Motor evoked potentials (MEPs) are commonly used during surgery for spinal cord tumor resection. However, it can be difficult to record reliable MEPs from the muscles of the lower extremities during surgery in patients with preoperative weakness due to spinal cord compression. In this study, motor function of patients' lower extremities and their association with intraoperative MEP recording were compared.Patients undergoing thoracic spinal cord tumor resection were studied. Patients' motor function was checked immediately before the surgical procedure. MEP responses were recorded from the tibialis anterior and foot muscles, and the hand muscles were used as control. Electrical current with train of eight pulses, 200 to 500 V was delivered through 2 corkscrews placed at C3' and C4' sites. Anesthesia was maintained by total intravenous anesthesia using a combination of propofol and remifentanil after induction with intravenous propofol, remifentanil, and rocuronium. Rocuronium was not repeated. Bispectral Index was maintained between 40 to 50.From 178 lower limbs of 89 patients, myogenic MEPs could be recorded from 100% (105/105) of the patients with 5 of 5 motor strength in lower extremity; 90% (36/40) from the patients with 4/5 motor strength; only 25% (5/20) with 3/5; and 12.5% (1/8) with 2/5 motor strength; none (0/5) were able to be recorded if the motor strength was 1/5.The ability to record myogenic MEPs is closely associated with the patient's motor function. They are difficult to obtain if motor function is 3/5 motor strength in the lower extremity. They are almost impossible to record if motor function is worse than 3/5.
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated syndrome caused by the production of anti-NMDAR receptor antibodies. The syndrome characterised by psychosis, seizures, sleep disorders, hallucinations and short-term memory loss. Ovarian teratoma is the confirmed tumour associated with anti-NMDAR antibodies. The patients with anti-NMDAR encephalitis complicated by ovarian teratoma require surgical treatment under general anesthesia. NMDARs are important targets of many anesthetic drugs. The perioperative management and complications of anti-NMDAR encephalitis, including hypoventilation, paroxysmal sympathetic hyperactivity (PSH) and epilepsy, are challenging for ansthesiologists. This report described two female patients who presented for resection of the ovarian teratoma, they had confirmed anti-NMDAR encephalitis accompanied by ovarian teratoma. Two patients received gamma globulin treatments and the resection of the ovarian teratoma under total intravenous anesthesia. They were recovered and discharged on the 20th and 46th postoperative day respectively. There is insufficient evidence about the perioperative management, monitoring and anesthesia management of anti-NMDAR encephalitis. This report was based on the consideration that controversial anesthetics that likely act on NMDARs should be avoided. Additionally, BIS monitoring should to be prudently applied in anti-NMDAR encephalitis because of abnormal electric encephalography (EEG). Anesthesiologists must be careful with regard to central ventilation dysfunctions and PSH due to anti-NMDAR encephalitis.
Prospective clinical studies on blood pressure (BP) management targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) have recently been published. Our objective was to assess the impact on clinical outcomes of BP management guided by established systolic BP (SBP) targets within the first 24 hours after successful EVT. Four randomized controlled trials (RCTs) including 1556 participants across 5 SBP target settings identified from 5 databases up to September 6, 2023 were included in this systematic review and meta-analysis. All the intensive SBP target groups in these RCTs were combined to facilitate head-to-head comparisons. Patients receiving intensive SBP management had lower risk of 90-day functional independence as assessed by the modified Rankin scale score (relative risk [RR], 0.81; 95% confidence interval [CI], 0.72 to 0.91; I 2 , 12%), excellent outcomes (RR,0.86; 95% CI, 0.75 to 0.99; I 2 , 7%), favorable outcomes (RR, 0.85; 95% CI, 0.78 to 0.92; I 2 , 0%), and quality of life (standardized mean difference, -0.22; 95% CI, -0.35 to -0.10; I 2 ,0%). There were no differences in the probability of any intracerebral hemorrhage (RR, 1.04; 95% CI, 0.92 to 1.19; I 2 ,0%), symptomatic intracerebral hemorrhage (RR, 1.10; 95% CI, 0.76 to 1.60; I 2 , 0%), stroke-related death (RR, 1.16; 95% CI, 0.80 to 1.68; I 2 , 0%), or parenchymal hematoma (RR, 1.71; 95% CI, 0.74 to 3.98; I 2 , 47%) between SBP targets. This meta-analysis provides evidence from RCTs suggesting that intensive SBP control (target<160 mm Hg) may be detrimental to clinical outcomes in AIS patients with successful reperfusion after EVT.
