J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
In conclusion, there should be proper communication among neurointensive team members about the type of procedure, specific neurological examination (type and frequency), requirement of anticoagulation, and target goal for MAP. There is need to develop guidelines/protocols for such refractory cases and this would certainly help in improving the outcomes. Tumul Chowdhury, MD, DM* Bernhard Schaller, MD, PhD, DScw *Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada wDepartment of Research, University of Southampton, Southampton, UK
REFERENCES 1. Anand S, Goel G, Gupta V. Continuous intra-arterial dilatation with nimodipine and milrinone for refractory cerebral vasospasm. J Neurosurg Anesthesiol. 2013. [Epub ahead of print]. 2. Dankbaar JW, Slooter AJ, Rinkel GJ, et al. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care. 2010; 14:R23. 3. Athar MK, Levine JM. Treatment options for cerebral vasospasm in aneurysmal subarachnoid hemorrhage. Neurotherapeutics. 2012;9:37–43. 4. Siasios I, Kapsalaki EZ, Fountas KN. Cerebral vasospasm pharmacological treatment: an update. Neurol Res Int. 2013; 2013:571328. 5. Jain V, Rath GP, Dash HH, et al. Stellate ganglion block for treatment of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage—a preliminary study. J Anaesthesiol Clin Pharmacol. 2011; 27:516–521.
Perioperative Hypertension: White Coat, Masked, and Appropriately Referred for Treatment To the Editor: We are grateful to Schonberger and colleagues for their thoughtful reThe authors have no funding relevant to this publication or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
flections on our paper, most of which we acknowledge with thanks without the need for further comment. They mention the phenomenon of masked hypertension, which is a well-recognized “office” occurrence, but which, as they correctly suggest, has been given little or no attention in the OR environment. Our investigation did in fact entail a fourth group that was intended in part to examine this issue. That group was not included in the final analysis because of the limited number of qualifying patients and the statistical complexities it introduced. Concurrent with the identification of the patients in the 3 groups described in our paper (normotensive, moderately hypertensive, and severely hypertensive at the time of first on-the-table blood pressure determination [1st ORBP], n = 101/group), we identified a group of “Lopertensives” (n = 79) in whom 1st OR-BP was 40 dB), and a signal interference resembling ECG appeared on the raw electroencephalogram trace. Although the target concentration of propofol was gradually increased to 6 mg/mL, the BIS value was maintained above 80 for 5 hours until the end of surgery. During surgery, there was minimal hemodynamic instability and bleeding, no hypothermia, or any clinical signs indicating awareness except BIS. At the end of surgery, the BIS value still remained elevated despite removal of electrical monitoring devices including ECG and needle electrodes placed for motorevoked potential monitoring. Then we recognized that the right carotid artery was strongly pulsating near the mandibular electrode #4. For further investigation, an additional BIS sensor was applied on the standard site (Fig. 1A; arrowhead). Interestingly, the BIS value (around 20) and EMG activity (around 10 dB) of the standard site were markedly lower than those at the mandibular position. The electro-
266 | www.jnsa.com
J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
FIGURE 1. A, Standard frontotemporal and alternative mandibular application of the bispectral index (BIS) sensor. B, The BIS monitor with standard placement (top) and that with alternative mandibular placement (bottom) of the sensor obtained at the same time at the end of surgery. The BIS value (around 20) and electromyographic (EMG) activity (around 10 dB) of the standard site are markedly lower than those of the mandibular position. The electroencephalogram (EEG) trace of the standard site does not show the electrocardiogram-like waveform, which appears in that of the mandibular position.
