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Malignant Hyperthermia: A Life-Threatening Condition in Patients Undergoing Surgical Intervention

Joyti PAL ; Pragya GUPTA ; Ved Prakash MAURYA ; Arun Kumar SRIVASTAVA ; Devendra GUPTA ; Luis Rafael MOSCOTE-SALAZAR ; Tariq JANJUA ; Amit AGRAWAL

Journal of Neurointensive Care.2024;7(2):41-48. doi:10.32587/jnic.2024.00801

Malignant hyperthermia (MH) is a rare, potentially fatal genetic disorder characterized by an unexplained elevation of expired carbon dioxide despite increased minute ventilation, muscle rigidity, and rhabdomyolysis, hyperthermia, tachycardia, acidosis, and hyperkalemia. It can be triggered by many pharmacological agents such as potent inhalation agents (halothane/ isoflurane/ sevoflurane/ desflurane), the depolarizing muscle relaxant (succinylcholine), and extreme physiological conditions such as vigorous exercise and working excessively in a hot and dry environment. Prompt and early recognition of the condition and rapid initiation of treatment measures are necessary to salvage the patient. Since MH is commonly encountered in the operating room or early postoperative period, anesthetists and surgeons need to keep themselves updated regarding the same. This review article aims to summarize our understanding of MH's pathophysiology, current diagnostics, management, and treatment strategies, along with a brief review of literature of published cases in Indian Subcontinent.

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Clinical Course and Outcomes of Brain Tumor Patients Admitted to Medical Intensive Care Unit: A Descriptive Analysis

Anisha BENIWAL ; Hemant BENIWAL ; Manoj VERMA

Journal of Neurointensive Care.2024;7(2):56-62. doi:10.32587/jnic.2024.00794

Background: There is a shortage of data on brain tumor patients admitted in to intensive care unit (ICU) from developing countries. We aimed to assess the clinical course and 30-day mortality with factors affecting the mortality of brain tumor patients who were admitted to medical ICU. Methods: This study was a single-centre retrospective observational cohort study and was conducted in a medical ICU of a tertiary care center in India. We included 42 patients admitted in to the medical oncology ICU over 3 years. Data regarding demographics, baseline characteristics, clinical and laboratory data, need for organ support, and 30-day mortality were collected. Factors associated with increased mortality in these patients were determined. Results: Overall 30-day mortality was 30.95%. The most common indication for ICU admission was altered sensorium (57.1%) followed by sepsis (23.8%). Age [odds ratio, OR: 0.843 (95% confidence interval, CI: 0.721–0.986)], and need for invasive mechanical ventilator (IMV) support [OR: 484.62 (95% CI: 2.707–8676.02)] or vasopressor support [OR: 523.83 (95% CI: 2.12– 3,023.13)] were directly associated with 30-day mortality. Severity indices such as Sequential Organ Failure Assessment (SOFA) score, SAPS II (Simplified Acute Physiology Score II), and Acute physiology and chronic health evaluation II (APACHE II), APACHE III and APACHE IV scores were higher in non-survivors than survivors. Conclusion Advancing age and need for IMV or vasopressor support may be associated with worse prognosis in brain tumor patients admitted in to ICU. A scoring system could be used along with clinical judgement to triage brain tumor patients for ICU admission.

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Simple Analysis Using Immunohistochemical Staining for Tumor-Infiltrating Lymphocytes in Brain Metastasis of Small Cell Lung Cancer

Da Hyun PARK ; Young Zoon KIM

Journal of Neurointensive Care.2024;7(2):49-55. doi:10.32587/jnic.2024.00780

Background: We investigated the distribution of tumor-infiltrating lymphocytes (TILs) and the expression of programmed cell death-ligand 1 (PD-L1) in patients with brain metastasis (BM) from small cell lung cancer (SCLC). Methods: A retrospective analysis was performed on 12 surgical specimens of BMs from SCLC at our institute for 5 years. The Immunofluorescence-based Tissue Microenvironment Analysis Panel (MAP) was utilized for the detection of TILs, including CD3, CD8, PD-1, and PD-L1, in pathological archival specimens of BMs. The correlation between the overall survival (OS) and the above-mentioned markers was analyzed in the patients. Results: Positive rates of CD3+ TILs in the tumor parenchyma versus tumor stroma were 0.60±0.94% versus 1.76±2.72% (p=0.010), respectively; positive rates of CD8+ TILs in the tumor parenchyma versus tumor stroma were 0.80±0.78% versus 2.46±3.72% (p=0.016), respectively. There was no co-expression of CD8+ and PD-1+ TILs in the tumor parenchyma of 11 cases, and the infiltration density of co-expressed CD3+ and PD-1+ TILs was more than 10/mm2 in only 1 case. There was no co-expression of CD3+ and PD-1+ TIL in the stroma of 10 cases, and the infiltration density of CD8+ and PD-1+ TILs was more than 10/mm2 in 2 cases. Immunohistochemistry was used to detect the expression of PD-L1 in 12 cases of BMs, and 3 cases (25%) were positive. Survival analysis showed that patients with positive CD3+ TILs had significantly longer OS (p=0.040). Conclusions The distribution of TILs in BM of SCLC is low and mainly distributed in the stroma, with the low expression of PD-L1 in the tumor tissues.

