Letters to Editor
to widen the skin and subcutaneous tissue, but frequently inserted unnecessarily far.[3,4] Other possible mechanisms of injury include kinking of guidewire resulting in misdirection of the dilator and insertion of wire outside the vessel. However, this had not happened in this case as the guidewire was still in the vein, and it was not bent when removed. Dilators provided in the pediatric central venous catheterization (CVC) sets are thin and sharp-tipped and can henceforth present as such a complication. Several reports suggest the advantages of ultrasonography for risk reduction and improved cannulation success for all access sites in adults and children in different settings. However, a recent survey of the Society of Cardiovascular Anesthesiologists members revealed that 67% never or almost never used ultrasound when performing CVC, with only 15% always or almost always using ultrasound. The dilator position if doubtful can be checked using ultrasound or by a pressure manometry. As per the ASA guidelines in the pediatric population the confirmation of venous placement is checked for needle, guidewire, and catheter. Using ultrasound for position of dilator is also important in pediatric cannulation as there can be trauma with dilator also. Ultimately, the physician should be cognizant of the many complications associated with CVCs, recognizing that prevention of even most unusual complication becomes a worthwhile initiative. Kavitha Jayaram, Srilata Moningi, Dilip Kumar Kulkarni, R. Gopinath Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, India Address for correspondence: Assist. Prof. Kavitha Jayaram Nizam’s Institute of Medical Sciences, Hyderabad, India. E-mail: [email protected]
References 1.
2.
3.
4.
American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, et al. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012;116:539-73. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286:700-7. Oropello JM, Leibowitz AB, Manasia A, Del Guidice R, Benjamin E. Dilator-associated complications of central vein catheter insertion: possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1996;10:634-7. Lobato EB, Gravenstein N, Paige GB. Dilator-associated complications of central vein catheter insertion: Possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1997;11:539-40.
Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.155214
A rare and deceptive venous anomaly, sinus pericranii To the Editor, This letter attempts to highlight concerns to the anesthesiologist when dealing with a case of sinus pericranii and hence that safe perioperative coverage of the same may be provided. A 21-year-old female patient presented with headache and heaviness over an enlarging frontal bone defect. Within the defect, a soft, compressible, mass lesion was observed, the clinical characteristic being its disappearance when the patient was in sitting position and its appearance when the patient was in recumbent position. A diagnosis of sinus pericranii, a rare venous anomaly was made and patient was scheduled for frontal craniotomy and excision. The preoperative examination was unremarkable, and general anesthesia was planned and executed for the case. After induction, a transcranial Doppler study was carried out. It did not reveal any abnormal flow velocities in the anterior cerebral artery or middle cerebral artery, on comparison of the bone defect window and transtemporal window, respectively. Decongestive therapy using 200 mL of 20% mannitol was administered to ensure a lax dura for the surgeon’s comfort. Craniotomy and exposure of the sinus pericranii was done without difficulty [Figure 1]. However, despite meticulous surgical technique, tears in the connecting venous channels (sinus pericranii to the superior sagittal sinus) occurred intraoperatively causing torrential blood loss (2.5 L). Hemorrhage was eventually controlled by the surgeons and patient was successfully resuscitated by the anesthesia team. After overnight elective ventilation, the patient was extubated and on examination found to have no neurological deficits. Stromeyer coined the term sinus pericranii in 1850.[1] It is a rare condition that is characterized by a large communication between the intracranial and the extracranial venous drainage pathways, in which blood circulate bidirectionally through dilated veins of the skull. It can be congenital, acquired or traumatic in nature. Sinus pericranii may be part of a syndrome in some patients, but can occur as an isolated
Journal of Anaesthesiology Clinical Pharmacology | April-June 2015 | Vol 31 | Issue 2
279
Letters to Editor 2.
3.
4.
5.
Yasuda S, Enomoto T, Yamada Y, Nose T, Iwasaki N. Crouzon disease associated with sinus pericranii: A report on identical twin sisters. Childs Nerv Syst 1993;9:119-22. Brisman JL, Niimi Y, Berenstein A. Sinus pericranii involving the torcular sinus in a patient with Hunter’s syndrome and trigonocephaly: Case report and review of the literature. Neurosurgery 2004;55:433. Kurosu A, Wachi A, Bando K, Kumami K, Naito S, Sato K. Craniosynostosis in the presence of a sinus pericranii: Case report. Neurosurgery 1994;34:1090-2. Park SC, Kim SK, Cho BK, Kim HJ, Kim JE, Phi JH, et al. Sinus pericranii in children: Report of 16 patients and preoperative evaluation of surgical risk. J Neurosurg Pediatr 2009;4: 536-42. Access this article online
Figure 1: Intraoperative image showing dilated venous anomaly on near midline, after craniotomy
condition. Associations with craniosynostosis, Crouzon’s syndrome, Apert’s syndrome and Hunter’s syndrome are well documented.[2-4] Therefore, a careful workup is necessary along with necessary planning for anesthesia. Sinus pericranii is compounded by multiplicity, venous channels connecting to the intracranial venous system, and presence of venous lakes in close association with the abnormality. The latter is associated with significant blood loss intraoperatively.[5] Of further concern to anesthesiologist are the following two: hemorrhage and venous air embolism. The potential for blood loss should not be underestimated without disaster, especially in a case with multiplicity. This did occur in our case; however, we were prepared to handle the situation and were therefore able to salvage the situation. Although venous air embolism is another concern, requiring appropriate anticipation, monitoring and management, if it occurs, however did occur in our case. We conclude by stating that sinus pericranii is a rare venous anomaly, and that the above highlighted issues should be considered by the anesthesiologist whilst in preparation for surgery for such a case. Mohammed Meesam Rizvi, Raj Bahadur Singh, Arindam Sarkar, Sanjay Choubey Department of Anaesthesiology, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Raj Bahadur Singh, Department of Anaesthesiology and Critical Care, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India. E-mail: [email protected]
References 1.
