Neurosurgical Anesthesiology

Correlation Between Invasive and Noninvasive Technique of Intracranial Pressure Measurement in Children With Traumatic Brain Injury: An Observational Study Background: Direct measurement of intracranial pressure (ICP) is an invasive technique with potential complications, which has prompted the development of alternative, noninvasive, methods of ICP assessment. The aim of this study was to determine the relationship between noninvasive ultrasound-based measurement of optic nerve sheath diameter (ONSD), transcranial Doppler-derived pulsatility index (PI), and invasive ICP measurements in children with traumatic brain injury (TBI). Methods: Children aged 1 to 18 years undergoing invasive ICP monitoring following TBI were included in the study. Noninvasive ONSD and PI measurements were compared with simultaneous invasive ICP. Results: In all, 406 measurements of ONSD and PI were obtained in 18 patients. ONSD and PI correlated with ICP (r=0.76 and 0.79, respectively), combining ONSD and PI resulted in an even stronger correlation with ICP (r=0.99). Formulas were derived from mixed-effect models that best fitted the data for noninvasive ICP estimation. A combination of ONSD and PI had the highest ability to detect ICP >20 mm Hg (area under the receiver operating characteristic curve=0.99, 95% confidence interval: 0.99-1.00). Optimal cutoff values for the prediction of intracranial hypertension were 5.95 mm for ONSD (sensitivity, 92%; specificity, 76%) and 1.065 for PI (sensitivity, 92%; specificity, 87%). Conclusions: In children with TBI, a combination of ONSD and PI strongly correlates with invasive ICP and has potential to screen for intracranial hypertension noninvasively. ONSD and PI may be useful tools for assessing ICP where invasive monitoring is unavailable or contraindicated. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Gyaninder P. Singh, DM. E-mail: drsingh_gp@yahoo.co.in. Received August 2, 2020 Accepted November 20, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Kratschmer Reflex During Transnasal Endoscopic Pituitary Surgery No abstract available

