Perioperative Anesthetic Management in Preterm 12 Days Infants with Giant Meningoencephalocele at Mid Occipital and Secondary Trigonocephaly

Introduction: A meningoencephalocele is herniation of neural element along with meninges through a congenital defect in cranium. The incidence of encephalocele is approximately 1/5000 live births; occipital encephalocele is more common in females than males. It is called as giant meningoencephalocele when the head is smaller than the meningoencephalocele. These giant meningoencephaloceles harbor a large amount of cerebrospinal fluid (CSF) and brain tissue, so there occur various surgical challenges and anesthetic challenges in positioning and intubation. Case: A 12 days neonate was consulted to the neurosurgery department with complaints of large swelling over the back of head and difficulty in feeding. She was diagnosed with ventriculomegaly and meningoencephalocele since 32-33 pregnancy. The swelling was small at the time of birth, but it gradually increased in size. The child was born by section caesarean because of fetal distress and meningoenchepalocele. The neonate current weight was 3.195 grams with Post Conceptional Age (PCA) 35-36 weeks. On examination, the patient large spherical swelling was present over occipital region and there was no head control. The patient was active, conscious with no impression of focal neurological deficit. Systemic examination was unremarkable. The head circumference was 30 cm and circumference of occipital swelling was 40 cm. Potential problems in this patient include preoperative preparation and optimization of general condition, difficulty in positioning the patient, difficult airway (intubation), periodic apnea and potential hemodynamic disturbances and a sudden decrease in intracranial pressure during cele resection. Conclusion: Perioperative management in this case started from preoperative to postoperative evaluation. Preoperative preparation in anticipation of airway difficulties and communication with the operator is very important. Appropriate anesthetic techniques should aim to maintain stable hemodynamics and oxygenation and prevent a sudden increase or decrease in intracranial pressure.

Penurunan Kecemasan Keluarga Pasien Stroke Dengan Family Centered Empowerment Model

Stroke merupakan keadaan yang terjadi akibat adanya gangguan suplai darah ke otak yang awal timbulnya mendadak, progresi cepat berupa defisit neurologis fokal yang berlangsung 24 jam atau langsung menimbulkan kematian. Dampak dari stroke selain bagi pasien juga menimbulkan dampak psikologis kecemasan bagi keluarga pasien dari ketidaksiapan keluarga dalam merawat pasien stroke. Kecemasan pada keluarga dapat diatasi dengan pemberian edukasi berbasis family centered empowerment model. Penelitian ini bertujuan untuk mengetahui penurunan kecemasan keluarga pasien stroke dengan family centered empowerment model di RSUD Gambiran Kota Kediri. Desain penelitian menggunakan pra experiment dengan rancangan one group pretest and posttest design. Pengambilan sampel secara non probability sampling dengan teknik accidental sampling yang berjumlah 54 orang. Pengumpulan data menggunakan kuesioner kecemasan HARS dan dianalisa dengan uji Wilcoxon Signed Ranks Test. Hasil menunjukkan nilai p = 0,000 yang artinya ada pengaruh family centered empowerment model terhadap penurunan kecemasan keluarga pasien stroke. Kata Kunci : family centered empowerment model; kecemasan; keluarga; strokeAnxiety Reduction Of Family Patients With Stroke And Family Empowerment Centered ModelAbstractStroke is a condition that occurs due to disruption of blood supply to the brain which has a sudden onset, rapid progression in the form of a focal neurological deficit that lasts 24 hours or immediately causes death. The impact of stroke in addition to the patient also causes psychological effects of anxiety for the patient's family from the family's unpreparedness in caring for stroke patients. Anxiety in the family can be overcome by providing education based on the family centered empowerment model. This study was aimed to determine the decrease in family anxiety of stroke patients with the family centered empowerment model at Gambiran Hospital, Kediri City. The research design used a pre-experimental design with a one group pretest and posttest design. The Sampling was taken by non-probability sampling with accidental sampling technique, totaling 54 people. Data was collected using the HARS anxiety questionnaire and analyzed using the Wilcoxon Signed Ranks Test. The results showed the value of p = 0.000 which means that there is an effect of family centered empowerment model on reducing family anxiety of stroke patients.Key Word: family centered empowerment model; anxiety; family; stroke