Intraoperative awake anesthesia is a safe and reliable method performed in glioma surgery in brain eloquent areas,for the purpose of a maximum resection of the lesions and protection of brain function.Plasma target-controlled infusion(TCI) is used in the course of opening cranium and closing cranium to maintain optimal sedation,which is supplemented by excellent scalp nerve block for analgesia,and a laryngeal mask is used to secure the patient's airway.During cerebral function monitoring and lesion excision,appropriately modifying the plasma concentration of propofol TCI can make the patient achieve optimal sedation.
Objective
To investigate the clinical characteristic and anesthesia management in patients with pregnancy complicated with cerebrovascular disease.
Methods
We reviewed the clinical data, anesthesia management and outcome of pregnant women with cerebrovascular disease retrospectively from June 2010 to December 2017 in Beijing Tiantan Capital Medical University.
Results
A total of 30 cases of pregnant women with cerebrovascular disease were collected, including 5 cases of ischemic cerebrovascular disease: 3 cases of cerebral infarction, 2 cases of cerebral venous sinus thrombosis, 25 cases of hemorrhagic cerebrovascular disease, 4 cases of moyamoya, 1 case of preeclampsia, 4 cases of aneurysms, 13 cases of arteriovenous malformations, 3 cases of arteriovenous vascular malformation. Five cases underwent neurosurgery before cesarean section. Four cases of caesarean section during the same period of emergency neurosurgy, 6 cases of caesarean section after neurosurgery, and 15 cases of non-neurosurgical treatment after caesarean section. Thirty cases of obstetric anesthesia, including 3 cases in the second trimester and 27 cases in the second trimester, 16 cases of spinal anesthesia, 11 cases of general anesthesia. Two cases resulted in maternal death, 1 case resulted in fetal death.
Conclusions
The management of cerebrovascular diseases in pregnancy should be closely coordinated and managed by obstetrician, anesthesiologist and neurosurgeon. The patient's neurological symptoms, intracranial lesions (hematoma size, site), gestational age and fetal maturity, as well as the desire of pregnancy should be fully evaluated to timely terminate pregnancy and neurosurgical intervention and improve maternal fetal outcome.
Key words:
Pregnancy; Cerebrovascular disease; Anesthesia
Objective There was no study on the effect of lidocaine on postoperative cognitive dysfunction (POCD) in patients after supratentorialtumor surgery.Methods Ninety-four patients undergoing elective supratentorial craniotomy were randomly,double-blindly separated into two groups,lidocaine group (L group,n=46),a dose of lidocaine (2％) was administered as an intravenous bolus (1.5 mg/kg) after induction followed by an intravenous infusion at rate of 2 mg ·kg-1 ·h-1 until the end of surgery,and normal saline group (N group,n=48),0.9％ saline infusion was given in the same volume at the same rate.Results Eighty patients completed preoperative and postoperative neuropsychological tests.There was no significant difference in each preoperative and postoperative neuropsychological test between groups(P＞0.05).The incidence of POCD at one week after surgery in the L group (15.0％) was significantly lower than that in the N group (40.0％)(P＜0.05).The incidence of POCD at one month or longer after surgery was not significantly different between groups (P＞0.05).Conclusions Lidocaine decreased the incidence of POCD in the patients with supratentorial tumor at one week.