encephalogram trace of the standard site did not show the ECG-like waveform, which appeared in that of the mandibular position (Fig. 1B). The elevation in EMG, which appeared 1 hour after induction and was continued throughout the remainder of this case, can be associated with the fact that muscle relaxant was not given during the surgery except at induction. More importantly, we suggest that the EMG elevation may be due to the opioid-induced muscle rigidity as described by Bruhn et al,2 and it is possible that the mandibular position picks up the rigidity of the masseter
or neck muscle, whereas the standard montage would not. Taken together, we think that increased EMG activity of neck muscles or the masseter muscle and ECG activity due to close proximity to the carotid artery could cause false elevation of the BIS because BIS elevation and EMG elevation were observed simultaneously, which remained elevated in the present case. Therefore, we suggest again that caution should be taken when utilizing alternative positions of the BIS. We are currently conducting a study to better evaluate the safety and utility of this mandibular position. r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
Young-Sung Kim, MD Byung-Gun Lim, MD, PhD Il-Ok Lee, MD, PhD Department of Anesthesiology and Pain Medicine, Guro Hospital, College of Medicine, Korea University, Seoul, Korea
REFERENCES 1. Nelson P, Nelson JA, Chen AJ, et al. An alternative position for the BIS-Vista montage in frontal approach neurosurgical cases. J Neurosurg Anesthesiol. 2013;25: 135–142. 2. Bruhn J, Bouillon TW, Shafer SL. Electromyographic activity falsely elevates the bispectral index. Anesthesiology. 2000;92: 1485–1487. 3. Liu N, Chazot T, Huybrechts I, et al. The influence of a muscle relaxant bolus on Bispectral and Datex-Ohmeda entropy values during propofol-remifentanil induced loss of consciousness. Anesth Analg. 2005; 101:1713–1718. 4. Hemmerling TM, Migneault B. Falsely increased bispectral index during endoscopic shoulder surgery attributed to interferences with the endoscopic shaver device. Anesth Analg. 2002;95:1678–1679. 5. Puri GD, Nakra D. ECG artifact and BIS in severe brain injury. Anesth Analg. 2005; 101:1566–1567.
Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache To the Editor: We read the article by Shabat et al1 with interest. Authors have attempted to evaluate the beneficial effects of pulsed radiofrequency (RF) on suprascapular nerve in patients with chronic headache associated with shoulder or suprascapular region pain with a hypothesis that the lower cervical roots might be the causative factor for chronic headache in such patients. A detailed clinical examination of shoulder focused on those muscles innervated by the suprascapular nerve, particularly abduction (supraspinatus) and external rotation (infraspinatus), along with cervical spine could have given a valuable insight to the diagnosis (shoulder pathology vs. radiculopathy). Unlike The authors have no funding or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
the study by Persson et al,2 where the occurrence of cervical radiculopathy was confirmed with selective nerve root blocks (SNRB), Shabat et al1 did not contemplate SNRB for suspected C5 or C6 root involvement, although they have attributed the headache to the lower cervical nerve roots (C5, C6, C7). Without a positive diagnostic test the methodology presented in the study for diagnosing lower cervical root involvement was overly dependent on the computed tomography/ magnetic resonance imaging which could be inaccurate. RF of suprascapular nerve (following the standard approach,3,4 which is essentially the RF of suprascapular nerve at suprascapular notch) is unlikely to provide relief from chronic headache if the musculoskeletal causes were responsible for shoulder region pain. It is unclear what exactly the authors meant by “postprocedure discomfort in the same innervated region,” whether it was the back of head, shoulder region or C5, C6, C7 dermatomal distribution? The described techniques of pulsed RF application (120 s, 421C; nothing has been mentioned about the pulse width and repetition) could be insufficient to effect the suprascapular nerve at the target site as the described “standard approaches”3,4 employed a wider duration (480 s), repeat PRF application, and combination of PRF and conventional thermal RF. Two issues need to be resolved if authors intended to demonstrate that lower cervical roots compression is the cause of headache: (i) why patients did not have complaints of distal pain, but only shoulder pain; and (ii) what could be the probable mechanism by which treatment at a distal site (RF of suprascapular nerve at suprascapular notch) can treat a pain condition for which the pathology is far more proximal (cervical root compression). Nilay Chatterjee, MD, DM* Chinmoy Roy, MD, FIPPw *Department of Neuroanesthesiology Sree Chitra Tirunal Institute for Medical Science and Technology, Trivandrum wDepartment of Pain Medicine, Institute of Neurosciences, Kolkata, West Bengal India
Correspondence
REFERENCES 1. Shabat S, Leitner J, Folman Y. Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache. J Neurosurg Anesthesiol. 2013;25:340–343. 2. Persson LC, Carlsson JY, Anderberg L. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J. 2007;16:953–959. 3. Simopoulos TT, Nagda J, Aner MM. Percutaneous radiofrequency lesioning of the suprascapular nerve for management of chronic shoulder pain: a case series. J Pain Res. 2012;5:91–97. 4. Luleci N, Ozdemir U, Dere K, et al. Evaluation of patients’ pulsed radiofrequency treatment applied to the suprascapular nerve in patients with chronic shoulder pain. J Back Musculoskelet Rehabil. 2011;24:189–194.