Clinical characteristics and outcome of primary brain abscess: a retrospective analysis

Background Patients with primary brain abscess often present with atypical symptoms, and the outcome varies. We investigated the demographic, laboratory, and neuroimaging features of patients with brain abscess at our hospital and identified factors associated with their outcomes. Methods We retrospectively collected the data of patients diagnosed with primary brain abscess at our hospital between January 2011 and December 2020. Their clinical characteristics, predisposing factors, laboratory and neuroimaging findings, treatment, and outcome were analyzed. Results Of the 57 patients diagnosed with primary abscess, 51 (89.47%) were older than 40 years, and 42 (73.68%) were male. Only eight patients (14.04%) showed the classical triad of headache, fever, and focal neurological deficit. Fifteen patients (26.31%) had comorbidities, of which diabetes mellitus was the most common. Positive intracranial purulent material cultures were obtained in 46.15% of the patients, and gram-negative enteric bacteria were found in 33.33% of them, with Klebsiella pneumoniae being the most frequently observed. Surgical treatment, most commonly in the form of stereotactic drainage, was received by 54.39% of the patients. Good outcomes were achieved in 75.44% of the patients. Multivariate logistic regression analysis showed that patients with headaches were more likely to have a poor outcome (odds ratio 6.010, 95% confidence interval 1.114–32.407, p = 0.037). Conclusions Male patients and those older than 40 years were more susceptible to brain abscess than female patients and those younger than 40 years, respectively. Only a few patients showed the classical triad of clinical symptoms. Diabetes mellitus was the most common comorbidity. Positive intracranial specimens’ culture results were uncommon, with gram-negative enteric bacteria, especially Klebsiella pneumoniae, being the main organisms found. Most patients had a good outcome, and the presence of headache may influence the outcome.

Persistent intrathecal interleukin-8 production in a patient with SARS-CoV-2-related encephalopathy presenting aphasia: a case report.

Background Neurological manifestations of coronavirus disease 2019 (COVID-19) are increasingly recognized and include encephalopathy, although direct infection of the brain by SARS-CoV-2 remains controversial. We herein report the clinical course and cytokine profiles of a patient with severe SARS-CoV-2-related encephalopathy presenting aphasia. Case presentation An 81-year-old man developed acute consciousness disturbance and status epileptics several days after SARS-CoV-2 infection. Following treatment with remdesivir and dexamethasone, his consciousness and epileptic seizures improved; however, amnestic aphasia and agraphia remained. Two months after methylprednisolone pulse and intravenous immunoglobulin, his neurological deficits improved. We found increased levels of interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1 (MCP-1), but not IL-2 and IL-10 in the serum and cerebrospinal fluid (CSF), and the levels of serum IL-6 and MCP-1 were much higher than those in the CSF. The level of IL-8 in the CSF after immunotherapy was four times higher than that before immunotherapy. Conclusion The cytokine profile of our patient was similar to that seen in severe SARS-CoV-2-related encephalopathy. We demonstrated (i) that the characteristic aphasia can occur as a focal neurological deficit associated with SARS-CoV-2-related encephalopathy, and (ii) that IL8-mediated central nervous system inflammation follows systemic inflammation in SARS-CoV-2-related encephalopathy and can persist and worsen even after immunotherapy. Monitoring IL-8 in CSF, and long-term corticosteroids may be required for treating SARS-CoV-2-related encephalopathy.