280
Mitsukawa N, Satoh K, Hayashi T, Furukawa Y, Suse T, Uemura T, et al. Sinus pericranii associated with craniosynostosis. J Craniofac Surg 2007;18:78-84.
Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.155215
Anesthetic management of a patient with Wilms tumor, aniridia, genital anomalies and mental retardation syndrome undergoing right nephrectomy To the Editor, Wilms tumor, aniridia, genital anomalies and mental retardation syndrome is a congenital disorder, consists of multiple systemic anomalies. It accounts 2% of patients with Wilms’ tumor.[1] Anomalies uncommonly seen are congenital diaphragmatic hernia (CDH),[2,3] cardiomyopathy, congenital heart diseases (CHD) and scoliosis. Wilms tumor and male genital anomalies are caused by deletion of the WT1 gene. Aniridia is due to deletion of PAX 6 gene and deletion of multiple genes leads to mental retardation.[4] A 4-year-old, 12 kg female child presented with pain abdomen for 5 days and hematuria for 3 days. Mother gave history of abdominal distention since 1 month, which was gradual in onset, progressive and associated with delayed milestones. No significant birth or family history was noticed. On examination child was moderately mentally retarded (slow in understanding, using language, and limited ability to communicate, could count fingers). Airway examination
Journal of Anaesthesiology Clinical Pharmacology | April-June 2015 | Vol 31 | Issue 2
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
to widen the skin and subcutaneous tissue, but frequently inserted unnecessarily far.[3,4] Other possible mechanisms of injury include kinking of guidewire resulting in misdirection of the dilator and insertion of wire outside the vessel. However, this had not happened in this case as the guidewire was still in the vein, and it was not bent when removed. Dilators provided in the pediatric central venous catheterization (CVC) sets are thin and sharp-tipped and can henceforth present as such a complication. Several reports suggest the advantages of ultrasonography for risk reduction and improved cannulation success for all access sites in adults and children in different settings. However, a recent survey of the Society of Cardiovascular Anesthesiologists members revealed that 67% never or almost never used ultrasound when performing CVC, with only 15% always or almost always using ultrasound. The dilator position if doubtful can be checked using ultrasound or by a pressure manometry. As per the ASA guidelines in the pediatric population the confirmation of venous placement is checked for needle, guidewire, and catheter. Using ultrasound for position of dilator is also important in pediatric cannulation as there can be trauma with dilator also. Ultimately, the physician should be cognizant of the many complications associated with CVCs, recognizing that prevention of even most unusual complication becomes a worthwhile initiative. Kavitha Jayaram, Srilata Moningi, Dilip Kumar Kulkarni, R. Gopinath Department of Anesthesiology and Critical Care, Nizam’s Institute of Medical Sciences, Hyderabad, India Address for correspondence: Assist. Prof. Kavitha Jayaram Nizam’s Institute of Medical Sciences, Hyderabad, India. E-mail: [email protected]
References 1.
2.
3.
4.
American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, et al. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012;116:539-73. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286:700-7. Oropello JM, Leibowitz AB, Manasia A, Del Guidice R, Benjamin E. Dilator-associated complications of central vein catheter insertion: possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1996;10:634-7. Lobato EB, Gravenstein N, Paige GB. Dilator-associated complications of central vein catheter insertion: Possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1997;11:539-40.
Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.155214
A rare and deceptive venous anomaly, sinus pericranii To the Editor, This letter attempts to highlight concerns to the anesthesiologist when dealing with a case of sinus pericranii and hence that safe perioperative coverage of the same may be provided. A 21-year-old female patient presented with headache and heaviness over an enlarging frontal bone defect. Within the defect, a soft, compressible, mass lesion was observed, the clinical characteristic being its disappearance when the patient was in sitting position and its appearance when the patient was in recumbent position. A diagnosis of sinus pericranii, a rare venous anomaly was made and patient was scheduled for frontal craniotomy and excision. The preoperative examination was unremarkable, and general anesthesia was planned and executed for the case. After induction, a transcranial Doppler study was carried out. It did not reveal any abnormal flow velocities in the anterior cerebral artery or middle cerebral artery, on comparison of the bone defect window and transtemporal window, respectively. Decongestive therapy using 200 mL of 20% mannitol was administered to ensure a lax dura for the surgeon’s comfort. Craniotomy and exposure of the sinus pericranii was done without difficulty [Figure 1]. However, despite meticulous surgical technique, tears in the connecting venous channels (sinus pericranii to the superior sagittal sinus) occurred intraoperatively causing torrential blood loss (2.5 L). Hemorrhage was eventually controlled by the surgeons and patient was successfully resuscitated by the anesthesia team. After overnight elective ventilation, the patient was extubated and on examination found to have no neurological deficits. Stromeyer coined the term sinus pericranii in 1850.[1] It is a rare condition that is characterized by a large communication between the intracranial and the extracranial venous drainage pathways, in which blood circulate bidirectionally through dilated veins of the skull. It can be congenital, acquired or traumatic in nature. Sinus pericranii may be part of a syndrome in some patients, but can occur as an isolated
Journal of Anaesthesiology Clinical Pharmacology | April-June 2015 | Vol 31 | Issue 2
279
Letters to Editor 2.
3.
4.
5.
Yasuda S, Enomoto T, Yamada Y, Nose T, Iwasaki N. Crouzon disease associated with sinus pericranii: A report on identical twin sisters. Childs Nerv Syst 1993;9:119-22. Brisman JL, Niimi Y, Berenstein A. Sinus pericranii involving the torcular sinus in a patient with Hunter’s syndrome and trigonocephaly: Case report and review of the literature. Neurosurgery 2004;55:433. Kurosu A, Wachi A, Bando K, Kumami K, Naito S, Sato K. Craniosynostosis in the presence of a sinus pericranii: Case report. Neurosurgery 1994;34:1090-2. Park SC, Kim SK, Cho BK, Kim HJ, Kim JE, Phi JH, et al. Sinus pericranii in children: Report of 16 patients and preoperative evaluation of surgical risk. J Neurosurg Pediatr 2009;4: 536-42. Access this article online
Figure 1: Intraoperative image showing dilated venous anomaly on near midline, after craniotomy
condition. Associations with craniosynostosis, Crouzon’s syndrome, Apert’s syndrome and Hunter’s syndrome are well documented.[2-4] Therefore, a careful workup is necessary along with necessary planning for anesthesia. Sinus pericranii is compounded by multiplicity, venous channels connecting to the intracranial venous system, and presence of venous lakes in close association with the abnormality. The latter is associated with significant blood loss intraoperatively.[5] Of further concern to anesthesiologist are the following two: hemorrhage and venous air embolism. The potential for blood loss should not be underestimated without disaster, especially in a case with multiplicity. This did occur in our case; however, we were prepared to handle the situation and were therefore able to salvage the situation. Although venous air embolism is another concern, requiring appropriate anticipation, monitoring and management, if it occurs, however did occur in our case. We conclude by stating that sinus pericranii is a rare venous anomaly, and that the above highlighted issues should be considered by the anesthesiologist whilst in preparation for surgery for such a case. Mohammed Meesam Rizvi, Raj Bahadur Singh, Arindam Sarkar, Sanjay Choubey Department of Anaesthesiology, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Raj Bahadur Singh, Department of Anaesthesiology and Critical Care, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India. E-mail: [email protected]
References 1.
280
Mitsukawa N, Satoh K, Hayashi T, Furukawa Y, Suse T, Uemura T, et al. Sinus pericranii associated with craniosynostosis. J Craniofac Surg 2007;18:78-84.
Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.155215
Anesthetic management of a patient with Wilms tumor, aniridia, genital anomalies and mental retardation syndrome undergoing right nephrectomy To the Editor, Wilms tumor, aniridia, genital anomalies and mental retardation syndrome is a congenital disorder, consists of multiple systemic anomalies. It accounts 2% of patients with Wilms’ tumor.[1] Anomalies uncommonly seen are congenital diaphragmatic hernia (CDH),[2,3] cardiomyopathy, congenital heart diseases (CHD) and scoliosis. Wilms tumor and male genital anomalies are caused by deletion of the WT1 gene. Aniridia is due to deletion of PAX 6 gene and deletion of multiple genes leads to mental retardation.[4] A 4-year-old, 12 kg female child presented with pain abdomen for 5 days and hematuria for 3 days. Mother gave history of abdominal distention since 1 month, which was gradual in onset, progressive and associated with delayed milestones. No significant birth or family history was noticed. On examination child was moderately mentally retarded (slow in understanding, using language, and limited ability to communicate, could count fingers). Airway examination
Journal of Anaesthesiology Clinical Pharmacology | April-June 2015 | Vol 31 | Issue 2
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
![[Bluish swelling of the scalp. Sinus pericranii: A rare vascular anomaly ].](/assets/img/hold.png)
