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A drawing for the main branches responsible for the cutaneous sensory innervations of the forehead and scalp.
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![Ramsay sedation scale [23].](publication/339112886/figure/tbl1/AS:856263395131392@1581160510193/Ramsay-sedation-scale-23_Q320.jpg)
Methodology: Forty patients were randomly allocated into 4 equal groups based on LA mixture used for scalp block: Group I:received 1.5 mg/kg bupivacaine 0.25% + 5 mg/kg lidocaine 1% with 1:200,000 epinephrine. Group II:same as Group I + 8 mg dexamethasone. Group III:same as Group I + 500 mgMgSO4. Group IV:same as Group I + 8 mgdexamethasone + 500 m...
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Awake craniotomy with language mapping is being increasingly applied to avoid postoperative language dysfunctions worldwide. However, the effectiveness and reliability of this technique remain unclear due to the paucity of studies comparing the awake craniotomy with general anesthesia. To determine the benefit of awake craniotomy for language, moto...
Introduction: The use of dexmedetomidine with concurrent scalp block is increasingly being utilized as an effective and safe anesthetic approach for awake craniotomy (AC). Dexmedetomidine is an alpha-2 adrenergic receptor (α2-AR) agonist with dose-dependent sedative, analgesic, and anxiolytic properties while preserving respiratory function. The ch...
Background:
Valproic acid (VPA) represents one of the most efficient antiseizure medications (ASMs) for both general and focal seizures, but some patients may have inadequate control by VPA monotherapy. In this study, we aimed to verify the hypothesis that excitatory dynamic rebound induced by inhibitory power may contribute to the ineffectiveness...
Introduction and importance:
Brain abscess is an uncommon but potentially fatal infection of the brain parenchyma that can affect 5 % to 18.7 % of people with uncorrected complex congenital heart defects. In management of patients with complex cardiac defects, the main concern is that they are prone to develop perioperative complications. Hence su...
Background
Cystic meningioma is a rare variety with similar histological profiles like the solid tumors. It has been documented in both supratentorial and infratentorial compartments presenting radiologically as a large cyst with mural nodule mimicking hemangioblastoma.
Case Description
We managed a middle-aged woman who presented with recurrent s...
Citations
... A study comparing the infiltration of bupivacaine combined with lidocaine with and without adjuvants found that adding dexamethasone, magnesium sulfate, or both to a scalp block before an awake craniotomy resulted in improved block effectiveness during the intraoperative and postoperative periods. 19 During the operative procedure, the patient in this case was able to communicate effectively, maintained active contact, and was fully conscious, with stable hemodynamic status. There were no incidents of desaturation, and the patient did not report significant pain or experience nausea and vomiting. ...
Background: Awake craniotomy is a neurosurgical procedure performed while the patient is conscious and cooperative, commonly used to remove brain tumors or epileptic foci located close to brain regions that control in real-time critical functions such as speech, movement, or vision.Case: A 26-year-old male presented to Haji Adam Malik Hospital, Medan with progressive blurred vision in both eyes and headaches over three months diagnosed with secondary headache due to intracranial space-occupying lesions (SOL) (thalamic glioma). The patient was referred to a neurosurgical colleague for further treatment in the form of a craniotomy. The craniotomy was performed using awake anesthesia techniques for the excision of diffuse glioma in the thalamic region. The awake anesthesia technique involved intravenous premedication with 0.25 mg atropine sulfate, 5 mg dexamethasone, 50 mg phenytoin, 2.5 mg diazepam, 100 mcg fentanyl, and dexmedetomidine administered at 20 mcg/hour to achieve the desired sedation level. Prior to incision, infiltration was performed in the area to be incised using 0.75% ropivacaine 20 ml mixed with 2% lidocaine 4 ml, and before the burr hole was made in the cranium, 50 mcg fentanyl was administered intravenously. The surgery proceeded according to protocol, and the patient was transferred to the recovery room.Discussion: Awake craniotomy requires clear communication for brain mapping, making severe aphasia and respiratory disorders like sleep apnea contraindications. Dexmedetomidine is favored for sedation due to its minimal respiratory effects. Local analgesia with ropivacaine and lidocaine ensures pain control and hemodynamic stability, reducing opioid use. The lack of bispectral index monitoring to assess sedation depth is a noted limitation.Conclusion: Considering the benefits and challenges associated with awake surgery, the use of this method should be considered on an individual case basis to ensure surgical success and patient safety.
