monitoring according to the type of surgery, and
expected length of stay depending on the type of postoperative care unit.
Finally, mean time to discharge depending on the type of surgery was
also scored.
Results: We obtained a total of 45 answers from 30 hospitals (41.09% of
the hospitals in Spain). The national survey revealed differences among
hospitals greater than expected, having big university hospitals neuro-
surgical care units with much better equipment and specialized staff.
Other smaller hospitals failed either in terms of equipment or specialized
units or dedicated staff, even when the general postoperative care of the
patient met safety standards.
Conclusions: This national survey offers actual information on the cur-
rent way different hospitals with neurosurgical activity manage its pa-
tients, depending on their personnel and resources. Because of those
differences, there is no standard of care of the neurosurgical patient in
terms of postoperative care circuits.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
EN16-NS20
Use Of ICM+ Software in the Management of Cerebral Spinal
Fluid Pathology at Hospital Clinic Barcelona: Preliminary
Experience
J.J. González Sánchez, J. Torales, L. Reyes, S. Garcı́a, T. Topzcewski,
J. Enseñat. Department of Neurological Surgery, Hospital Clinic,
Barcelona.
Background: Our objective was to describe the initial experience with
ICM+ software (University of Cambridge) to monitor intracranial
pressure and cerebral spinal fluid (CSF) pathologic conditions in our
Department of Neurosurgery.
Methods: Authors started using ICM+ software in April 2015. During
this period, we have monitored 35 patients. We have carried out 15
infusion tests, 4 overnight (24 h) intracranial pressure (ICP) monitoring,
11 external ventricular drainage, and 5 ventricular-peritoneal shunt
monitoring. ICP raw data, heart rate, AMP (ICP wave amplitude), and
intracranial pressure-volume compensatory reserve index (RAP) were
acquired in all patients. We specifically registered cerebrospinal fluid
outflow resistance (Rout) during infusion test, different ICP wave
pattern rates during overnight ICP monitoring and ICP variations due
to tilt position and catheter occlusions when performing shunt and
ventricular external drainage registrations.
Results: All patients could be monitored without incidences. No in-
fections were registered due to invasive procedures (lumbar or shunt
reservoir taping). In the group of infusion test patients, ICM+ gen-
erated final results faster than previous used methods thanks to infusion
test automatic calculation software. In all cases, ICM+ provided new
data besides raw ICP values (RAP and ICP AMP) that allowed us taking
final decisions with more accuracy. Dynamic tests (tilt and occlusion
tests) during ventricular external drainage and shunt monitoring were
really useful to determine the need for definitive shunt implantation or
the need for shunt revision. ICM+ avoided external CSF drainage over-
manipulation before deciding the need for definitive shunt. No patients
required final shunt implantation after removing external ventricular
drainage based on ICM+ results. In all cases of shunt registration,
ICM+ allowed us to localize the place of shunt malfunction before
system surgical revision.
Conclusions: ICM+ implantation in our Department has improved the
management of patients with primary or secondary hydrocephalus. The
use of ICM+ in the clinical setting has allowed authors to improve
previous used test (ie, infusion test) in terms of automation and ICP raw
data processing. Moreover, ICM+ has given us new ICP monitoring
tests for patients wearing CSF shunt systems.
PEDIATRIC NEURONESTHESIA
EN16-PN01
Modified Sphinx Position for Surgical Procedures on Scaphoce-
phalic Patients
M.J. Mayorga-Buiza, M.L. Tosca, M. Rivero-Garvia, J. Marquez-
Rivas. University Hospital Virgen del Rocio, Sevilla, Spain.
Background: The development of less invasive surgical techniques allows
for surgical treatment of craniofacial pathologies at earlier ages and in
more complex situations. The modified prone (sphinx) position favors
venous return, protects against cervical, and/or ocular lesions and is safe
and comfortable for neurosurgeons and anesthesiologists, although use
of the technique is not fully extended.
Methods: Descriptive retrospective study of children placed in a modified
sphinx position for simple, multiple, or complex suture procedures over
the past 13 years. Positioning: the patient is placed prone, with a padded
ring, created individually for each patient, supporting the head at the
malar area. This allows the endotracheal tube to be guided and con-
nected to ventilation easily. Cervical hyperextension is avoided by laying
the body in the reverse Trendelenburg position (at 30 to 45 degrees), and
access to anterior or posterior parts is gained by tilting the table. Arms
are placed forward, to favor venous return, and the trunk is stabilized by
means of customized harnesses at the gluteal region. Photographs were
taken during the perioperative period, for analysis by an external expert,
and intraoperative and postoperative complications were evaluated:
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Supplement: EuroNeuro 2016
medullary, radicular and brachial, and ophthalmological lesions.
Monitoring continued until definitive discharge and up to 2 to 4 years
afterwards.
Results: 442 cranial remodelling procedures: 234 sagittal or complex
craniosynostosis procedures requiring a modified sphinx position, 73
endoscopy assisted. There were no cases of accidental extubation, nor
was it necessary to reposition tubing. There were no episodes of intra-
operative edema or vascular lesions that could not be controlled. In 1
patient a small lesion to the sagittal sinus was caused, which was re-
paired without difficulty; in 2 patients dural tears were repaired without
complications. We observed no case of position-derived complications
during monitoring until definitive discharge.
Conclusions: This position maximizes access to the cranial vault, from
anterior and posterior approaches, in patients with scaphocephaly and
other cranial malformations. Tilting the table to maximize access has no
effect on the initial posture. This position may be used in both endos-
copy-assisted and open procedures and is safe and comfortable for the
anesthesiologist. We consider that this type of procedure, increasingly
frequent at early ages, demands careful consideration and planning with
regard to anesthesiologists.
EN16-PN02
Is Ventricular Endoscopy Safe in Term and Large Preterm
Newborn Infants?
M.J. Mayorga-Buiza, M. Rivero-Garvia, J. Marquez-Rivas. University
Hospital Virgen del Rocio, Sevilla, Spain.
Background: Neuroendoscopic third ventriculostomy (NTV) is described
as a safe technique for the management of obstructive hydrocephalus in
children. Nevertheless, some reported complications are serious or even
lethal, and anesthesiologists need to react accordingly.1
Method: We analyzed retrospectively all cases of newborns that received
NTV over the previous 2 years in our hospital. Surgical indication,
anesthetic management, and surgery-derived complications arising dur-
ing and immediately after surgery were evaluated.
Results: During the study period, 12 newborns (aged 0 to 30 d) received
NTV in the center. Hospital protocol was followed in all cases: in-
halation anesthesia, noninvasive blood pressure, and peripheral perfu-
sion (1 or 2 lines) monitoring. Postoperative care was provided in an
ICU. All patients were extubated in ICU, having required MV for an
average of 48 hours. We observed no cases of bleeding in surgery or any
of the other intraoperative complications described in the literature. The
only complications deriving from the procedures were 2 cases of con-
vulsions in the first 24 hours and 1 case of septic meningitis.
Conclusions: Neonatal NTV is a safe technique when performed by ex-
pert pediatric neurosurgeons and anesthesiologists.
Reference:
1. Baykan N, Isbir O, Gerc¸ek A, et al. Ten years of experience with
pediatric neuroendoscopic third ventriculostomy: features and peri-
operative complications of 210 cases. J Neurosurg Anesthesiol. 2005;
17:33–37.
EN16-PN03
Let us Save the Brain With Cerebral Oximetry
I.S. Seker, O. Ozlu, A. Ozkan. Duzce University Faculty of Medicine,
Turkey.
Background: In newborns tracheal atresia and tracheoesophageal fistula
surgery may result in hemodynamic instability leading to cerebral per-
fusion insufficiency because of pulmonary vessels and truncus brachio-
cephalic retraction.
Case Report: A male newborn, 40 weeks gestational age and body weight
3150 g was delivered with cesarean section. He was meconium stained
and was transferred from state hospital to the university hospital at the
first postpartum day, because of tracheo-eosophageal atresia (EA/TEF).
