Challenges in paediatric neurosurgery

Improvements in technique, knowledge and expertise have brought about rapid advances in the fields of paediatric neurosurgery and anaesthesia, and many procedures limited earlier to adults are now being increasingly attempted in neonates and small children, with good outcomes. This article highlights the challenges faced by the operating team while handling some of the technically complex procedures like awake craniotomy, interventional neuroradiology, minimally invasive neurosurgery, procedures in intraoperative magnetic resonance imaging suites, and neonatal emergencies in the paediatric population

Pregnancy-induced pituitary apoplexy: Two lives at stake

Pituitary apoplexy in a pregnant woman is a devastating condition that develops secondary to a massive increase in the size of the pituitary gland and hyperplasia of lactotroph cells caused by high estrogen levels of pregnancy. The resultant sudden hemorrhage or infarction into the pituitary gland or a tumor leads to gland destruction with serious consequences like acute adrenal insufficiency, circulatory shock, neurological deterioration, and visual loss. Prompt handling of complications is necessary to prevent maternal and fetal mortality. Resuscitation is aimed at the early correction of hemodynamic instability, fluid-electrolyte abnormalities, hormone deficiencies, and intracranial hypertension. Urgent decompressive pituitary surgery may be required if the patient has rapidly declining vision and neurological status. Management of such patients is challenging and requires multi-disciplinary collaboration. We describe here the emergency handling of pituitary apoplexy in a pregnant woman

Incidental thrombocytosis: Should it concern the anesthesiologist?

Preoperative thrombocytosis, often detected incidentally in surgical patients and inadvertently overlooked, has important implications for the anesthesiologists. The primary form is a chronic clonal myeloproliferative disorder usually affecting adults while the secondary type is a benign reactive disease commonly found in children. Serious perioperative hemostatic complications are reported in primary thrombocytosis and hence, a detailed preoperative evaluation and initiation of therapy to lower the platelet count (PC) is required before undertaking surgery. Patients with reactive thrombocytosis however, usually have complication-free surgeries, and if there is no prior evidence of hemostatic complications and the reactive cause can be identified, no specific perioperative intervention may be required. A thorough preanesthetic checkup and implementation of basic thrombo-prophylaxis measures in all patients with a raised PC is advocated. We present here our experience with three infants diagnosed with high preoperative PC, presumably due to reactive causes, who underwent uneventful neurosurgeries at our institution

Intraoperative Central Diabetes Insipidus during Aneurysmal Clipping Surgery: An Unusual Phenomenon

Central diabetes insipidus (DI) is a known complication associated with pituitary surgeries occurring in postoperative period. However, development of DI following aneurysmal subarachnoid hemorrhage (SAH) is rarely reported. We describe here a case of intraoperative DI in a patient undergoing aneurysmal clipping surgery that posed a challenge for both diagnosis and management. A 55-year-old female, diagnosed with SAH due to ruptured left middle cerebral artery (MCA) aneurysm, was posted for aneurysmal clipping. A preoperative sudden rebleeding led to neurological deterioration and patient was taken up for the evacuation of hematoma and aneurysmal clipping. Intraoperatively, 2 hours into surgery, polyuria (700–1,000 mL/hour) was noted. Arterial blood gas analysis revealed severe hypernatremia with increased serum osmolality and urine-specific gravity showed hypo-osmolar urine. Possibility of mannitol induced diuresis, overzealous administration of intravenous fluid, and other causes of DI were ruled out. Medical management of DI was initiated and after 45 minutes, urine output was reduced and serum sodium measurements showed decreasing trend indicating responsiveness to treatment. Postoperatively noncontrast computed tomography head showed temporal bleeding with MCA infarct, infarct in thalamic, and hypothalamic region with hydrocephalus. Intraoperative development of central DI was attributed to the evolving ischemic injury to the hypothalamus at the time of rebleeding that was not apparent in preoperative scan. DI resolved postoperatively after 18 hours of medical management. Development of DI during aneurysmal surgery was unexpected and unanticipated. The cause of intraoperative DI was found to be pre-existing ischemic injury of hypothalamic region that subsequently evolved to infarct which was not evident in preoperative scan. A careful observation of preoperative scans and vigilant monitoring may help in early diagnosis and management of such complication in perioperative period