... detect level of consciousness as previously reported by our team. [18] For patients who underwent surgery under GA, total intravenous anesthesia protocol was performed with avoidance of halogenated inhaled agents, which can increase the latency and decrease the amplitude of evoked potentials. In addition, if motor mapping is indicated, chemical muscle relaxants must be avoided. ...
Background
Multidisciplinary pre-surgical evaluation is vital for epilepsy surgery decision and outcomes. Resective epilepsy surgery with assisted monitoring is currently a standard treatment for focal drug resistant epilepsy (DRE). In resource-limited countries, lack of epilepsy surgery center is a huge challenge. We presented and illustrated how to create a multidisciplinary protocol with resource-limited settings in a developing country and epilepsy surgery outcome using brain mapping and monitoring techniques for ensuring satisfactory resection.
Methods
We created multicentric incomplete but complementary units covering all epilepsy-related sub-specialties and covering a wide geographical area in our country. Then, we conducted a prospective and multicentric study with low resource settings on patients with focal DRE, who underwent resective epilepsy surgery and were followed up for at least 12 months and were evaluated for postoperative seizure outcome and complications if present. Preoperative comprehensive clinical, neurophysiological, neuropsychological, and radiological evaluations were performed by multidisciplinary epilepsy team. Intraoperative brain mapping including awake craniotomy and direct stimulation techniques, neurophysiological monitoring, and electrocorticography was carried out during surgical resection.
Results
The study included 47 patients (18 females and 29 males) with mean age 20.4 ± 10.02 years. Twenty-two (46.8%) patients were temporal epilepsy while 25 (53.2%) were extra-temporal epilepsy. The epilepsy surgery outcome at the last follow up was Engel Class I (seizure free) in 35 (74.5%), Class II (almost seizure free) in 8 (17%), Class III (worthwhile improvement) in 3 (6.4%), and Class IV (no worthwhile improvement) in 1 patient (2.1%).
Conclusion
With low resource settings and lack of single fully equipped epilepsy center, favorable outcomes after resective surgery in patients with focal DRE could be achieved using careful presurgical multidisciplinary selection, especially with using intraoperative brain mapping and electrocorticography techniques.
... With some variations in different centers, propofol, remifentanil, and dexmedetomidine are frequently used medications in AC [48][49][50] ; however, medication use varies between different centers. Eighteen studies (94.7%) reported the primary analgesic and sedation used in AC. [22][23][24][25][26][27][28][29][30][31][32][33][34][36][37][38][39][40] Propofol/fentanyl combination was used for sedation/ analgesia in 10 studies (52.6%) 22,24,[26][27][28][29][30][31]36,37 (Supplementary Table 3, http://links.lww.com/NEU/D712). Sixteen studies (84.2%) provided information on operation time. ...
... With some variations in different centers, propofol, remifentanil, and dexmedetomidine are frequently used medications in AC [48][49][50] ; however, medication use varies between different centers. Eighteen studies (94.7%) reported the primary analgesic and sedation used in AC. [22][23][24][25][26][27][28][29][30][31][32][33][34][36][37][38][39][40] Propofol/fentanyl combination was used for sedation/ analgesia in 10 studies (52.6%) 22,24,[26][27][28][29][30][31]36,37 (Supplementary Table 3, http://links.lww.com/NEU/D712). Sixteen studies (84.2%) provided information on operation time. ...
... Sixteen studies (84.2%) provided information on operation time. [22][23][24][25][26][27][28][30][31][32][34][35][36][37]39,40 The longest mean operation time was more than 237 minutes, 24 whereas the shortest operation time was 1 hour 33 (Supplementary Table 3, http://links.lww.com/NEU/D712). ...
Background:
Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC.
Objective:
To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa.
Methods:
We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included.
Results:
Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources.
Conclusion:
Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.
... e local anesthetic was bupivacaine-lidocaine mixture with adjuvants as Mg sulfate and dexamethasone as previously reported by our team. [28] Usually 3-5 ml is enough for each nerve. A field block was then applied in the region of the incision. ...
Background
Intraoperative mapping techniques maximize safety and efficacy during perirolandic glioma resection but may induce seizures and limit the procedure. We aim to report the incidence and predictors of stimulation-induced seizures during mapping either patient is awake or under general anesthesia (GA).