He has spontaneous ventilation with 70 to 80 breaths per minute and
mild hypotonic and lethargic. A lot of white foamy oral secretion was
aspirated. Respiratory rough ratles were auscultated. Hemodynamic
parameters were stable. Thoracoscopic primary repair of EA/TEF by
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right thoracotomy was planned at the third day of birth. Anesthesia was
induced using pentothal (5 mg/kg), fentanyl (4 mg), and rocuronium
(0.5 mg/kg) intravenously. Sevoflurane 2% and 50% O2: in air were used
for maintenance. The neonate positioned in a semiprone position, his
right side elevated and right arm placed above his head. During right
lung compression to expose posterior esophagus, no values was observed
with pulse oximetry probe placed on right hand, and radial artery was
not palpated. At the same time, oxygen saturation was observed as 96%
to 97% by left foot probe. Because right cerebral oximetry values (rSO2)
were decreased to 31% rapidly, the lung compression was ceased. Right
pulse oximetry and right rSO2 values were returned to baseline. Also
pupillary anisocoria was observed (right/left: 3/1 mm) during right lung
compression. Whenever rSO2 < 40%, operation was ceased throughout
the procedure (Fig. 1). At the end of the operation he was transferred to
the newborn intensive care unit. He was extubated at the ninth post-
operative hour without any respiratory or hemodynamically instability.
Discussion: During the newborn operations involving the great vessels,
the cerebral perfusion could be preserved using cerebral oximetry.
Learning Points: Cerebral oximetry is more efficient than pulse oximetry
for detecting cerebral tissue oxygenation and could be helpful to mini-
mize neuronal damage in newborn infant.
References:
1. Broembling N, Campbell F. Anesthetic management of congenital
tracheoesophageal fistula. Pediatr Anesth. 2011:21;1092–1099.
2. Tortoriello TA, Stayer SA, Mott AR, et al. A noninvasive estimation
of mixed venous oxygen saturation using near-infrared spectroscopy
by cerebral oximetry in pediatric cardiac surgery patients. Pediatr
Anesth. 2005:15;495–503.
FIGURE 1: rSO2 trend values during the procedure.
EN16-PN04
A Comparison of Dexmedetomidine and Propofol as Sole Sedative
Agent for Children Undergoing Cerebral Magnetic Resonance
Imaging Examination: a Randomized Prospective Study
T. Saber Souissi, F. Moadh, H. Ines, B.K. Siwar, M. Nidhar, K. Chokri.
National Institute of Neurology, Tunisia.
Background: Cerebral magnetic resonance imaging (MRI) procedures
require deep sedation to prevent patient’s movement while maintaining
respiratory and hemodynamic stability. Dexmedetomidine (D) is a
highly selective alfa2-adrenergic receptor agonist with both analgesic and
sedative properties and no major cardiorespiratory depression. In this
study we compare the efficacy and safety of dexmedetomidine versus
propofol (P) in children undergoing cerebral MRI.
Methods: Sixty patients of ASA I and II, aged from 1 to 7 years, scheduled
for cerebral MRI were included in this randomized prospective study. Vital
parameters were monitored continuously and recorded at 5 minutes intervals
during the study period. Exclusion criteria were patients with heart or lung
disease, extremity trauma, allergy to any of the study medications, emergency
procedures, and patient who had received any study drug in the last 30 days.
Patients were taken into the MRI room after a Rosen Sedation Score of 2
were achieved. The protocol was in group D (n = 30), an initial dose of D
2 mg/kg was infused IV over 10 minutes followed by a maintenance infusion of
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
1 mg/kg/h and in group P, propofol was infused IV over 10 minutes at 2.5 mg/
kg, followed by a maintenance infusion of 4 mg/kg/h. If a Rosen score of 2
was not achieved, a second bolus of 2 mg/kg of D or 1 mg/kg of P was
repeated in group D or P, respectively, over another 10 minutes before the
start of the maintenance infusion. All Children were not given premedication
and patients who continue to move after the second bolus or while the pro-
cedure is in progress were excluded from the study. The quality of the MRI
examination was evaluated by a radiologist using a 3-point scale. Discharge
criteria were the return of vital signs and level of consciousness to baseline.
Results: Demographic details were similar between the 2 groups. Seven
patients in the D group and 10 patients in group P had transient hy-
potension that was improved following administration of fluids and no
requirement of inotropic or vasopressor therapy. Bradycardia occurred
in 8 patients of group D but there were no manifestations of bradicardia
in group P. Nine patients of P group had a significant decrease in SpO2
following bolus administration, which was not seen in group D. Three
patients of group P presented apnea necessitating manual ventilation.
Bradypnea occurred in 8 patients of group D and did not warrant any
intervention. Dexmedetomidine was associated with prolonged recovery
time compared with propofol. MRI examination was successfully com-
pleted in 59 patients: 1 patient from group D was excluded and the
quality was significantly better in group D than in group P.
Conclusions: Compared with propofol, no complications were seen in
any child who received dexmedetomidine. We conclude that dexmede-
tomidine represents an effective medication to use for successful sedation
for cerebral MRI in pediatric patients.
EN16-PN05
Tuberous Sclerosis Syndrome: an EEG-based Case Report of 2
Male Siblings
K. Jha, Y. Kumar, T. Kumar, R. Singh, L.Tiwari, S. Kumari. All India
Institute of Medical Sciences, Patna, India.
Background: Tuberous sclerosis is one of the rare genetic disorders of
autosomal dominant inheritance with varied presentation.1,2 We de-
scribe 2 cases of tuberous sclerosis here born to same parents.
Case Report: The cases were male progeny from same parents presented to
AIIMS Patna and evaluated for seizure in the Department of neuro-
physiology. Case I: A 2 and 1/2-year-old male child reported with seizure.
First episode of seizure reported at an early age of just 10 days, associated
findings included periventricular calcification, multiple depigmented patches
and mesenteric lymphadenitis. EEG revealed 1 to 2 Hz delta activities
evolving to hypsarrhythmic pattern with diffuse sharp waves and episodes of
high frequency activities with multiple frontal spikes and waves. Case II: 5-
month-old male sibling of the previous case with history of normal prenatal
development except for the prenatal diagnosis of cardiac hamartomatous
reported with first episode of seizure. EEG depicted similar features with
generalized burst suppression and diffuse multifocal epileptiform waves and
trains of 12 to 14 Hz high voltage sinusoidal discharges.
Discussion: A case scenario with 2 under 5 male siblings with classic pre-
sentations of tuberous sclerosis complex. Early seizure (10 d), strikingly
similar seizure pattern and EEG features marks it a unique case for study.
Learning Points: It is a rare case scenario of early childhood presentation
of TS affected siblings with classic EEG features.
References:
1. Goh S, Kwiatkowski DJ, Dorer DJ, et al. Infantile spasms and
intellectual outcomes in children with tuberous sclerosis complex.
Neurology. 2005; 65(2):235–238.
2. Kano T, Satoh Y, Mori M. Renal angiomyolipoma: report of 2 cases
of tuberous sclerosis in female siblings. Hinyokika Kiyo. 1984;30(8):
1057–1062.
EN16-PN06
Perioperative Complications in Pediatric Endoscopic Third Ven-
triculostomies: 5 Years Revised
C. Costa*, P. Santos*, L. Pintow, J. Oliveira*. *Centro Hospitalar São
joão. wFaculdade de Medicina Universidade Porto, Portugal.
Background: Neuroendoscopy is routinely used in pediatrics and endo-
scopic third ventriculostomy (ETV) is the treatment of choice in obstructive
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
hydrocephalus.1,2 Perioperative complications range from 5% to 30% and
are duo to surgical maneuvres that lead to neurological and hemodynamic
disturbances.3,4 Our aim is to describe the perioperative complications as-
sociated with pediatric ETV in our institution.
Methods: A retrospective study was conducted between January 2010
and June 2015. We included patients submitted to ETV with less than 18
years of age. Data collected: age, sex, diagnosis, anesthesia technique,
intraoperative monitoring, intraoperative complications, postoperative
complications, and Intensive Care Unit length of stay (ICULOS). For
descriptive analysis we used Fisher’s Exact Test, Mann-Whitney U and
Kruskal Wallis (version 22 SPSS).