Abstract 1122‐000174: Stroke Risk of Carotid Artery Stenting Using Balloon‐Guide Catheter Versus Distal Embolic Protection Devices

Introduction : Prevention of distal embolization during carotid artery stenting (CAS) is a key element of procedural technique and is standardly performed using distal protection devices (DPDs). Data in support of DPDs, however, are limited. Here, we present our experience of proximal occlusion using a balloon guide catheter (BGC) during CAS as the primary method of distal embolic protection. Methods : We conducted a retrospective review of patients undergoing CAS at our healthcare system between January of 2018 to March of 2021. Procedures were categorized by embolic protection strategy: DPD or BGC (with or without DPD). Emergent cases were defined as patients receiving CAS within <24 hours of presenting with an ischemic stroke or TIA ipsilateral to the carotid disease side. Severe stenosis was defined as 70–99% per NASCET criteria. The primary outcome was rate of procedural ischemic stroke between the DPD and BGC groups, and was defined as acute focal neurological deficit lasting for ≥ 24 hours following CAS related to an embolic event during the procedure. Results : A total of 126 CAS procedures were performed during the study period. 91 cases were performed under proximal BGC protection (of which 24 also included DPD usage) and 35 CAS cases via DPD as a primary mean for embolic protection. The median age for the cohort was 68 [IQR 62‐76], 37% females, 31% (n = 39) cases were treated emergently, and elective cases were 69% (n = 87). Baseline characteristics were similar in both groups except for hyperlipidemia (BGC vs DPD, 71.4% vs 42.9%; p = 0.003) and history of smoking (BGC vs DPD, 56% vs 34.4%; p = 0.029). Severe carotid stenosis was present in 80.2% BGC group and 77.1% in DPD (p = 0.573). Post‐stenting balloon angioplasty was more frequent in the BGC group as compared with DPD (54% vs. 26%, BGC vs. DPD, p = 0.005). Procedural embolic stroke rates were low in both groups, and not significantly different (1.1% vs. 2.9%, BGC vs. DPD, p = 0.48). Conclusions : CAS with BGC as the primary means of distal embolic protection showed comparable, low rates of procedural embolic ischemic events compared to those with DPD. These findings suggest BGC embolic strategies may be a viable alternative to DPD usage.

Management of A Cerebral Cavernoma During Pregnancy: Case Report

Intracranial cavernoma is a vascular malformation composed of thin-walled vascular vessels. Blood flow in these lesions is much lower than in AVMs and their hemorrhages are usually small. The presentation is often subacute with seizures or focal neurological deficit, which can be confused in pregnant women with pregnancy toxaemia especially if the malformation is bleeding. We report the case of a 35-year-old patient , 30 weeks pregnant , admitted for delivery who presented with acute intracranial hypertension syndrome with obnubilation of consciousness. Emergency brain CT showed a right fronto-parietal intracranial hematoma. MRI with angiographic sequences show a left parietal hematoma without visible arteriovenous malformation. The patient underwent emergency surgery to evacuate her intracranial hematoma, then the patient was transferred to a gynecological unit for emergency fetal extraction. Histo-pathological analysis of the removed fragments showed an intracranial cavernoma appearance. Urgent surgical evacuation is only necessary if the prognosis is vital.

Perioperative Anesthetic Management in Preterm 12 Days Infants with Giant Meningoencephalocele at Mid Occipital and Secondary Trigonocephaly

Introduction: A meningoencephalocele is herniation of neural element along with meninges through a congenital defect in cranium. The incidence of encephalocele is approximately 1/5000 live births; occipital encephalocele is more common in females than males. It is called as giant meningoencephalocele when the head is smaller than the meningoencephalocele. These giant meningoencephaloceles harbor a large amount of cerebrospinal fluid (CSF) and brain tissue, so there occur various surgical challenges and anesthetic challenges in positioning and intubation. Case: A 12 days neonate was consulted to the neurosurgery department with complaints of large swelling over the back of head and difficulty in feeding. She was diagnosed with ventriculomegaly and meningoencephalocele since 32-33 pregnancy. The swelling was small at the time of birth, but it gradually increased in size. The child was born by section caesarean because of fetal distress and meningoenchepalocele. The neonate current weight was 3.195 grams with Post Conceptional Age (PCA) 35-36 weeks. On examination, the patient large spherical swelling was present over occipital region and there was no head control. The patient was active, conscious with no impression of focal neurological deficit. Systemic examination was unremarkable. The head circumference was 30 cm and circumference of occipital swelling was 40 cm. Potential problems in this patient include preoperative preparation and optimization of general condition, difficulty in positioning the patient, difficult airway (intubation), periodic apnea and potential hemodynamic disturbances and a sudden decrease in intracranial pressure during cele resection. Conclusion: Perioperative management in this case started from preoperative to postoperative evaluation. Preoperative preparation in anticipation of airway difficulties and communication with the operator is very important. Appropriate anesthetic techniques should aim to maintain stable hemodynamics and oxygenation and prevent a sudden increase or decrease in intracranial pressure.