Methods
Retrospective analysis of 64 patients (40 awake and 24 GA) with perirolandic glioma underwent resection using intraoperative mapping techniques between 2014 and 2019. Preoperative data, operative details, postoperative neurological status, and extent of resection (EOR) were analyzed. Predictors of intraoperative seizures were assessed.
Results
The mean cortical and subcortical stimulation intensities needed to evoke motor responses were significantly lower in awake cases than in GA patients (4.9 ± 0.42 vs. 8.9 ± 1.2 mA) and (8.3 ± 0.62 vs. 12.1 ± 1.1 mA), respectively ( P = 0.01). Incidence of intraoperative seizures was lower but statistically non-significant in awake cases (10% vs. 12.5%) ( P = 0.76). Preoperative multiple antiepileptic drugs (AEDs) ( P = 0.03) and low-grade glioma ( P = 0.04) were statistically significant predictors for intraoperative seizures. Mean EOR in awake cases was 92.03% and 90.05% in GA cases ( P = 0.23). Postoperative deficits were permanent after 3 months only in 5% of awake patients versus 8.3% of GA group ( P = 0.59).
Conclusion
Awake craniotomy with intraoperative mapping can be done safely for perirolandic gliomas with lower but statistically nonsignificant incidence of intraoperative seizures and this could be attributed to statistically significant lower stimulation intensities required for mapping. Preoperative multiple AEDs and low-grade glioma are significant predictors for intraoperative seizures.
... Adjuvants like opioids, dexmedetomidine 12 , dexamethasone and magnesium sulphate 13 have been investigated by different investigators for their effect on the improvement of the quality and duration of the block with varying results. Meta-analysis of different randomised control studies (RCTs) have demonstrated a consistent reduction of pain severity 14 , which extends 6 hours after craniotomy 15 . ...
... CPB (superficial) can also be attempted under ultrasound guidance too. An ultrasound linear transducer (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) is placed on the lateral neck, overlying the sternocleidomastoid muscle at the level of the cricoid cartilage and then scanning is posteriorly done. The cervical plexus is appreciated as a small assembly of hypoechoic nodules (honeycomb appearance) just superficial to the prevertebral fascia that covers the interscalene groove. ...
Regional anesthesia has been an undervalued entity in neuroanesthetic practice. However, in the past few years, owing to the development of more advanced techniques, drugs and the prolific use of ultrasound guidance, the unrecognised potential of these modalities have been highlighted. These techniques confer the advantages of reduced requirements for local anesthetics, improved hemodynamic stability in the intraoperative period, better pain score postoperatively and reduced analgesic requirements in the postoperative period. Reduced analgesic requirement translates into lesser side effects associated with analgesic use. Furthermore, the transition from the traditional blind landmark-based techniques to the ultrasound guidance has increased the reliability and the safety profile. In this review, we highlight the commonly practised blocks in the neuroanesthesiologist's armamentarium and describe their characteristics, along with their individual particularities.
Intraosseous (IO) catheter insertion and use for the infusion of medications and fluids can be associated with significant pain for conscious patients. Many factors contribute to the severity of pain experienced by patients, including the pressure required for IO infusion, patients’ preexisting pain tolerance, and other patient-specific factors. This chapter describes the anatomical and physiological considerations relevant to pain perception with IO infusion, as well as current and experimental evidence for pain mitigation strategies in awake subjects. Current evidence on the efficacy of existing pain control measures will be discussed, as well as promising areas of future research.
Regional techniques find use as anesthesia and analgesia modalities in children in several clinical scenarios. As anesthesia techniques, nerve blocks are integral to performing awake craniotomy, and some spinal procedures, while as analgesia techniques, they contribute to postoperative analgesia after several neurosurgical procedures. Regional techniques have been well established in the adult population for a long time, but they are gaining popularity among children only recently. As experience grows and expertise develops, these are gaining more acceptance among paediatric neuroanaesthetists, due to their many benefits and very few risks. The principles of these regional techniques are shared with adults, but few salient points stand out, which have been discussed in detail through this chapter. Although less commonly encountered in children, preexisting neurological conditions may have a bearing on utilizing the regional techniques for anesthesia or analgesia. There is an increasing number of children with previous neurosurgery, presenting for a follow-up or an unrelated medical intervention, who may be a candidate for the regional techniques; this aspect is described from the pediatric perspective in the latter part of this chapter.