Genome-wide Association Study of Postoperative Cognitive Dysfunction in Older Surgical Patients Background: Postoperative cognitive dysfunction (POCD) is a common neurocognitive disorder after surgery and anesthesia, particularly in elderly patients. Various studies have suggested genetic risk factors for POCD. The study aimed to detect genome-wide associations of POCD in older patients. Methods: In this prospective observational cohort study, participants aged 65 years and above completed a set of neuropsychological tests before, at 1 week, and 3 months after major noncardiac surgery. Test variables were converted into standard scores (z-scores) based on demographic characteristics. POCD was diagnosed if the decline was >1 SD in ≥2 of the 15 variables in the assessment battery. A genome-wide association study (GWAS) was performed to determine potential alleles that are linked to the POCD phenotype. In addition, candidate genes for POCD were identified in a literature search for further analysis. Results: Sixty-three patients with blood samples were included in the study. POCD was diagnosed in 47.6% of patients at 1 week and in 34.2% of patients at 3 months after surgery. Insufficient sample quality led to exclusion of 26 patients. In the remaining 37 patients, a GWAS was performed, but no association (P<5×10−8) with POCD was found. The subsequent gene set enrichment analysis of 34 candidate genes did not reveal any significant associations. Conclusion: In this patient cohort, a GWAS did not reveal an association between specific genetic alleles and POCD at 1 week and 3 months after surgery. Future genetic analysis should focus on specific candidate genes for POCD. Preliminary data in this manuscript were presented at the Euroanaesthesia Congress, Vienna, Austria, June 1–3, 2019, as well as at the European Society of Human Genetics Conference, June 6–9, 2020. This research was supported by departmental sources and a grant no. 32003B-121956 from the Swiss National Science Foundation. L.A.S. has received speaker honoraria from Medtronic Schweiz (Münchenbuchsee, Switzerland), Covidien (Neuhausen am Rheinfall, Switzerland) MSD, (Luzern, Switzerland), Hamilton Medical (Bonaduz, Switzerland), Lilly (Vernier, Switzerland), and Orion Pharma (Zug, Switzerland). N.G. has received consultancy fees from PIPRA AG (Zug, Switzerland). None of these fees were related to this study. The remaining authors have no conflicts of interest to disclose. Address correspondence to: Nicolai Goettel, MD. E-mail: nicolai.goettel@usb.ch. Received September 21, 2020 Accepted October 27, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Management of Endovascular Treatment for Acute Ischemic Stroke During the COVID-19 Pandemic at a Single Institution in Beijing, China: A Brief Report Background: The coronavirus disease (COVID-19) pandemic is currently a major challenge for health care systems around the world. For a time-sensitive emergency such as acute ischemic stroke (AIS), streamlined workflow times are essential to ensure good clinical outcomes. Methods: The aim of this single-center, retrospective, observational study was to describe changes in stroke workflow patterns and clinical care during the COVID-19 pandemic. Data from AIS patients undergoing emergent endovascular treatment (EVT) between 23 January and 8 April 2020 were retrospectively collected and compared with data from patients admitted during a similar period in 2019. The primary outcome was difference in time from symptom onset to recanalization. Secondary outcomes included workflow times, clinical management, discharge outcomes, and health-economic data. Results: In all, 21 AIS patients were admitted for emergent EVT during the 77-day study period, compared with 42 cases in 2019. Median time from symptom onset to recanalization was 132 minutes longer during the pandemic compared with the previous year (672 vs. 540 min, P=0.049). Patients admitted during the pandemic had a higher likelihood of endotracheal intubation (84.6% vs. 42.4%, P<0.05) and a higher incidence of delayed extubation after EVT (69.2% vs. 45.5%, P<0.05). National Institutes of Health Stroke Scale at hospital discharge was similar in the 2 cohorts, whereas neurointensive care unit stay was longer in patients admitted during the pandemic (10 vs. 7 days, P=0.013) and hospitalization costs were higher (123.9 vs. 95.2 thousand Chinese Yuan, P=0.052). Conclusion: Disruptions to medical services during the COVID-19 pandemic has particularly impacted AIS patients undergoing emergent EVT, resulting in increased workflow times. A structured and multidisciplinary protocol should be implemented to minimize treatment delays and maximize patient outcomes. This study was supported by the Beijing Municipal Science and Technology Commission (Z191100006619068) and Beijing Municipal Administration of Hospitals (DFL20180502). The study investigators did not receive compensation for participating in the study. No funding agencies had any role in the design or conduction of the study, study management, data collection, analysis, interpretation, decision to publish, or preparation of the manuscript. S.L. and M.Z. contributed equally to the manuscript as co-first authors. Y.P. and R.H. contributed equally to the manuscript. R.H. is a member of the Editorial Board of Journal of Neurosurgical Anesthesiology. The remaining authors have no conflicts of interest to disclose. Address correspondence to: Yuming Peng, MD, PhD, E-mail: florapym766@163.com. Received June 20, 2020 Accepted October 25, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Early Lymphopenia and Infections in Nontraumatic Subarachnoid Hemorrhage Patients Introduction: Subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. A certain degree of immunodepression has been reported during critical illness, and lymphopenia identified as an independent predictor of poor outcome; no data are available for critically ill SAH patients. We aimed to evaluate the prevalence of lymphopenia among SAH patients and its association with hospital-acquired infection. Methods: Retrospective cohort study of adult patients admitted to an intensive care unit with nontraumatic SAH between January 2011 and May 2016. Lymphocyte count was obtained daily for the first 5 days; lymphopenia was defined as lymphocyte count <1000/mm3. The occurrence of infection during