Anesthetic Management of an Acromegalic Patient With McCune Albright Syndrome for Endoscopic Transsphenoidal Adenoma Removal To JNA Readers: McCune Albright syndrome (MAS) is a genetic disease characterized by fibrous dysplasia of bone, cafe´ au lait skin spots, and precocious puberty.1 Patients with this syndrome usually require general anesthesia for repair of bone lesion–related fractures, but may also require surgery for treatment of endocrine disorders. We describe perioperative management of a 15-year-old female patient with MAS who underwent transsphenoidal resection of pituitary adenoma. A sellar mass suggestive of pituitary macroadenoma compressing the optic chiasma was shown on magnetic resonance imaging and her insulin-like growth factor 1 level was raised up to 840 ng/mL (normal range, 126 to 261 ng/mL). Results of The authors have no funding or conflicts of interest to disclose.
www.jnsa.com |
267
Volume 26, Number 3, July 2014
In conclusion, there should be proper communication among neurointensive team members about the type of procedure, specific neurological examination (type and frequency), requirement of anticoagulation, and target goal for MAP. There is need to develop guidelines/protocols for such refractory cases and this would certainly help in improving the outcomes. Tumul Chowdhury, MD, DM* Bernhard Schaller, MD, PhD, DScw *Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada wDepartment of Research, University of Southampton, Southampton, UK
REFERENCES 1. Anand S, Goel G, Gupta V. Continuous intra-arterial dilatation with nimodipine and milrinone for refractory cerebral vasospasm. J Neurosurg Anesthesiol. 2013. [Epub ahead of print]. 2. Dankbaar JW, Slooter AJ, Rinkel GJ, et al. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care. 2010; 14:R23. 3. Athar MK, Levine JM. Treatment options for cerebral vasospasm in aneurysmal subarachnoid hemorrhage. Neurotherapeutics. 2012;9:37–43. 4. Siasios I, Kapsalaki EZ, Fountas KN. Cerebral vasospasm pharmacological treatment: an update. Neurol Res Int. 2013; 2013:571328. 5. Jain V, Rath GP, Dash HH, et al. Stellate ganglion block for treatment of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage—a preliminary study. J Anaesthesiol Clin Pharmacol. 2011; 27:516–521.