Results: Thirty-eight patients were enrolled, 15 male and 23 female. Thirty-
seven percent were younger than 3 years old. The majority were treated for
tumors (42%), aqueductal stenosis (21%), and cysts (18%). Sevoflurane
(79%) was mostly used for anesthesia maintenance. Regarding invasive
monitoring, 58% had invasive arterial pressure (IAP). Intraoperative he-
modynamic complications included tachycardia (24%), bradycardia
(18%), and hypertension (11%). Neurological postoperative complications
included seizure (11%), nystagmus (8%), myoclonus (5%), and headache,
meningitis, and hemiparesis (3%). Respiratory complications were need
for reintubation (8%) and pneumonia (5%). Fever appeared in 21% of
cases. ICULOS median was 5.5 days. The neurosurgical diagnosis inter-
fered with ICULOS (P = 0.013). Patients with intraoperative bradycardia
(P = 0.044) had longer ICULOS. Patients with intraoperative complica-
tions are more likely to have a neurological postoperative complication
(P = 0.086). No statistical significance was found between intraoperative
complications and age or PAI monitoring.
Conclusions: Perioperative complications after ETV may adversely in-
fluence patient’s outcome and invasive monitoring (IAP and intracranial
pressure) allow early recognition and treatment.1-3 IAP should have been
used in all patients and we aim to measure pressure inside the endoscope
so that neurological and cardiorespiratory complications decrease as
well as ICULOS.
References:
1. Fàbregas N, Craen RA. Anaesthesia for endoscopic neurosurgical
procedures. Curr Opin Anaesthesiol. 2010;23:568–575.
2. Meier PM, Guzman R, Erb TO. Endoscopic pediatric neurosurgery:
implications for anesthesia. Paediatr Anaesth. 2014;24:668–677.
3. Schubert A, Deogaonkar A, Lotto M, et al. Anesthesia for minimally
invasive cranial and spinal surgery. J Neurosurg Anesthesiol. 2006;18:
47–56.
4. Salvador L, Hurtado P, Valero R, et al. Importance of monitoring
neuroendoscopic intracranial pressure during anesthesia for neuro-
endoscopic surgery: review of 101 cases. Rev Esp Anestesiol Reanim.
2009;56:75–82.
EN16-PN07
Anesthetic Management of Children With Cervical Spine Injury:
A Retrospective Review of 112 Cases
Ch. Vikas, G.P. Singh, G.P. Rath. Department of Neuroanaesthesiology
and Critical Care, All India Institute of Medical Sciences, New Delhi,
India.
Background: Not much has been described in the literature on the an-
esthetic management of children with cervical spine injury.
Methods: After approval from Institute Ethics Committee, medical re-
cords of children (aged 18 y and below) with cervical spine injury who
underwent admission and treatment from October 2008 to September
2015, in our center were reviewed, retrospectively. As per age, they were
divided into 2 categories, that is, age 8 years and below and 8 to 18 years.
Various data were collected with regard to demographics, mode, type,
and the level of injury, presence of canal compromise, American Spinal
Injury Association (ASIA) Impairment Scale at admission and discharge,
anesthetic induction, intraoperative complications, duration of surgery
and anesthesia, duration of postoperative mechanical ventilation, and
hospital stay. ASIA scale of D and E were regarded as Good Outcome
while scales of A, B, C or death were taken as Poor Outcome.
Results: A total of 112 children with cervical spine injuries were admitted
and received treatment during the study period. Among them 101 chil-
dren underwent surgery for the fixation of the injury to cervical spine. 16
patients were in the age group 0 to 8 years and 96 in 8 to 18 years,
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
respectively. Children in age group 0 to 8 years (56.3%) had better outcome
as compared with those in 8 to 18 years age group (39.6%). “Fall” con-
stituted as the major cause of injuries (n = 68, 69.6%). Majority of the
children had injury to upper cervical spine (58.9%). Spinal canal was
compromised in 77.4% of children; they had poor outcome. A total of 45
(40.17%) patients suffered complications during hospital stay. Of these 37
(82.23%) had poor outcome. Anesthesia was induced with intravenous
agents and was maintained with inhalational anesthetics, in all the children.
In majority of the children, the airway was secured with fibreoptic-guided
intubation (62.4%). A total of 9 children died, owing to varying reasons.
Conclusions: The overall outcome was good in 41.96% patients. The
outcome was poor in children of age group 8 to 18 years, who had canal
compromise, ASIA scale at admission A, B, or C, and those who suf-
fered complications during the hospital stay.
EN16-PN08
Seizures in Per Operative Brainstem Tumor in Pediatric Patients
A.L. Linder Alcantara, L. Carlos Salles, Ch. Marcio. Instituto Estadual
do Cerebro Paulo Niemeyer, Brazil.
Background: Despite the prevalence of seizures in children with in-
fratentorial tumors be 6%, we found few reports of its impact on per
operative setting.1
Case Report: A 9-year-old female patient (33 kg) previously healthy, on
clinical examination reported symptoms of vomiting and dizziness a year ago
and was treated for gastroesophageal reflux with no improvement. After 9
months magnetic resonance imaging was performed and brain stem affecting
the right portion of medulla and right cerebellar peduncle was diagnosed.
Patient began treatment before surgical intervention with dexamethasone
4 mg/6 hours 1 week before. Admitted in the operating room induction with
Oxygen under mask and started TIVA with remifentanil 0.5 mg/kg/min,
Propofol 150 mg/kg/min, and dexmedetomidine 0.5 mg/kg/h, held 20 mg ro-
curonium for intubation. Monitored with ECG, pulse oximetry, NIBP, PAI,
BIS, esophageal thermometer and capnography. Jointly held neuro-
physiological monitoring SSEP, PEM, PEA-TC, EMG, and EEG throughout
the intraoperative. Patient operated in prone position, performed by median
access subocciptal craniotomy. Patient remained stable, however during me-
dulla manipulation presented generalized tonic-clonic movements, hyper-
tension, sudden drop in signal BIS monitoring and evoked potential. Held
bolus of propofol 2 mg/kg, with improvement.
Discussion: Despite having no history of seizures, the evidence observed
during complications leads us to think of seizure.
Learning Points: Neuro physiological monitoring, convulsive pre-
operative crisis, brain stem tumor, brain tumor pediatric patient.
Reference:
1. Quarante LH, Mena-Bernal JH, Martı́n BP, et al. Posterior reversible
encephalopathy syndrome (PRES): a rare condition after resection of
posterior fossa tumors: two new cases and review of the literature.
Childs Nerv Syst. 2015. [Epub ahead of print].
EN16-PN09
Guidelines for Dual Approach of Craniopharyngioma by Cra-
niotomy and Simultaneous Access Transphenoidal in Pediatric
Patients
A.L. Linder Alcantara, L. Carlos Salles, A. Accioly Guasti, S.M. Souza
de Lima. Instituto Estadual do Cerebro Paulo Niemeyer, Brazil.
Background: Due to the low incidence of simultaneous surgical approach
for craniopharyngioma, it becomes necessary to establish guidelines for
the preparation of this type of patient, mainly because it is a pediatric
patient.1 The presence of 2 surgical teams and the distance of the an-
esthesiologist in relation to the patient must be taken inito account.
Case Report: A 7-year-old patient, 24 kg, diagnosed with craniophar-
yngioma before craniotomy, but with the tumor above the component
and infraselar with consequent compression of the optic chiasm. On
admission into the operation room, the patient was administered Mid-
azolam 3 mg IV as preanesthetic medication along with remifentanil
0.5 mg/kg/min, propofol 100 mg/kg/min, dexmedetomidine 0.3 mg/kg/h,
and intubation with rocuronium 20 mg. Monitored with ECG, pulse
oximetry, NIBP, PAI, precordial Doppler, capnography, hourly diuresis.
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Patient position was supine, with right leg exposure. A surgical team was
positioned at the head of the surgical field and the other to the right. The
left side was occupied by the microscope and endoscope and the anes-
thesia team was positioned at the bottom of the surgical field. Caring of
the venous access’s prolongation for protecting the arms and legs due to
the distance that remained of the patient, precordial Doppler to air
embolism monitoring and heartbeat, collected blood tests for serum so-
dium verification and hourly diuresis to observe possible polyuria.
Discussion: Knowledge of the particularities of each pathology as well as
the positioning and access road makes neuroanesthesia a complex
specialty, especially for handling of a pediatric patient. The dual access
to craniopharyngioma resection, in addition to being rare, still requires a
lot of studies to evaluate the potential complications, and it cannot be
considered, therefore, a simple sum of 2 access roads.