CEREBRAL VENOUS THROMBOSIS SECONDARY TO SARS-COV-2 INFECTION

Cerebral venous thrombosis (CVT) is a relatively rare form of neurovascular emergency, and may present as headache, seizure, or focal neurological deficit. It typically has a higher occurrence in younger women. Recently, there are increasingly cases of CVTreported in association with COVID-19, which fall outside the typical demographics, suggesting a hyper-coagulable state attributable to COVID-19. Here, we present a case of CVTin a young gentleman with concomitant COVID-19, who presented with first-onset seizure.

Clinical Characteristics and Outcome of Primary Brain Abscess: a Retrospective Analysis

Background: Patients with primary brain abscess often present with atypical symptoms, and the outcome is varied. We investigated the demographic, laboratory, and neuroimaging features of patients with brain abscess at our hospital and identified factors associated with their outcome.Methods: We retrospectively collected the data of patients diagnosed with primary brain abscess at our hospital between January 2011 and December 2020. Their clinical characteristics, predisposing factors, laboratory and neuroimaging findings, treatment, and outcome were analyzed. Results: Of the 57 patients diagnosed with primary abscess, 51 (89.47%) were older than 40 years and 42 (73.68%) were male. Only eight patients (14.04%) showed the classical triad of headache, fever, and focal neurological deficit. Fourteen patients (24.56%) had comorbidities, of which diabetes mellitus was the most common. Positive pus cultures were obtained in 46.15% of the patients, and gram-negative enteric bacteria were found in 33.33% of them, with Klebsiella pneumoniae being the most frequently observed. Surgical treatment, most commonly in the form of stereotactic drainage, was received by 54.39% of the patients. Good outcomes were achieved in 75.44% of the patients. Multivariate logistic regression analysis showed that patients with headache were more likely to have a poor outcome (odds ratio 6.010, 95% confidence interval 1.114–32.407, p = 0.037).Conclusions: Male patients and those older than 40 years were more susceptible to brain abscess than female patients and those younger than 40 years, respectively. Only a few patients showed the classical triad of clinical symptoms. Diabetes mellitus was the most common comorbidity. Positive pus culture results were uncommon, with gram-negative enteric bacteria, especially Klebsiella pneumoniae, being the main organisms found. Most patients had a good outcome, and the presence of headache may influence the outcome.

Giant Mixed Vesical Calculus in a Patient in North Central, Nigeria: A Case Report

A 30-year old male Business man presented at the accident and emergency unit of Abnira Medical Centre in Jos city on account of inability to pass urine for over fifteen hours. There was concomitant excruciating lower abdominal pain and swelling that is tender to touch. A positive history of generalized weakness, fatigue, nausea, heamaturia was given. However, no fever, vomiting, headache nor history of fainting attacks. On examination, he was afebrile, acyanosed with associated tachycardia (pulse rate 121bpm) and tachypnea (respiratory rate of 27c/min).He was oriented in place, person and time with no focal neurological deficit. There were no cardiac and other respiratory signs picked on examination. His abdomen was soft and non-tender, with normal bowel sounds. However, there was renal angle tenderness. Biochemical investigations done on presentation showed normal sodium, potassium, chlorite, and bicarbonate. He has some evidence of dehydration and pre-renal azotemia (increased creatinine, urea and uric acid).His liver function tests, lipase, thyroid function test, phosphate, magnesium and albumin-corrected calcium were all normal.