Perioperative Hypertension: White Coat, Masked, and Appropriately Referred for Treatment To the Editor: We are grateful to Schonberger and colleagues for their thoughtful reThe authors have no funding relevant to this publication or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
flections on our paper, most of which we acknowledge with thanks without the need for further comment. They mention the phenomenon of masked hypertension, which is a well-recognized “office” occurrence, but which, as they correctly suggest, has been given little or no attention in the OR environment. Our investigation did in fact entail a fourth group that was intended in part to examine this issue. That group was not included in the final analysis because of the limited number of qualifying patients and the statistical complexities it introduced. Concurrent with the identification of the patients in the 3 groups described in our paper (normotensive, moderately hypertensive, and severely hypertensive at the time of first on-the-table blood pressure determination [1st ORBP], n = 101/group), we identified a group of “Lopertensives” (n = 79) in whom 1st OR-BP was 40 dB), and a signal interference resembling ECG appeared on the raw electroencephalogram trace. Although the target concentration of propofol was gradually increased to 6 mg/mL, the BIS value was maintained above 80 for 5 hours until the end of surgery. During surgery, there was minimal hemodynamic instability and bleeding, no hypothermia, or any clinical signs indicating awareness except BIS. At the end of surgery, the BIS value still remained elevated despite removal of electrical monitoring devices including ECG and needle electrodes placed for motorevoked potential monitoring. Then we recognized that the right carotid artery was strongly pulsating near the mandibular electrode #4. For further investigation, an additional BIS sensor was applied on the standard site (Fig. 1A; arrowhead). Interestingly, the BIS value (around 20) and EMG activity (around 10 dB) of the standard site were markedly lower than those at the mandibular position. The electro-
266 | www.jnsa.com
J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
FIGURE 1. A, Standard frontotemporal and alternative mandibular application of the bispectral index (BIS) sensor. B, The BIS monitor with standard placement (top) and that with alternative mandibular placement (bottom) of the sensor obtained at the same time at the end of surgery. The BIS value (around 20) and electromyographic (EMG) activity (around 10 dB) of the standard site are markedly lower than those of the mandibular position. The electroencephalogram (EEG) trace of the standard site does not show the electrocardiogram-like waveform, which appears in that of the mandibular position.
encephalogram trace of the standard site did not show the ECG-like waveform, which appeared in that of the mandibular position (Fig. 1B). The elevation in EMG, which appeared 1 hour after induction and was continued throughout the remainder of this case, can be associated with the fact that muscle relaxant was not given during the surgery except at induction. More importantly, we suggest that the EMG elevation may be due to the opioid-induced muscle rigidity as described by Bruhn et al,2 and it is possible that the mandibular position picks up the rigidity of the masseter
or neck muscle, whereas the standard montage would not. Taken together, we think that increased EMG activity of neck muscles or the masseter muscle and ECG activity due to close proximity to the carotid artery could cause false elevation of the BIS because BIS elevation and EMG elevation were observed simultaneously, which remained elevated in the present case. Therefore, we suggest again that caution should be taken when utilizing alternative positions of the BIS. We are currently conducting a study to better evaluate the safety and utility of this mandibular position. r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
Young-Sung Kim, MD Byung-Gun Lim, MD, PhD Il-Ok Lee, MD, PhD Department of Anesthesiology and Pain Medicine, Guro Hospital, College of Medicine, Korea University, Seoul, Korea
REFERENCES 1. Nelson P, Nelson JA, Chen AJ, et al. An alternative position for the BIS-Vista montage in frontal approach neurosurgical cases. J Neurosurg Anesthesiol. 2013;25: 135–142. 2. Bruhn J, Bouillon TW, Shafer SL. Electromyographic activity falsely elevates the bispectral index. Anesthesiology. 2000;92: 1485–1487. 3. Liu N, Chazot T, Huybrechts I, et al. The influence of a muscle relaxant bolus on Bispectral and Datex-Ohmeda entropy values during propofol-remifentanil induced loss of consciousness. Anesth Analg. 2005; 101:1713–1718. 4. Hemmerling TM, Migneault B. Falsely increased bispectral index during endoscopic shoulder surgery attributed to interferences with the endoscopic shaver device. Anesth Analg. 2002;95:1678–1679. 5. Puri GD, Nakra D. ECG artifact and BIS in severe brain injury. Anesth Analg. 2005; 101:1566–1567.
Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache To the Editor: We read the article by Shabat et al1 with interest. Authors have attempted to evaluate the beneficial effects of pulsed radiofrequency (RF) on suprascapular nerve in patients with chronic headache associated with shoulder or suprascapular region pain with a hypothesis that the lower cervical roots might be the causative factor for chronic headache in such patients. A detailed clinical examination of shoulder focused on those muscles innervated by the suprascapular nerve, particularly abduction (supraspinatus) and external rotation (infraspinatus), along with cervical spine could have given a valuable insight to the diagnosis (shoulder pathology vs. radiculopathy). Unlike The authors have no funding or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
the study by Persson et al,2 where the occurrence of cervical radiculopathy was confirmed with selective nerve root blocks (SNRB), Shabat et al1 did not contemplate SNRB for suspected C5 or C6 root involvement, although they have attributed the headache to the lower cervical nerve roots (C5, C6, C7). Without a positive diagnostic test the methodology presented in the study for diagnosing lower cervical root involvement was overly dependent on the computed tomography/ magnetic resonance imaging which could be inaccurate. RF of suprascapular nerve (following the standard approach,3,4 which is essentially the RF of suprascapular nerve at suprascapular notch) is unlikely to provide relief from chronic headache if the musculoskeletal causes were responsible for shoulder region pain. It is unclear what exactly the authors meant by “postprocedure discomfort in the same innervated region,” whether it was the back of head, shoulder region or C5, C6, C7 dermatomal distribution? The described techniques of pulsed RF application (120 s, 421C; nothing has been mentioned about the pulse width and repetition) could be insufficient to effect the suprascapular nerve at the target site as the described “standard approaches”3,4 employed a wider duration (480 s), repeat PRF application, and combination of PRF and conventional thermal RF. Two issues need to be resolved if authors intended to demonstrate that lower cervical roots compression is the cause of headache: (i) why patients did not have complaints of distal pain, but only shoulder pain; and (ii) what could be the probable mechanism by which treatment at a distal site (RF of suprascapular nerve at suprascapular notch) can treat a pain condition for which the pathology is far more proximal (cervical root compression). Nilay Chatterjee, MD, DM* Chinmoy Roy, MD, FIPPw *Department of Neuroanesthesiology Sree Chitra Tirunal Institute for Medical Science and Technology, Trivandrum wDepartment of Pain Medicine, Institute of Neurosciences, Kolkata, West Bengal India
Correspondence
REFERENCES 1. Shabat S, Leitner J, Folman Y. Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache. J Neurosurg Anesthesiol. 2013;25:340–343. 2. Persson LC, Carlsson JY, Anderberg L. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J. 2007;16:953–959. 3. Simopoulos TT, Nagda J, Aner MM. Percutaneous radiofrequency lesioning of the suprascapular nerve for management of chronic shoulder pain: a case series. J Pain Res. 2012;5:91–97. 4. Luleci N, Ozdemir U, Dere K, et al. Evaluation of patients’ pulsed radiofrequency treatment applied to the suprascapular nerve in patients with chronic shoulder pain. J Back Musculoskelet Rehabil. 2011;24:189–194.
Anesthetic Management of an Acromegalic Patient With McCune Albright Syndrome for Endoscopic Transsphenoidal Adenoma Removal To JNA Readers: McCune Albright syndrome (MAS) is a genetic disease characterized by fibrous dysplasia of bone, cafe´ au lait skin spots, and precocious puberty.1 Patients with this syndrome usually require general anesthesia for repair of bone lesion–related fractures, but may also require surgery for treatment of endocrine disorders. We describe perioperative management of a 15-year-old female patient with MAS who underwent transsphenoidal resection of pituitary adenoma. A sellar mass suggestive of pituitary macroadenoma compressing the optic chiasma was shown on magnetic resonance imaging and her insulin-like growth factor 1 level was raised up to 840 ng/mL (normal range, 126 to 261 ng/mL). Results of The authors have no funding or conflicts of interest to disclose.
www.jnsa.com |
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