Learning Points: Craniopharyngioma, pterional access, tranesfenoidal
access, pediatric patients.
Reference:
1. Venegas E, Concepcion B, Martin T, et al. Practice guideline for
diagnosis and treatment of craniopharyngioma and parasellar tumors
of the pituitary gland. Endocrinol Nutr. 2015; 62 (1): E1–13.
EN16-PN10
Anesthetic Management for Tetralogy of Fallot (TOF) With
Cerebral Abscess: A Retrospective Review of 52 Children
S.K. Dube*, M. Nitasha*, I. Kapoor*, G.P. Rath*, S. Mohapatraw.
*Department of Neuroanaesthesiology and Critical Care. wDepartment of
Microbiology; All India Institute of Medical Sciences, New Delhi, India.
Background: Intracranial abscess in children is one of the most serious
complications of congenital cardiac defect. Most of our current knowledge
on the management of these children is based on clinical reports empha-
sizing on the surgical aspects of the problem. However, the reports on
anesthetic management of the children with tetralogy of Fallot (TOF) un-
dergoing craniotomy for evacuation of intracranial abscess are rare. Hence,
a retrospective study was undertaken to analyze the anesthetic management
of children of TOF with brain abscess who underwent surgical evacuation.
Methods: After approval from the institutional ethics committee, data of
patients presenting with TOF and intracranial abscess between January
2001 and March 2013 were reviewed.
Results: Total 52 patients (46 male and 11 female) with TOF with brain
abscess were reviewed. The median age was 5 years. Common modes of
presentation were fever (75%), headache (33%), seizures (30%), vomiting
(30%), neurological deficit (20%), and difficulty in feeding (7%). Frontal lobe
was the commonest site of abscess localization (70%). Four patients under-
went prior correction for cardiac defect before abscess drainage. Common
preoperative problems encountered were electrolyte abnormality (45%),
coagulopathy (40%), and metabolic acidosis (35%). Majority of the patients
(91%) received general anesthesia (GA) for abscess drainage. Mode of in-
duction of anesthesia was primarily intravenous (89%) and in 11% cases
sevoflurane was used for induction. Most common intravenous agent used
was thiopentone (65%) followed by ketamine (21%), propofol (10%), and
etomidate (4%). Anesthesia was maintained with sevoflurane/isoflurane along
with intermittent boluses of fentanyl and rocuronium/vecuronium. We had 5
mortalities in our study group and was due to cardiac arrhythmia/hemody-
namic instability/hyper cyanotic spell. There was no difference in adverse
patient outcome between the patients who received GA or local anesthesia
and between the patients who had intravenous or inhalational induction.
Conclusions: The type of anesthetic technique does not affect the outcome
in children with TOF with intracranial abscess. Intravenous technique was
the preferred mode of anesthetic induction in children of TOF with brain
abscess with thiopentone or ketamine being the most common choices.
EN16-PN11
Posterior Fossa Surgery in Children
S. Serrano-Casabón, D. Artés-Tort. Anesthesiology department. Sant
Joan de Deu Hospital. Barcelona University, Barcelona, Spain.
Background: The most common brain tumors in children are posterior
fossa tumors. The aim of this study was to identify common complications
during the perioperative period of posterior fossa tumors resection in our
hospital.
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
Methods: We performed a retrospective review of the posterior fossa
resections done in our hospital, from January 2005 to July 2015. We
collected demographic data, initial neurological status and outcome,
position during surgery, hemodynamic changes, and incidence of venous
air, blood transfusion requirement, polyuria, infection, and days in in-
tensive care unit (ICU).
Results: We could collect data from 67 patients. Mean age was 8.5 years
(range, 11 d to 18 y). 54% were male. Anesthesia was performed with pro-
pofol, remifentanyl, and cisatracurium. All patients had standard monitoring,
BIS and central line (91% internal jugular v.) and arterial line (86.6% radial
a.) insertion. A total of 32 patients were operated in the sitting position, 21 in
park-bench position and 14 in prone position. Significant hemodynamic
changes during surgery were collected. Hypotension in 11 patients (16.4%),
hypertension in 12 patients (17.9%), bradycardia in 20 patients (29.9%), and
tachycardia in 5 patients (7.5%). These changes were related with surgical
stimulus. We had 4 cases of venous air embolism (6%). In all cases the patient
was in the sitting position, which means 12.5% of patients in the sitting
position. In total, 24 patients (35.8%) needed red blood cell transfusion during
surgery. Five patients (7.5%) presented diabetes insipidus and were treated
with desmopressin. Surgery lasted 7 hours (range, 5 to 10 h). Only 9 patients
were extubated at the end of surgery. A total of 44 patients were extubated
within the 24 hours after surgery. ICU mean stay was 7 days (range, 1 to
18 d). During the postoperative period in ICU, 7 patients presented hyper-
tension and bradycardia due to raised intracranial pressure. Neurological
outcome worsened in 6 patients. No deaths were collected.
Conclusions: Intraoperative complications are usually related to the posi-
tion of the patient during surgical resection, the stimulation of vital
structures (floor of the fourth ventricle, medullary reticular formation,
pons, nerves V, IX and X) and blood loss. Close monitoring is very im-
portant and anesthesiologists should be prepared to treat hemodynamic
changes and cardiac arrhythmias. During the postoperative period special
care should be taken in monitoring high intracranial pressure events.
EN16-PN12
Late Onset Pompe Disease With Severe Kyphoscoliosis for
Posterior Correction of Deformity: the Anesthetic Considerations
P. Tan, J. Chan, S. Belaja, N. Esa. Department of Anaesthesia and
Intensive Care, Sarawak General Hospital, Sarawak, Malaysia.
Background: Late-onset Pompe disease is characterized by progressive
respiratory and skeletal muscle weakness with virtually no cardiac
symptoms.1,2
Case Report: A 17-year-old adolescent (26 kg, 135 cm) with late onset
Pompe disease associated with kyphoscoliosis (Cobb’s angle, 115 degrees)
and severe restrictive lung disease presented for posterior correction of
deformity. He has hypoventilation syndrome with type II respiratory
failure requiring nocturnal noninvasive ventilation at home. Awake fi-
breoptic-guided intubation was performed in view of his restricted neck
extension. Anesthesia was maintained with target-controlled infusion of
propofol and remifentanil with avoidance of muscle relaxant. Intra-
operative neuromonitoring (somatosensory-evoked potential and trans-
cranial motor-evoked potential), entropy, invasive blood pressure, and
central venous pressure monitoring were instituted. Surgery was com-
plicated with massive blood loss (2.5 times of blood volume) requiring
massive transfusion of autologous and allogenic blood and blood prod-
ucts. The managing team decided to halt the procedure in view of the
stormy surgical course. The second stage of correction was performed 2
weeks later which was associated with even more blood loss (3.5 times of
blood volume) and massive blood transfusion. He was successfully
weaned to noninvasive ventilation on day 1 after both stages of surgery
and had an uneventful recovery though after a prolonged stay in hospital.
Discussion: Preexisting muscle weakness and respiratory morbidity may
complicate perioperative course. Concerns include loss of airway control
and rapid desaturation during induction, increased risks of aspiration, ate-
lectasis, lung infections, and protracted mechanical ventilation. A compli-
cated spinal surgery involving major fluid shifts as illustrated requires
attention to the probable complications of massive blood transfusion like
fluid overload and transfusion-related acute lung injury that may further
compromise the underlying pulmonary impairment. Furthermore, it is a
potential difficult challenge steering the patient through multiple anesthetics
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
for staged operations as he may be sensitive to the cardiorespiratory de-
pressant effects of the anesthetic drugs. Neuromuscular blockade should be
monitored (its use is usually unnecessary but if unavoidable reduced doses
are recommended) and suxamethonium should be avoided due to the risks
of rhabdomyolysis and hyperkalaemia.
Learning Points: Late onset Pompe disease with respiratory insufficiency
presents the practitioner with unique challenges perioperatively. A suc-
cessful outcome was the result of a multidisciplinary approach enabling
early planning and timely problem solving.
References:
1. Cilliers HJ, Yeo ST, Salmon NP. Anaesthetic management of an
obstetric patient with Pompe disease. Int J Obstet Anesth. 2008;17:
170–173.