the first 21 days after hospital admission, hospital mortality, and unfavorable neurological outcome (Glasgow Outcome Scale score 1 to 3 at 3 mo) were recorded. Results: Data from 270 patients were analyzed (median age 54 y; male 45%); 121 (45%) patients had lymphopenia and 62 (23%) patients developed infections. Median (25th to 75th percentiles) lymphocyte count at hospital admission was 1280 (890 to 1977)/mm3. Lymphopenia patients had more episodes of infection (38/121, 31% vs. 24/139, 17%; P=0.003) than nonlymphopenia patients, while mortality and unfavorable outcome were similar. Lymphopenia was not independently associated with the development of infection, unfavorable neurological outcome or with mortality. Conclusions: Early lymphopenia is common after SAH, but is not significantly associated with the development of infections or with poor outcome. This study was present as an e-poster at LIVES congress—ESICM, September 28th to October 2nd, Berlin, Germany. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Elisa Gouvêa Bogossian, MD, MSc. E-mail: elisagobog@gmail.com. Received August 5, 2020 Accepted October 6, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Utility and Predictive Value of CHIIDA Score in Pediatric Traumatic Brain Injury: A Prospective Observational Study Background: The Children's Intracranial Injury Decision Aid (CHIIDA) is a tool designed to stratify children with mild traumatic brain injury (mTBI). The aim of this study was to assess the utility and predictive value of CHIIDA in the assessment of the need for intensive care unit (ICU) admission in pediatric patients with mTBI. Methods: This prospective observational study included 425 children below 18 years of age admitted to the ICU of a tertiary care hospital with mTBI (Glasgow Coma Scale 13 to 15). The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Sensitivity, specificity, predictive values and likelihood ratios were calculated at CHIIDA scores 0 and 2. Results: Among 425 children with mTBI, 210 (49%) had a CHIIDA score 0, 16 (4%) scored 2 points, and 199 (47%) scored more than 2 points. Thirty-six (8.47%) patients experienced the primary outcome, and there were 3 deaths. A cutoff CHIIDA >0 to admit to ICU had a sensitivity of 97.22% (95% confidence interval [CI], 97.05%-97.39%) and a negative predictive value of 99.54% (95% CI, 99.50%-99.56%). A cutoff of score >2 had a sensitivity of 97.22% (95% CI, 97.05%-97.39%), and negative predictive value of 99.56% (95% CI, 99.54%-99.59%). The post-test probability at cutoff score of 0 and 2 was 16.65% and 16.27%, respectively. Conclusions: CHIIDA score does not serve as reliable triage tool for identifying children with TBI who do not require ICU admission. The pilot data of this study has been presented at the 19th annual conference of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) 2018 and published as an abstract in the conference proceedings in the Journal of Neuroanaesthesiology and Critical Care 2018. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Ruchi A. Jain, MD, DNB, PDFC. E-mail: ruchiajain@gmail.com. Received July 5, 2020 Accepted September 29, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Hemoglobin Concentration May Influence the Incidence of Postoperative Transient Neurological Events in Patients With Moyamoya After Extracranial-intracranial Arterial Bypass: A Retrospective Single Center Experience Background: Moyamoya is a rare condition characterized by cerebral angiographic findings of intracranial carotid artery stenosis with abnormal net-like vessels in the brain, and often presents as transient ischemic attacks or intracranial hemorrhage. Revascularization in the form of extracranial-intracranial (EC-IC) artery bypass has demonstrated efficacy in preventing ischemic attacks and intracranial hemorrhage, although it is associated with a relatively high rate of perioperative ischemic and hemorrhagic stroke. This retrospective analysis aims to evaluate the possible association between postoperative hemoglobin (Hgb) concentration and early postoperative transient neurological events (TNEs) experienced at our center. Methods: Consecutive patients undergoing EC-IC bypass between January 1, 2017 and August 31, 2019 were identified, resulting in a study population of 24 patients with 34 individual cases for different cerebral hemispheres. Postoperative Hgb level was evaluated upon arrival to the intensive care unit (ICU) and the primary outcome was the occurrence of TNEs within 24-hours after surgery. Results: The incidence of TNEs within 24 hours postoperatively was 12% (n=4). Statistically significant differences were demonstrated between patients who did and did not experience TNEs in the postoperative period: total Hgb value (mean 9.4 vs. 11.3 g/dL, respectively; P=0.012) and percentage of patients with Hgb <10 g/dL (75% vs. 20%, respectively; P=0.048). Patients with a postoperative Hgb value <10 g/dL upon arrival to the ICU were significantly more likely to experience TNEs (odds ratio, 12; 95% confidence interval, 1.053-136.794; P=0.045). Conclusions: This study reports a possible association between postoperative Hgb level and the occurrence of TNEs within the first 24 hours after surgery in patients undergoing EC-IC for moyamoya. Present address: Nicholas V. Mendez, MD, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA. Catherine Chen, MD, Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH. Angela M. Richardson, MD, PhD, Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI. Previous presentations: (1) Online abstract for the Annual Meeting of the Florida Society of Anesthesiologists; 2020 June; Palm Beach, FL. (2) Online abstract for the Annual Meeting of the International Anesthesia Research Society; 2020 May; San Francisco, CA. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Nicholas V. Mendez, MD. E-mail: nckmendez@gmail.com. Received June 22, 2020 Accepted September 28, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Transcranial Ultrasound as a Useful Tool in Early Detection and Follow-up of Hydrocephalus in Acute Subarachnoid Hemorrhage No abstract available

Stellate Ganglion Block Effects on Cerebral Vascular Tone: A Missing Piece of the Puzzle No abstract available

Facemask as Eye Cover: Think Beyond Mask Ventilation No abstract available

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