Achmet Ali

Comparison of 3% Hypertonic Saline and 20% Mannitol for Reducing Intracranial Pressure in Patients Undergoing Supratentorial Brain Tumor Surgery: A Randomized, Double-blind Clinical Trial

Background: In the present study, we hypothesized that 3% hypertonic saline (HS) is more effective than 20% mannitol to reduce intracranial pressure (ICP) and to modify brain bulk in patients undergoing an elective supratentorial craniotomy. Materials and Methods: After institutional review board approval, patients scheduled to undergo supratentorial craniotomy were enrolled into this prospective, randomized, double-blind study. The patients were monitored for routine hemodynamic parameters, depth of anesthesia, and ICP. They received 5 mL/kg 20% mannitol (n=20) or 3% HS (n=19) as infusion for 15 minutes. The patients’ ICP values were monitored during hypertonic fluid infusion and throughout 30 minutes after infusion as a primary outcome. Secondary outcomes were hemodynamic variables, serum sodium value, blood gases, and surgeon brain relaxation assessment score (1=relaxed, 2=satisfactory, 3=firm, 4=bulging). In addition, the length of intensive care unit and hospital stay were recorded. Results: Demographic and tumor characteristics were similar between groups. The basal (before hypertonic infusion, ICPT0) and last (30 min after hypertonic infusion finished, ICPT45) ICP values were 13.7±3.0 and 9.5±1.9 mm Hg, respectively, for the M group, which were comparable with the corresponding levels of 14.2±2.8 and 8.7±1.1 mm Hg in the HS group (P>0.05). The median amount of ICP reduction between T0 and T45 timepoints were 4 (1 to 7) and 5 (1 to 9) mm Hg for group M and group HS, respectively (P=0.035). Baseline central venous pressure, pulse pressure variation, and serum sodium and lactate values were similar between groups, but the last measured pulse pressure variation and lactate value were lower, and sodium value was higher in group HS than in group M (P<0.05). Duration of hospital and intensive care unit stay were similar between groups. Conclusions: Our results suggest that 3% HS provided more effective ICP reduction than 20% mannitol during supratentorial brain tumor surgery.

Surgery for Pyogenic Brain Abscess over 30 Years: Evaluation of the Roles of Aspiration and Craniotomy.

AIM To evaluate the roles of craniotomy and aspiration in the treatment of pyogenic brain abscess throughout 30 years of computerized tomography. MATERIAL AND METHODS A retrospective study of 224 patients who were surgically treated at Istanbul Medical Faculty, Department of Neurosurgery between 1982 and 2012 was undertaken. The records were analyzed for demographic, clinical and radiological findings, surgical interventions (resection, free-hand aspiration and image-guided aspiration), data regarding abscesses (etiological factors, site, size, number, localization and identified microorganism), corticosteroid and antibiotic usage and complications, and the outcomes were reviewed. RESULTS The male-to-female ratio was 2.2, and the mean age was 26.2±1.25 years. The most common presenting symptom was headache (56.7%), followed by nausea and vomiting (28.5%). Otitis media and mastoiditis were the most common causes of abscess (41.9%), and 44 patients had multiple abscesses. Aerobic gram-positive microorganisms were the most frequently isolated pathogens in culture (51.5%). Primary surgical interventions were as follows: craniotomy and resection (38.8%), free-hand aspiration (49.1%) and image-guided aspiration (12.1%). The aspiration-to-resection ratio was 1.36 (64/47) in the first decade, 2.94 (50/17) in the second decade and 1 (23/23) in the last decade. Age, level of consciousness at the time of admission and potent corticosteroid usage were found to be significantly associated with mortality (p=0.001, p≤0.001 and p=0,038, respectively). The total morbidity and mortality ratios were 4.9% and 9.8%, respectively. Seizures were more common in patients of craniotomy group (p=0.023). CONCLUSION Treatment of pyogenic brain abscess remains challenging, despite advances in surgical and imaging technology, and craniotomy retains a significant role in surgical treatment.

Transcortical Removal of Third Ventricular Colloid Cysts: A comparison of Conventional, Guided Microsurgical and Endoscopic Approaches and a Review of the Literature.

AIM To compare the clinical results of different transcortical approaches for the removal of third ventricular colloid cysts (CC). MATERIAL AND METHODS Records of 41 colloid cyst patients who underwent transcortical conventional microsurgical, microsurgical with the aid of stereotactically guided cylindrical retractor (minitubular), and endoscopic removal between 1999 and 2015 were retrospectively analyzed. The clinical results of these three different transcortical surgical approaches were compared and a literature review of published series was conducted. RESULTS Ages ranged between 16 and 66 years (mean: 36.8). There were 18 female and 23 male patients. Headache was the main presenting symptom. The mean CC diameter was 15.5 mm. Intraventricular hemorrhage was encountered in 2 patients. Three patients needed postoperative ventriculoperitoneal shunt surgery. Postoperative seizures were seen in 3, postoperative neurological deficit in 3 and residual tumor in 2 patients. The conventional approach resulted in significantly higher rates of postoperative seizure compared to the minitubular and endoscopic approaches (p=0.012). The rate of residual cyst was significantly higher in endoscopic approach compared to conventional and minitubular approaches (p=0.024). Conventional approach led to significantly higher rates of neurological deficit compared to the two other approaches (p < 0.05). CONCLUSION With respect to complication rates, the stereotactic and endoscopic approaches are both safe and reliable compared to conventional microsurgical approach that has unacceptably high rates of seizures and neurological deficit. Concerning completeness of removal, both microsurgical approaches are by far superior to neuroendoscopy. The stereotactic microsurgical approach compares favorably in both respects with endoscopic and conventional microsurgical approaches.