2. Kim WS, Cho AR, Hong JM, et al. Combined general and epidural
anesthesia for major abdominal surgery in a patient with Pompe
disease. J Anesth. 2010;24:768–773.
NEURORADIOLOGY
EN16-NR01
Incidence of Contrast-induced Acute Kidney Injury at a Major
Tertiary Interventional Neuroradiology Centre
M. Patek*, S. Paynew. *Advanced Neuroanaesthesia Trainee, Queen
Elizabeth University Hospital, Glasgow, Scotland. wClinical Research
Fellow, University of Glasgow, Scotland, UK.
Background: Contrast-induced acute kidney injury (CIAKI) is a com-
plication of intravenous contrast administration for interventional
neuroradiology procedures. CIAKI is associated with significant mor-
bidity and mortality.1 We sought to determine the incidence of CIAKI at
our institution by retrospective data analysis.
Methods: All patients undergoing endovascular management of intracranial
aneurysm in 2014 were identified retrospectively from theater logbooks. These
logbooks were also used to ascertain duration of procedure and volume of
contrast used. Blood results were retrieved from the Clinical Portal laboratory
database. CIAKI was diagnosed biochemically according to KDIGO defi-
nitions2: serum creatinine rise by Z26 mmol/L within 48 hours or rise Z1.5-
fold from the baseline value within 1 week of contrast administration.
Results: A total of 182 endovascular procedures for treatment of cerebral
aneurysm were undertaken in 2014. Most of these procedures were
emergencies (n = 114, 62.6%) and most patients were female (n = 134,
73.6%). The average age of patients was 54.8 years (range, 19 to 90 y).
The average duration of procedure was 2:08 hours (range, 1:05-4:45 h),
and average volume of contrast used was 131.3 mL (range, 41 to
290 mL). Three patients (1.6%) developed CIAKI. None had preexisting
renal dysfunction and all procedures were emergencies.
Discussion: The incidence of CIAKI in patients undergoing endovascular
management of cerebral aneurysms at our institution is comparable to
other available data.3 However, studies of neuroradiology populations
are scarce and differing criteria for diagnosing CIAKI make compar-
isons difficult. Data on urine output were not available and our inability
to identify oliguria may lead to an underdiagnoses of CIAKI.
References:
1. Valette X, Parienti JJ, Plaud B, et al. Incidence, morbidity, and
mortality of contrast-induced acute kidney injury in a surgical in-
tensive care unit: a prospective cohort study. J Crit Care. 2012;27:
322.e1–322.e5.
2. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kid
ney Injury Work Group. KDIGO clinical practice guideline for acute
kidney injury. Kidney Int Suppl. 2012;2:1–138.
3. Prasad V, Gandhi D, Stokum C, et al. Incidence of contrast material-
induced nephropathy after neuroendovascular procedures. Radiology.
2014;273(3), 853-858.
EN16-NR02
Assessment of Outcome of Patients With Carotid Cavernous
Fistula Undergoing Embolization in Neuroradiologic Suite
G. Singh Tomar, H. Prabhakar, Ch. Mahajan, I. Kapoor, P.K. Bithal.
All India Institute of Medical Sciences, New Delhi, India.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
Background: Goal of this study was to assess the early outcome of pa-
tients with carotid cavernous fistula (CCF) undergoing balloon/coil
embolization under general/local anesthesia with primary outcome of
condition at discharge (in terms of relief of symptoms) and duration of
hospital stay and perioperative adverse events such as hemodynamic
instability, hyperperfusion syndrome, mortality, etc.
Methods: All admitted patients with CCF for use of their medical records
were included from year 2010 to 2015 at our institution in retrospective
analysis. Data on patient demographics, clinical presentation, CCF
morphology, embolization materials, degree of obliteration on an im-
mediate postembolization angiogram and on a delayed follow-up an-
giogram, procedure-related complications, preembolization clinical
status, and clinical outcomes at discharge and at follow-up were collected
for each patient. Study has been registered with CTRI/2015/11/006349.
Results and Discussion: Of 32 patients enrolled, 2 were excluded from data
analysis as procedure was abandoned because of anatomic difficulty in
access. Median age of patients with CCF at presentation time was 32.9
years (range, 48) and were mostly male (81.25%). Majority of patients
diagnosed with traumatic type direct CCF (83.34%) and presented with
sign/symptoms of proptosis (93.34), decrease in vision (63.34%), chemosis
(56.67%), diplopia (43.34%), ptosis (13.34%), altered sensorium (6.67%),
third (20%) and sixth cranial nerve palsy (6.67%). Ten (33.34%) cases
were carried out under general anesthesia and coil embolization. Totally
83.34% patients showed improvement in sign/symptoms (vision im-
provement immediately within 24 h) of which 10% were partially embol-
ized and improved. Median duration of hospital stay was 8.6 days (range,
26). Among postprocedural complication, headache was noticed among
70% patients and 13.34% had balloon displacement. Unfortunately 1
patient died after 30 days of coil embolization diagnosed to have coexisting
SAH with aneurysmal rupture and underwent neurosurgery.
Conclusions: To conclude, endovascular therapy in form of coil embo-
lization or balloon occlusion is the preferred treatment for most CCFs.
Endovascular treatment offer better results with a less invasive ap-
proach, avoiding the difficult surgical drilling, the associated morbidity
from affected cranial nerves and residual fistulas.
EN16-NR03
General Anesthesia for Mechanical Thrombectomy in a Tertiary
UK Hospital
G. Bose, V. Mehta, N. Qadir, G. Kakkar, R. Mittal. Department of
Neuroanaesthesia, Royal Stoke University Hospital, Stoke-on-Trent, UK.
Background: Endovascular recanalization by mechanical thrombectomy
(MT) is used as one of the treatments for acute ischemic stroke. This
study is to describe the incidence, timelines, outcomes, and complica-
tions associated with general anesthesia (GA) for MT in our unit.
Method: Retrospective analysis was conducted on all patients requiring
GA for MT in our unit from 2010 to 2015. Demographic and clinical
information obtained from the Stroke Open Registry included National
Institute of Health Stroke Scale (NIHSS) at presentation, 24 hours and 1
week, modified Rankin Scale at 90 days, intervention timelines, hemo-
dynamic control, and causes of mortality.
Results and Discussion: A total of 160 patients requiring GA for MT
were identified, accounting for 84.7% of all MTs performed in our unit
over this period. Patients with posterior circulation strokes (16.3%) and
those intubated for transfers from other units (23.1%) were included in
our study. This may explain the high incidence of GAs in our unit. The
mean age was 63 ± 14 years. Median NIHSS on presentation was 17
(interquartile range, 13 to 21). Almost 66% of patients requiring GA had
either moderate to severe or severe stroke. Mean values for anesthetic
time and time to groin puncture were 17 ± 11 and 18 ± 9 minutes, re-
spectively. Average time from admission to recanalization was
240 ± 138 minutes. Blood pressure was maintained within 15% of the
baseline in 73% of patients. A total of 48.1% patients had a favorable
outcome (modified Rankin Scale r2) at 90 days, compared with 15%
quoted in the study by Davis.1 In comparison to 25% mortality in the
GA group in the study by Mcdonald,2 the overall mortality in our study
was 17%, with pneumonia accounting for a fourth of these deaths.
Conclusions: Various confounding factors may affect the outcome of
patients undergoing MT for acute ischemic stroke, including the choice
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Supplement: EuroNeuro 2016
of anesthesia and the NIHSS on presentation. However, in patients re-
quiring GA for MT, outcomes can be improved and mortality reduced
by achieving better hemodynamic control, ensuring effective oxygen-
ation and ventilation and reducing time delays between symptom onset
and endovascular recanalization.
References:
1. Davis MJ, Menon BK, Baghirzada LB, et al; Calgary Stroke Pro
gram. Anesthetic management and outcome in patients during en-
dovascular therapy for acute stroke. Anesthesiology. 2012;116:
396–405.
2. McDonald JS, Brinjikji W, Rabinstein AA, et al. Conscious sedation
versus general anaesthesia during mechanical thrombectomy for stroke:
a propensity score analysis. J Neurointerv Surg. 2015;7:789–794.