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Virtual Neurosurgery Education Conferences on Social Medi: A Perspective

Minaam FAROOQ ; Noor ATIQ ; Amr BADARY ; Bipin CHAURASIA

Journal of Neurointensive Care.2024;7(1):37-39. doi:10.32587/jnic.2023.00759

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Endovascular Treatment Strategies for Vertebral Artery Dissection: A Single-Center Experience and Literature Review

Junhyung KIM ; Sang Kyu PARK ; Joonho CHUNG

Journal of Neurointensive Care.2024;7(1):1-11. doi:10.32587/jnic.2023.00738

Although some vertebral artery dissection (VADs) cases heal naturally, others progress to stroke, necessitating intervention. Endovascular treatment (EVT) has gained prominence as a viable approach for addressing VADs owing to its perceived low risk of procedure-related complications and high effectiveness. In this review, we share our practical experience of this technique by incorporating the indications and methods for VAD treatment via EVT. Our EVT strategies covered the management of both ruptured and selected cases of unruptured VADs. Unruptured cases that require treatment include those complicated by lesions with recurring or progressive ischemia, large dissecting aneurysms with mass effects, early changes in the VAD structure during follow-up, and involvement of the basilar or bilateral vertebral arteries (VAs). In cases of ruptured VADs, we aimed to occlude the site of rupture through either VA occlusion or stent-assisted coiling. For unruptured VADs, the goal is to restore the original blood flow dynamics using a range of stenting techniques. The choice of EVT technique should be made on a case-by-case basis, considering factors such as the patient's presenting symptoms, hemodynamic status, adequacy of collateral blood supply, and anatomical characteristics of the important arteries and perforators.

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Cardiac Arrest in Traumatic Brain Injury

Oday ATALLAH ; Md Moshiur RAHMAN ; Bipin CHAURASIA ; Vishal CHAVDA ; Amit AGRAWAL

Journal of Neurointensive Care.2024;7(1):12-17. doi:10.32587/jnic.2024.00773

Traumatic brain injury (TBI) is a significant global health concern with substantial contributions to illness and mortality rates. This study aims to scrutinize the intricate interplay between neurological and circulatory abnormalities post-TBI, particularly focusing on the challenge posed by cardiac arrest in TBI patients. The study employs a comprehensive approach, utilizing clinical assessments, electrocardiograms, intracranial pressure monitoring, brain imaging, and biomarker utilization. It explores the effectiveness of these methods in detecting cardiac arrest in TBI patients. Additionally, the research delves into resuscitation techniques, hemodynamic stabilization, intracranial pressure management, and neurological enhancement as potential therapeutic modalities. The results highlight the importance of prompt initiation of cardiopulmonary resuscitation and adherence to advanced cardiac life support protocols in TBI patients with cardiac arrest. Prognostic factors such as injury severity, response time, effectiveness of resuscitation interventions, and pre-existing medical conditions are identified as crucial elements in predicting cardiac arrest outcomes in TBI patients. The study concludes by emphasizing the critical necessity of a comprehensive approach to understand and manage the complex relationship between cardiac arrest and TBI. Incorporating scientific discoveries, clinical perspectives, and technological advancements, the review underscores the importance of addressing this multifaceted medical challenge through a thorough analysis and effective management strategies.

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Comparison the Perfusion/Diffusion Mismatching Judging From CT-Based and MR-Based Study

Jae-Yong SHIM ; Do-Sung YOO ; Kwang-Wook JO ; Hae-Kwan PARK

Journal of Neurointensive Care.2024;7(1):29-36. doi:10.32587/jnic.2023.00752

Background: The development of endovascular devices and clinical experience, recanalization rate after intraarterial thrombectomy (IA-Tx) has increased. Recent papers reported that the amount of perfusion/diffusion (P/D)-mismatching in digital analysis from computer tomography perfusion (CTP) image is well correlated well with P/D-mismatching from magnetic resonance image. The purpose of this study is compare the patient clinical outcomes after IA-Tx, judging from CTP based and magnetic resonance imaging (MRI) based study. Methods: : 218 patients with anterior circulation large vessel occlusion (LVO) treated by IA-Tx were included in this analysis. In the MRI group (n=80), P/D-mismatching from MRI based image analysis by visual method and in the CTP group (n=138), and recently, P/D-mismatching was decided by automatized computer programmatic analyzed from CTP based image (Syngo.via program). Results: Favorable outcome (modified Rankin Score: 0–2), mortality, recanalization, and clinically significant hemorrhage was 56.3% (45/80), 6.25% (5/80), 81.3% (65/80) and 25% (20/80) in MRI group and 4.9% (62/138), 8.9%(18/138), 91.3%(126/138) and 40.6% (56/138) in CTP group (p=0.000, 0.235, 0.007 and 0.013). Reperfusion injury (27.5% vs, 15.0%, p=0.018) but favorable outcome was high 55.0% vs. 44.9 $, p=0.00) in the MRI study group. Conclusion : In our study, patient selection according to the P/D-mismatching from MR-based imaging and CTP-based image was not different in final clinical outcome. Recent IA-Tx, showed high recanalization rate but it also cause high incidence of reperfusion injury.

