The surgical treatment of the rare extracranial carotid artery aneurysm can lead to significant thromboembolic events in 4.4% of cases. Intraoperative monitoring has helped detect hypoperfusion and probable ischemic events, but this is not widely available in resource-limited hospitals in the Philippines. This case highlights the use of a portable standard 21-channel EEG machine for intraoperative monitoring in a tertiary government hospital. In addition, it highlights a conception of a protocol for the intraoperative electroencephalogram monitoring of carotid endoaneurysmorrhaphy procedures in a resource-limited setting. During the aneurysmorrhaphy procedure, the authors collaborated with the surgeons and the anesthesiologists to provide feedback about EEG changes during the operation. After a pre-induction baseline was recorded, continuous EEG monitoring was performed until the patient emerged from anesthesia. Mild EEG changes, attributed to relative hypotension, were observed during the procedure. These episodes were responsive to BP augmentation. There were no EEG changes observed during carotid cross-clamping. Shunting was not recommended to the surgical team. No new neurologic deficits were documented postoperatively and on follow-up after six months. This paper illustrates how an intraoperative team was formed, and intraoperative EEG was utilized for a complex carotid endoaneurysmorrhaphy for a patient with ECAA in a tertiary government hospital in the Philippines.

Human ; Resource-limited Settings ; Carotid Arteries ; Philippines

INTRODUCTION: Simultaneous bilateral angle-closure glaucoma is a potentially blinding disease. From 2001 to 2007, over 100 cases of Topiramate-associated bilateral acute angle glaucoma (TA-ACG) were reported. We report the first known case in the Philippines.

CASE REPORT: A 42-year old Filipino woman diagnosed with migraine presented with the sudden blurring of vision, with generalized headache after her second dose of 25mg Topiramate. Visual acuity was decreased to 20/200 in each eye. Intraocular pressures  (IOP) were elevated to OD 50mmHg and OS 55mmHg with shallow anterior chambers and 360 degree angle closure on gonioscopy. Stat doses of mannitol, acetazolamide, brimonidine, and latanoprost were given. Topiramate was discontinued. Laser iridotomy was performed with note of an immediate drop in IOP to OD 24mmHg and OS 18 mmHg. On the day of discharge, the patient's third day of admission, IOP had returned to 12 mmHg OU and best-corrected vision had improved to 20/20 in both eyes. B-scan ultrasonography confirmed choroidal thickening in both eyes.

DISCUSSION: Topiramate associated acute angle closure glaucoma (TA-AACG) as an idiosyncratic adverse effect was first reported by Banta et al in July 20018 with shallow anterior chambers, relative lens thickening, and 360° ciliochoroidal detachments in both eyes on A- and B-scan ultrasonography. Angle-closure was believed to result from the anterior rotation of the ciliary process and not from pupillary block, rendering laser iridotomy ineffective. Signiñicant lens thickening has been shown in TA-AACG. It is thought to result in part from relaxation of the zonules due to anterior ciliary rotation and ciliary edema, and from a direct drug effect. Myopia resulting from this is characteristic of TA-AACG and may persist from days to weeks after discontinuation of topiramate. The management of TAAACG requires stopping the drug. As TA-AACG and transient myopia usually resolves within days to weeks after stopping Topiramate, medical treatment with topical cycloplegic agents, topical beta-blockers and oral pressure-lowering agents often suffice as an interim measure. However, more invasive options such as laser iridotomy should be considered when significant pupillary block angle closure is present.

SUMMARY: Topiramate may be associated with acute angle-closure glaucoma wherein, in the Filipino patient, pupillary block may be present and should be addressed by laser iridotomy when possible.

Human ; Female ; Glaucoma, Angle-closure ; Latanoprost ; Mydriatics ; Acetazolamide ; Intraocular Pressure ; Gonioscopy ; Topiramate ; Brimonidine Tartrate ; Mannitol ; Rotation ; Philippines ; Acceleratory Factor From Growth Hormone ; Prostaglandins F, Synthetic ; Fructose ; Migraine Disorders ; Visual Acuity ; Myopia ; Headache ; Ultrasonography ; Edema ; Anterior Chamber