EN16-NR04
Comparison of a Single Dose of Dexmedetomidine and Clonidine
in the Control of Postanesthesia Shivering in Patients Undergoing
Endovascular Treatment of Ruptured Intracranial Aneurysms
S. Thamlaouiw, M. Farhatw, K. Ben Khlifaw, N. Maatarw, H. Souissi*,
Ch. Kaddourw. *National Institute of Neurology. wHospital Aziza
Othmana, Tunis, Tunisia.
Background: Shivering is a common postanesthesia adverse event in
patients undergoing general anesthesia. Clonidine (CLO) is known to
reduce and control the postanesthesia shivering (PAS). In this study we
compare the effectiveness of Dexmedetomidine (DEX), a centrally acting
a2-adrenergic agonist to CLO in suppressing the PAS, in patients un-
dergoing endovascular treatment of ruptured intracranial aneurysms.
Methods: Totally 40 ASA physical status I-II patients with a WFNS and
FICHER grade I-III were enrolled in this prospective, double-blinded study.
Patients were randomly allocated into 2 groups: group D (n = 20) received
DEX 1 mg/kg; group C (n = 20) received CLO 50 mg. DEX and CLO were
diluted by an investigator who was not involved in the study to a volume of
50 mL and presented as coded syringes. In the end of the procedure, drug was
administered intravenously over 10 minutes by the same anesthesiologist
during all the period of the study. The ambient temperature maintained at
201C to 211C and the postanesthesia care unit temperature was kept between
251C and 261C. The intravenous fluids were administrated at room temper-
ature and given without inline warming. All patients were actively warmed
after the end of the procedure. At the completion of drug administration,
shivering was assessed every 10 minutes over 50 minutes in the postanesthesia
care unit and graded as 0 = no shivering, 1 = mild fasciculation of the face or
neck, 2 = visible tremor involving >1 muscle group, 3 = gross muscular
activity involving the entire body. During the study vital parameters and
axillary temperature were monitored. Side effects and complications were
recorded. Time to extubation and duration of procedure was noted and the
treatment that stopped shivering was considered successful.
Results: There were no significant differences between the 2 groups in
terms of age, sex, weight, ASA status, WFNS grade, FISHER grade, time
to extubation, duration of procedure and grade of shivering. During
shivering the axillary temperature values decreases significantly compared
with baseline values (P < 0.05), but it did not differ between the groups.
The time taken for cessation of shivering was less in group D than in C.
By the end of the drug infusion, shivering was controlled in all patients of
group D, 3 patients of group C had incomplete response to drug but their
grade decreases to 1. In all patients no recurrences of shivering were
occurred. Nausea and vomiting were observed in 4 patients of group C.
Conclusions: We conclude that DEX is more effective compared with
CLO for control of PAS, due to higher response rate, lesser recurrence,
and lesser complications such as nausea and vomiting. More patients are
needed to confirm results.
EN16-NR05
Bilateral Wada Test With Etomidate and Bilateral Bispectral
Index Monitoring
C. Costa*, M. Veigaw, P. Santos*, G. Durães*. *Centro Hospitalar São
João, Porto. wHospital Central Funchal, Funchal, Portugal.
Background: The Wada test is used in preoperative evaluation of epi-
leptic patients to determine memory and language lateralization. It is a
procedure in which a short-acting anesthetic is injected in the internal
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
carotid artery (ICA) through a femoral catheter. The bilateral bispectral
index VISTA monitoring (BVMS) detects changes in the EEG and in the
power spectrum distribution through the density spectral array and
shows hemispherical asymmetry if present.1–3 We report a patient sub-
mitted to Wada test in which BVMS was useful to evaluate asymmetry
and EEG changes during the procedure.
Case Report: A 34-year-old woman, ASA III, left handed, with drug
resistant epilepsy due to right temporal and amigdalo-hypocampal
cortical dysplasia was scheduled for a Wada test. She was medicated
with levotiracetam 1500 mg/12 hours, valproic acid 1000 mg/12 hours,
eslicarbazepine 800 mg/12 hours, and presented no neurological deficits.
A pretest angiography was performed to access catheter placement and
arterial vascularization. The injection of contrast in both ICA revealed
that only the left side was associated with flow to the contralateral
hemisphere. The right ICA was injected first with a 1 mL etomidate
(2 mg/mL) bolus during 30 seconds that result in left hemiplegia for 39
seconds. BVMS showed right baseline asymmetry (70%), but at this
point asymmetry (20%) and BIS values decreased. Although not sig-
nificant, the right BIS had a minimum of 70 and the left was a stable 81.
After the etomidate bolus, a perfusion at 6 mL/h was initiated and the
memory of the contralateral hemisphere was tested. The perfusion
stopped after 3.1 minutes and total recovery occurred after 4.1. BVMS
showed a predominance of alfa waves, BIS values and asymmetry return
to baseline. The same method was used for the injection in the left
hemisphere, but in this case the BVMS showed a decrease in BIS to 81 in
both sides. They concluded that the surgical treatment should result in
memory disturbance.
Discussion: In this case, the injection in the affected side resulted in
different BIS values between hemispheres and a decreased in asymmetry
when compared with baseline. The contralateral injection resulted in
similar BIS on both sides that can be explained by the flow to the op-
posite hemisphere. Either way, BVMS allows characterization of base-
line state and responses to anesthetic and therefore it can be a helpful
tool in Wada test.
References:
1. Heller H, Hatami R, Mullin P, et al. Bilateral bispectral index mon
itoring during suppression of unilateral hemispheric function. Anesth
Analg. 2005;101:235–241.
2. Pacreu S, Vila E, Rodrı́guez C, et al. Changes in bilateral bispectral
index VISTA monitoring system during Wada test. Rev Esp Anestesiol
Reanim. 2014;61:579–582.
3. Mariappan R, Manninen P, McAndrews MP, et al. Intracarotid
etomidate is a safe alternative to sodium amobarbital for the Wada
test. J Neurosurg Anesthesiol. 2013;25:408–413.
EN16-NR06
Mechanical Thrombectomy for Acute Ischemic Stroke Treatment
Under General Anesthesia. Experience in a Tertiary Hospital
M. Garcia-Orellana, M. Mariscal, O. Romero, MA. Castaño, C. Jimé-
nez, J. Camiña, S. Miralbés. Son Espases Hospital, Palma de Mallorca, Spain.
Background: Use of general anesthesia (GA) during mechanical throm-
bectomy of acute ischemic stroke patients is controversial with some
suggestion of worse outcomes and death.1,2 We evaluate our outcomes
after thrombectomy performed under GA after the implementation of a
fast-track program in patients with acute ischemic stroke.
Methods: An observational retrospective analysis of all consecutive pa-
tients undergoing mechanical thrombectomy in our hospital between
December 2014 and October 2015 was performed. GA management
involved intubation and inhaled anesthetic agents. Demographic data
(sex, age, ASA), stroke characteristics (location, basal NIHSS), groin
puncture time, duration of the intervention, and outcomes (satisfactory
recanalization, disability, and survival) were collected.
Results: A total of 55 patients entered the study. The median age of
presentation was 68 years (range, 24 to 81, 43.6% were women). The
average ASA was 2.27. Basal NIHSS was 18 (6 to 25). The median from
the onset of symptoms to the groin puncture was 260 minutes (190 to
240). The median of anesthetic time before the procedure was 30 minutes
(10 to 50). The median of procedural duration was 40 minutes (10 to
160). Satisfactory recanalization (TICI 2b-3) was 89.09%. Intraoperative
complications related to procedure were: vessel perforation 2 (3.63%),
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
dissection 1 (1.81%), that had no impact on outcomes or mortality in
our group of patients. Median NIHSS at hospital discharge was 3 (0-19).
Totally, 69% of the patients had a modified Rankin Scale at 3 months
between 0 and 2. Mortality within 7 days was 9.09%. Symptomatic
intracranial hemorrhage within 7 days occurred in 3.63% of the patients.
Discussion: GA assures airway protection, allows performing shorter
interventions and decreases the risk of vessel perforation/dissection due
to patients’ movement. It may delay the treatment initiation but with the
implementation of a standard operation procedure for intubation
management (fast-track) times of our series are similar to non-GA.1,2
Compared with actual literature, in our experience, endovascular treat-
ment of ischemic stroke under GA is safe and effective.