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Intracranial Pressure Monitoring in Patients With Traumatic Brain Injury: An Umbrella Review of Systematic Review and Meta-Analysis

William A FLOREZ-PERDOMO ; Rakesh MISHRA ; Luis Rafael MOSCOTE-SALAR ; Rafael CINCU ; Ved Prakash MAURYA ; Amit AGRAWAL

Journal of Neurointensive Care.2024;7(1):18-28. doi:10.32587/jnic.2023.00731

Background: The objective of this study is to summarize the evidence in Cochrane and non-Cochrane systematic reviews, the effects, and the benefits of monitoring intracranial pressure (ICP) in patients with head trauma with an indication of ICP monitoring Methods: The process of preparing this overview followed the guidelines established by the Joanna Briggs Institute (JBI) for umbrella reviews. Two independent reviewers evaluated the quality of reporting, bias risk, methodologies, and evidence using three different tools: the Risk of Bias in Systematic Reviews (ROBIS) instrument, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). Results: A total of five papers met the criteria for inclusion in the study. These papers consisted of 49 primary research studies and 19 unique primary research studies. One of the SRs indicated that using intracranial pressure (ICP) monitoring led to a reduction in mortality. Two of the SRs had mixed results with temporal variation, while two found no significant difference in mortality with ICP monitoring. It is important to note that the quality of the SRs varied, with some being of higher quality than others. Conclusion There was no conclusive evidence that ICP monitoring reduces mortality in TBI patients. There was high heterogeneity in included primary research studies. Future research should aim to address the limitations of these studies and provide more conclusive evidence regarding the effectiveness of ICP monitoring in reducing mortality in patients with traumatic brain injury.

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C reactive Protein as a Point-of-Care Testing Tool in Primary Healthcare Settings

Shweta MISHRA ; M SUKUMAR ; Jayashankar ERUKKAMBATTU ; Md YUNUS ; Suresh Kumar THANVEERU ; Amit AGRAWAL

Journal of Neurointensive Care.2025;8(1):1-6. doi:10.32587/jnic.2024.00815

Excessive use of antibiotics is a significant public health concern with several severe implications for the development of Antibiotic Resistance and its impact on Gut Microbiota. C-reactive Protein (CRP) is non-specific, acute-phase reactant whose levels increase in response to infection or inflammation due bacterial and viral etiologies. Many studies have explored the role of CRP as a point-of-care tool to assist in decision-making and improve the efficiency of antibiotic prescribing practices among healthcare professionals in primary care settings. The main benefit of POC CRP testing is its ease of use, providing results within 2 to 3 minutes from a simple finger prick, which is optimal for an outpatient clinic. While several studies demonstrate reductions in antibiotic use with POC CRP testing, there are many controversies around those need to be resolved, including the cutoff values of CRP for antibiotic prescription, whether CRP can differentiate bacterial and viral etiologies, and whether a single CRP level can reflect the disease state. Future research needs to focus on developing uniform guidelines for interpreting CRP levels and evaluating whether serial CRP measurements, physician training, especially in primary care and rural settings, to reduce overprescribing. Ultimately, while POC CRP testing can support antibiotic stewardship, its utility must be carefully balanced with sound clinical judgment.

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The Role of Pharmacological Drying Agents in Weaning the Neurological Tracheostomised Patient

Katherine CLARKE ; Alisha DA SILVA ; Jonathan TOMKINS ; Wendy F BOWER

Journal of Neurointensive Care.2025;8(1):13-20. doi:10.32587/jnic.2024.00808

Background: The role of glycopyrrolate and other pharmacological drying agents is well established for secretion management in specific populations such as patients living with cerebral palsy or requiring palliative care. Whilst drying agents are used for weaning tracheostomised patients with an acute neurological condition, clinical decision–making pathways have not been well described. To examine the clinical practice of tracheostomy weaning and use of pharmacological drying agents in an acute neurological population admitted to a tertiary hospital. Methods: A retrospective cohort analysis between 2014 to 2019 of all patients tracheostomised after a neurological event. Data were extracted from medical records to obtain patient demographic details, history of presenting condition and weaning plans. Results: A total of 116 patients with a neurological diagnosis required a tracheostomy, of whom 20 patients were using at least one pharmacological drying agent during tracheostomy weaning process. Nine patients still required drying agents on discharge from hospital. Conclusion Patients who required drying agents in their tracheostomy wean demonstrated a trend towards a longer duration of tracheostomy and a longer length of stay than those who did not. Clinicians need to complete patient–centred objective measures regarding swallowing function and saliva management when considering if a drying agent will be required.

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