Key words:
Anesthesia; Lidocaine; Postoperative cognitive dysfunction; Supratentorial tumor
Abstract Background Patients with intracranial tumors are more sensitive to anesthetics than the general population and are therefore more susceptible to postoperative neurologic and neurocognitive dysfunction. Sevoflurane or propofol combined with remifentanil are widely used general anesthetic regimens for craniotomy, with neither regimen shown to be superior to the other in terms of neuroprotective efficacy and anesthesia quality. There is no evidence regarding the variable effects on postoperative neurologic and neurocognitive functional outcome under these two general anesthetic regimens. This trial will compare inhalational sevoflurane or intravenous propofol combined with remifentanil anesthesia in patients with supratentorial gliomas and test the hypothesis that postoperative neurologic function is equally affected between the two regimens. Methods This is a prospective, single-center, randomized parallel arm equivalent clinical trial, which is approved by China Ethics Committee of Registering Clinical Trials (ChiECRCT-20,160,051). Patients with supratentorial gliomas diagnosed by magnetic resonance imaging will be eligible for the trial. Written informed consent will be obtained before randomly assigning each subject to either the sevoflurane-remifentanil or propofol-remifentanil group for anesthesia maintenance to achieve an equal-desired depth of anesthesia. Intraoperative intervention and monitoring will follow a standard anesthetic management protocol. All of the physiological parameters and other medications administered during the intervention will be recorded. The primary outcome will be neurologic function change assessed by National Institute of Health Stroke Scale (NIHSS) within 4 h after general anesthesia when observer’s assessment of alertness/sedation (OAA/S) reaches 4. Secondary outcomes will include NIHSS and modified NIHSS change 1 and 2 days after general anesthesia, hemodynamic stability, intraoperative brain relaxation, quality of anesthesia emergence, quality of anesthesia recovery, postoperative cognitive function, postoperative pain, postoperative neurologic complications, as well as perioperative medical expense. Discussion This randomized equivalency trial will primarily compare the impacts of sevoflurane-remifentanil and propofol-remifentanil anesthesia on short-term postoperative neurologic function in patients with supratentorial gliomas undergoing craniotomy. The exclusion criteria are strict to ensure that the groups are comparable in all aspects. Repeated and routine neurologic evaluations after operation are always important to evaluate neurosurgical patients’ recovery and any newly presenting complications. The results of this trial would help specifically to interpret anesthetic residual effects on postoperative outcomes, and perhaps would help the anesthesiologist to select the optimal anesthetic regimen to minimize its impact on neurologic function in this specific patient population. Trial registration The study was registered and approved by the Chinese Clinical Trial Registry (Chinese Clinical Trial Registry, ChiCTR-IOR-16009177 ). Principle investigator: Nan Lin (email address: linnan127@gmail.com) and Ruquan Han (email address: hanrq666@aliyun.com) Date of Registration: September 8th, 2016. Country of recruitment: China.
BACKGROUND: Intraoperative flash visual evoked potential (FVEP) can be used to monitor visual function during spine surgery. However, it is limited due to the previous perception of its sensitivity to inhalation anesthesia. We conducted this trial to test the noninferiority of sevoflurane-propofol–balanced anesthesia (BA) versus popular propofol-based total intravenous anesthesia (TIVA) on the amplitude of FVEP during spine surgery. METHODS: A total of 60 patients undergoing spine surgery were randomized to receive either sevoflurane-propofol–balanced anesthesia (BA group) or propofol-based total intravenous anesthesia (TIVA group) for anesthesia maintenance. We titrated the propofol plasma concentration to keep the bispectral index (BIS) values between 40 and 50. The primary outcome was the P100-N145 amplitudes of FVEP at 120 minutes after induction of anesthesia. The noninferiority margin (δ) was defined as 10% of the P100-N145 amplitude at 120 minutes after induction in the TIVA group. If the confidence interval (CI) for mean differences of P100-N145 amplitude at 120 minutes after induction between BA and TIVA groups lied above the lower limit of −δ with P < .025, we defined BA group was noninferior to TIVA group. RESULTS: Fifty-nine patients were included in the final analysis. The amplitude of P100-N145 at 120 minutes after anesthesia induction in group BA was noninferior to group TIVA (3.8 [1.3] µV vs 3.2 [1.6] µV, −δ = −0.32, mean difference, 0.57, 95% CI, −0.18 to 1.33, P for noninferiority = .015). CONCLUSIONS: The effect of 0.5 minimum alveolar concentration (MAC) of sevoflurane-propofol–balanced anesthesia on the P100-N145 amplitude of FVEP was noninferior to that of propofol-based TIVA under comparable BIS range.
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