References:
1. Hassan AE, Akbar U, Chaudhry SA, et al. Rate and prognosis of patients
under conscious sedation requiring emergent intubation during neuro-
endovascular procedures. Am J Neuroradiol. 2013;34:1375–1379.
2. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of
intra-arterial treatment for acute ischemic stroke. N Engl J Med.
2015;372:11–20.
EN16-NR07
Rate of Postinterventional Complications and Discharge Outcome
Among Acute Ischemic Stroke Patients Undergoing General An-
esthesia for Mechanical Thrombectomy
M. Mariscal, M. Garcia-Orellana, O. Romero, M.A. Castaño, I. Le-
garda, J. Camiña, S. Miralbés. Son Espases Hospital, Palma de Mallorca,
Spain.
Background: Use of general anesthesia (GA) during mechanical throm-
bectomy (MT) provides airway protection and immobilization, allowing
shorter and safer procedures.1–3 Some trials report an increased risk of
aspiration pneumonia and death among these patients. We evaluate our
prevalence of postoperative complications (PCs) after MT under GA
with a fast track program in patients with acute ischemical stroke and its
contribution to longer hospital stays.
Methods: An observational retrospective analysis of all consecutive pa-
tients undergoing MT during 11 months was performed. Demographic
data, rates of PCs, outcome at discharge (modified Rankin Scale [mRS])
and in-hospital mortality were analyzed.
Results: Totally 55 patients entered the study, all underwent GA. The
median age of presentation was 68 years (range, 24 to 81, 43.6% were
women). Average ASA was 2.27. Basal NIHSS was 18 (6 to 25). In total,
68% of patients were extubated before their admission in our post-
operative intensive care unit or in <6 hours. The mean of intubation
days of the other 32% of patients was 3 days (1 to 19). Prevalence of
cardiovascular events was 32.7%, being the main cause the arrhythmias
(16.3% of all patients). Prevalence of PCs was 29%, being the main
cause pneumonia (18% of all patients). Symptomatic hemorrhage oc-
curred in 3.63% of patients. Our infectious complications involved:
urinary tract 5.45%, phlebitis 3.63%, and catheter bacteraemia 1.81%.
Median NIHSS at hospital discharge was 3 (0 to 19). Totally 69% of
patients had a mRS 0 to 2 at 3 months. Mortality within 7 days was
9.09%.The mean average of stay in intensive care unit was 1 day (0 to
30) and total was 11 days (1 to 85).
Discussion: Incidence of pneumonia is slightly higher in our group of
patients than in other series.1,2 Our median mRS is satisfactory and the
rate of complications vessel rupture/dissection was very low with no
impact on final outcomes. The rate of mortality at 7 days and hospital
stay is similar to other series.1,2 More randomized prospective studies are
needed to stop recommending GA in these procedures.
References:
1. Hassan AE, Akbar U, Chaudhry SA, et al. Rate and prognosis of
patients under conscious sedation requiring emergent intubation
during neuroendovascular procedures. Am J Neuroradiol. 2013;34:
1375–1379.
2. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of
intra-arterial treatment for acute ischemic stroke. N Engl J Med 2015;
372:11–20.
3. Herrmann O, Hug A, Bösel J, et al. Fast-track intubation for accel
erated interventional stroke treatment. Neurocrit Care 2012;17:
354–360.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Supplement: EuroNeuro 2016
EN16-NR08
Rescue Therapy in Cerebral Vasospasm at St George’s University
Hospital Fondation Trust
C. Fiandeiro, B. Wandschneiderr, J. Madigan, D. Mathew. St George’s
University Hospital, London, UK.
Background: The effective chemical management of refractory cerebral
vasospasm post aneurysmal subarachnoid hemorrhage remains unclear,
largely due to the complexity of the pathophysiology involved. A com-
bination of euvolemic-induced hypertension and intra-arterial vaso-
dilator are currently our rescue management for cerebral vasospasm.
Methods: A retrospective case series of 45 patient notes reviewed un-
dergoing intra-arterial balloon angioplasty and vasodilator therapy over
a 4-year period (2012 to 2015). The patients developed symptomatic
vasospasm after hemorrhage with either a sudden onset of confusion or
a new onset motor deficit and were managed on the neurocritical care.
Results: We had a total of 35 complete case notes, with a mean age of 54
years. The Glasgow Coma Scale prior and within 12 hours postchemical
angiography varied greatly. Days to chemical angioplasty after definitive
treatment with initial coiling (n = 29)/clipping (n = 5) ranged from 1 to
16 days. The dose of nimodipine or nicardipine given was not
standardized. Overall 7 patients died within this period of hospital-
ization, with 3 dying on neurointensive care unit. The average duration
of days on intensive care was 8 days, with patients requiring read-
missions to NITU. Time on the ward was from 3 to 58 days. As we are a
tertiary referral center, patients were repatriated to referral hospital, we
discharged 9 patients home from our hospital. The days to discharge
home from referral hospital ranged 3 to 144 days.
Conclusion: As rescue therapy of intra-arterial vasodilator therapy is
supported by expert opinion1 and is recommended as a low-risk treat-
ment2 in addition to established endovascular therapies, we feel there is a
benefit in including it in out multimodal management of trying to
minimize the disability associated with cerebral vasospasm. We aim to
investigate how we compare with neurosurgical centers nationally and
internationally.
References:
1. Athar MK, Levine JM. Treatment options for cerebral vasospasm in
aneurysmal subarachnoid hemorrhage. Neurotherapeutics. 2012;9:37–43.
2. Ott S, Jedlicka S, Wolf S, et al. Continuous selective intra-arterial
application of nimodipine in refractory cerebral vasospasm due to
aneurysmal subarachnoid hemorrhage. Biomed Res Int. 2014;2014:
970741.
EN16-NR09
“Puff of Smoke” in the Head: Moyamoya Disease in the Italian
Patients
S. Baroni, A. Marudi, F. Ragusa, E. Bertellini. Neuro-ICU, Modena,
Italy.
Background: Moyamoya disease (MMD) is a chronic, cerebrovascular
disease characterized by stenosis or occlusion of the arteries around the
circle of Willis, and development of collaterals vessels. The etiology is
poorly understood, but genetic, acquired and environmental factors
have been implicated.1 The incidence of MMD is higher in Asian
countries. We report 5 cases of MMD in Italian patients, with different
presentation and treatment.
Case Reports: (1) A 55-year-old woman presented epileptic crisis, Glasgow
Coma Scale (GCS) 4/15. Head computed tomography (CT) revealed hema-
toma of basal ganglia with intraventricular hemorrhage; angiography con-
firmed the diagnosis of MMD (Figs.1,2). Endoscopic removal of the
intraventricular hematoma and ventricular drainage were both performed. No
other treatment. Continue rehabilitation. (2) A 17-year-old female presented
headache during sporting activity, nausea, vomiting,vertigo. Negative neuro-
logical evaluation. MR and angiography confirmed the diagnosis of MMD.
No surgical treatment. (3) A 64-year-old woman with a history of hyper-
tension, hypothyroidism, dyslipidaemia, diabetes mellitus, HCV, presented
dysarthria, and right weakness. CT and MR angiography revealed tandem
occlusions of internal carotid artery and middle cerebral artery (MCA). An-
giography: MMD. Treated with intravenous thrombolysis, and surgical by-
pass extracranial-intracranial. (4) A 52-year-old man, with a history of
hyperthyroidism, prostate cancer, smoker, presented weakness left. CT an-
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Supplement: EuroNeuro 2016
FIGURE 1: Angiography confirmed the diagnosis of Moyamoya disease.
giography showed left temporal-parietal ischemic stroke from occlusion left
MCA and aneurism right MCA. Angiography confirmed MMD. No treat-
ment. Follow-up. (5) A 63-year-old man. Sudden loss of consciousness with
GCS 12/15 (E3,V3,M6). CT: thalamic hemorrhage and ventricular invasion.
Angiography: MMD. No treatment, only rehabilitation.
Discussion: We observed 2 different presentation of MMD, ischemic, and
hemorrhagic. Only 2 cases underwent surgical treatment.
Learning Point: MMD occurs predominantly in Japanese individuals but
has been found in all races with varying age distributions and clinical
FIGURE 2: Angiography confirmed the diagnosis of Moyamoya disease
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J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
manifestations. Treatment of MMD remains a challenge. A careful
follow-up is necessary.
Reference:
1. Pandey P, Steinberg GK. Neurosurgical advances in the treatment of
moyamoya disease. Stroke. 2011;42(11):3304–3310.
EN16-NR10
Anesthesia for Bypass Surgery in Moyamoya
F. Santos, P. Santos, G. Durães. Centro Hospitalar de São João, Porto,
Portugal.
Background: Moyamoya is an uncommon idiopathic and cerebrovascular
disease characterized by bilateral stenosis of the internal carotid artery
and the proximal portion of the middle and anterior cerebral arteries with
collateral vasculature proliferation called “moyamoya vessels.” It mani-
fests as cerebral ischemia or intracranial hemorrhage. There is strong
evidence that the direct or indirect revascularization may reduce the risk
of complications and is associated with better prognosis.1
Case Report: Female, 37 years, ASA III proposed for direct cerebral re-
vascularization with anastomosis of the superficial temporal (STA) with the
middle cerebral artery. Personal history: moyamoya disease with cognitive
impairment, previous stroke, multiple transient ischemic attack, and
hypertension. Medication: bisoprolol, candesartan/hydrochlorothiazide, spi-
ronolactone, acetylsalicylic acid, amlodipine, and levetiracetam. After neuro-
surgical evaluation and considering the pathology as well as the presence of
multiple foci of ischemia, surgery was scheduled. Standard monitoring of ASA,
invasive blood pressure and neurological monitoring: BIS, Cerebral oximetry
INVOS, tissue O2 pressure LICOX O2, and cerebral blood flow HEMEDEX
were used. It was carried out in an intravenous anesthesia: propofol, re-
mifentanil, and rocuronium. The anesthetic objective was neuroprotection,
favoring normocapnia to maintain cerebral oximetry and cerebral blood flow
stable, normothermia, normoglycemia, and tension-profile no less or more
than 20% from baseline. Intraoperative Doppler of the STA showed no flow
so the surgical option was encephaloduroarteriomyosynangiosis. Postoperative
period progressed without complications in the neurological intensive care unit
and the patient was extubated 12 hours after computed tomographic
control.
Discussion: Because of the chronic nature of cerebral ischemia and debili-
tating moyamoya disease, several procedures of cerebral revascularization
have been proposed to allow an increase in cerebral blood flow. It is vital that
the anesthesiologist has the proper knowledge of the implications and possible
complications that may occur.1 Despite the scarce literature, there is con-
sensus on a neuroprotective strategy for a chronically ischemic brain: privilege
of normocarbia—maximizing cerebral perfusion; normothermia; normovo-
lemia; close monitoring of blood pressure and aggressive treatment of anemia
to maximize oxygen delivery to tissues. The multimodal neuromonitoring
allowed the optimization of these parameters.
Reference:
1. Chong CT, Manninen PH. Anesthesia for cerebral revascularization
for adult moyamoya syndrome associated with sickle cell disease.
J Clin Neurosci. 2011;18:1709–1712.
EN16-NR11
Anesthesia and Brain Volumes on MRI
CH. Ng*, AKY. Leew. *Student, Faculty of Medicine, National
University of Singapore. wConsultant Department of Anaesthesiology,
Singapore General Hospital, Singapore.
Background: Control of brain volume is important in neurosurgery, but
there is little data on quantitative changes of brain volume under an-
esthesia. This study aims to understand the anesthesia-induced changes
in brain volume quantitatively.
Methods: We analyzed retrospective data from 15 patients who underwent
elective intracranial tumor resection in Singapore General Hospital in 2014.
Totally 2 preoperative magnetic resonance imaging (MRI) brain scans were
obtained for each patient, 1 outpatient scan without anesthesia, and 1 under
anesthesia just before surgery. Intracranial cerebrospinal fluid, gray matter,
and white matter volumes were quantified by processing the MRI brain scans
using an autosegmentation algorithm in 3D Slicer software. Preanesthetized
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Neurosurg Anesthesiol  Volume 28, Number 2S, April 2016
and postanesthetized brain volumes were compared. Demographics, drug
doses, end-tidal CO2, mean arterial pressures (MAPs), and other clinical pa-
rameters were analyzed to identify factors associated with changes in brain
volume.
Results: We studied 8 females and 7 males between 31 and 78 years of age.
Seven patients were anesthetized using total intravenous anesthesia (TIVA)
with propofol and remifentanil. Eight patients were anesthetized with sev-
oflurane at an end-tidal concentration <2%. The average end-tidal CO2
under anesthesia was 30 mm Hg, ranging from 21 to 37 mm Hg. Two MRI
scans could not be segmented. The change in brain volume under anesthesia
ranged from +6% to  6% compared with the preanesthetized state. The
average change was +2% in patients under TIVA and 0% in patients under
sevoflurane. The MAP fell by 5% in patients under TIVA, and fell by 19%
in patients under sevoflurane. The largest falls in MAP were associated with
the biggest decreases in brain volume. We found no significant change in
brain volume directly related to the use of anesthesia alone. The finding that
the largest falls in MAP were associated with the biggest decreases in brain
volume may be interesting for further research. We did not look at the
effects of active maneuvres to reduce brain volume perioperatively. Our
study limitations include the small sample size, lack of baseline end-tidal
CO2 measurements, and possible contributions of tumor growth.
Conclusions: We have demonstrated that anesthesia alone does not cause
significant changes in the volume of brain tissue. Interestingly, the largest
falls in MAP were associated with the biggest decreases in brain volume.
EN16-NR12
Interference of Blood Pressure Control Within 24 Hours in Acute
Ischemic Stroke. Systematic Review
A. Alves da Silva, G.J. Martiniano Porfı́rio, G. Sampaio Silva, A. Nagib
Atallah. Universidade Federal São Paulo, São Paulo, Brazil.
Background: Review the evidence on how acute variation in blood pressure
(BP) during first 24 hours of acute ischemic stroke can influence outcome,
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
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Supplement: EuroNeuro 2016
consider interesting preliminary evidence that without intervening medi-
cations may be superior to some use of drugs in modifying acute rise in
BP, and suggest that BP may decline spontaneously without administration
of medication may also have an influence on the acquired disabilities.
Methods: We searched the Cochrane Central Register of Controlled
Trials (CENTRAL) (The Cochrane Library 2015, Issue 12); MEDLINE
(1954 to July 2015); EMBASE (1980 to July 2013); CINAHL (1982 to
July 2015), database of Research in Stroke (2008 to 2015), Latin
American and Caribbean Health Sciences Literature (LILACS) (1982 to
December 2015), and reference lists of articles. We contacted researchers
in the field. Inclusion criteria were: (1) age 18 to 75 years; (2) clinical sign
with the diagnosis of ischemic stroke; (3) treatment onset within 3 to 9
hours after stroke onset; and (4) no prior neurological event that would
obscure the interpretation of the signal and current presenting neuro-
logical deficits. Review authors will work independently to assess risk of
bias by using criteria described in the Cochrane Handbook for SR to
assess trial quality. If the raters disagreed, the final rating was made by
consensus, with the involvement of another member of the review group.
When inadequate details the authors of the studies were contacted in
order to obtain further information. Primary outcomes: death or de-
pendency at the end of scheduled follow-up. Dependency is defined as
being severely dependent on others in activities of daily living, or being
significantly disabled; this corresponds to a Barthel Index score or a
modified Rankin Scale grade 3 to 6 at 3 months’ follow-up. Secondary
outcomes: (1) standardized nondisease-specific instrument for describing
and valuating health-related quality of life. EQ-5D (EuroQol) ques-
tionnaire. (2) The NIHSS measure of neurological deficit; the Barthel
Index measure of activities of daily living; the modified Rankin Scale
measure of the degree of disability or dependence in daily activities 90
days follow-up. (3) Average time of hospital discharge. (4) Time to
discharge from the neurointensive care unit or neurocritical care unit. (5)
Assessment of systolic and diastolic BP control. (6) Causality assessment
of adverse events following BP reduction within 24 hours of acute is-
chemic stroke.
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