The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients

The aim of this prospective study was to investigate the success of ultrasound in pediatric patients in determining the appropriate sized cuffed endotracheal tube and to compare the results with conventional height‐based (Broselow) tape and age‐based formula tube size.

Effect of Visible Light on Vasospasticity of Post–Subarachnoid Hemorrhage Cerebrospinal Fluid

Background and Objective Cerebral vasospasm (CV) is a serious complication of subarachnoid hemorrhage (SAH) with high morbidity and mortality rates. The mechanism of CV has not been determined. There are many theories related to this unsolved issue, one of which supports CV as a two‐stage phenomenon from a pathophysiologic perspective. The first stage consists of inhibition of neuronal nitric oxide synthase by oxyhemoglobin, which results in a decrease of nitric oxide (NO) production. The second stage consists of an increase in the levels of asymmetric dimethylarginine through bilirubin oxidation products (BOXes), which are oxidized by‐products of hemoglobin metabolism. These in turn inhibit endothelial nitric oxide synthase (eNOS), which results in the blockage of the second NO production mechanism. BOXes are sensitive to visible light, as is their precursor bilirubin. The hypothesis of CV prevention using the photosensitivity of BOXes was tested in this study. Material and Methods Cerebrospinal fluid (CSF) obtained from two patients with SAH was divided in half and either exposed to a standard dose of visible light or not exposed to any light. The CSF was spectrophotometrically investigated and the concentration of BOXes was measured. A comparison between CSF samples exposed to light and not exposed to light was made. Using two groups of 16 rats each, the vasospastic effect of the CSF exposed and not exposed to light on arteries of the cortical surface was measured. The cortex was exposed using the cranial window. Results Spectrophotometric analysis revealed that the concentration of BOXes in the CSF decreased significantly after being exposed to visible light (p < 0.001). There was a significant difference of the vasospastic effect of CSF on exposed cortical arteries (p < 0.001). Conclusion The concentration of BOXes and the vasospastic effect of CSF taken from patients with SAH were significantly reduced after being exposed to visible light if compared with CSF not exposed to light.

Ultrasonographic Measurement of Subglottic Diameter for Paediatric Cuffed Endotracheal Tube Size Selection: Feasibility Report

OBJECTIVE The aim of this feasibility study was to investigate the first attempt success of ultrasonography (USG) in paediatric patients in predicting an appropriate cuffed endotracheal tube (ETT) size. METHODS Fifty children who were 1-10 years of age and who received general anaesthesia with endotracheal intubation for adenoidectomy or adenotonsillectomy were enrolled in the study. In all participants, the transverse diameter of the subglottic airway was measured with USG at the cricoid level without ventilation. The outer diameter (OD) of the maximum allowable ETT was chosen according to the measured subglottic airway diameter. In the presence of resistance to passage of the tube into the trachea or in the absence of an audible leak at airway pressure of >25 cm H2O, the ETT was replaced with a tube whose internal diameter (ID) was 0.5 mm smaller. If a leak was audible at airway pressures of <10 cm H2O, if a seal could not be achieved with a cuff pressure of >25 cm H2O or if a peak airway pressure of >25 cm H2O was observed during ventilation, the tube was changed to a tube one size larger. The OD of the best-fit ETT was converted to the ID. The best-fit ID, the requirement for ETT replacement, the duration of airway diameter measurement by USG and the peak airway pressure were recorded. RESULTS The success rate of the first attempt with USG was 86%; the ETT was replaced in five patients with a tube one size larger and in two patients with a tube one size smaller. CONCLUSION Our findings show the subglottic diameter measured by USG to be a reliable predictor in estimating the appropriate paediatric ETT size.

A Comparison of the Effects of 20% Mannitol and 3% NaCl on Coagulation Parameters In Vitro using ROTEM: A Prospective Randomized Crossover Study

OBJECTIVE The aim of the present study is to compare the effect of 20% mannitol and 3% NaCl on blood coagulation in vitro using rotational thromboelastometry (ROTEM). METHODS Twenty-millilitre blood samples were obtained from 15 volunteers. In each group, 2 mL blood samples were collected into both polypropylene tubes and EDTA tubes for ROTEM and hemogram analysis. After sampling, blood samples were diluted with test solutions. Group C (control): Only blood, Group M (mannitol): 7% vol 20% mannitol concentration in the blood, Group hypertonic saline (HS): 7% vol 3% hypertonic saline (NaCl) in the blood, Group M/H (mannitol and hydroxyethyl starch solutions [HES]): 6% vol 20% mannitol concentration and 8% vol HES in the blood and Group HS/H (hypertonic saline and HES): 6% vol 3% hypertonic saline concentration and 8% vol HES in the blood. The following thromboelastometric parameters were measured automatically: clotting time (CT) and clot formation time (CFT) with intrinsic activation by tissue factor (InTEM), CT, CFT and maximum clot firmness (MCF) with extrinsic activation by tissue factor (ExTEM) and MCF with FibTEM. RESULTS The ExTEM CT value was found to be significantly longer in the M/H group than in the controls. The ExTEM CFT median and percentile values were: group C: 85 s (70-95 s), group M: 115 s (94-128 s), group HS: 102 s (84-114 s), group M/H: 128 s (110-144 s) and group HS/H: 118 s (107-132 s). In all the groups, FibTEM MCF values were significantly lower than the control and also there was a significant difference between groups M and HS according to FibTEM MCF values. CONCLUSION Whole-blood coagulation disorder induced by these solutions is mainly dependent on fibrinogen and fibrin interaction. However, 3% HS has much less negative effect on coagulation.

Pulse Pressure Variation and Weight-Loss Percentage Predict Hypotension After Anesthesia Induction in Neurosurgery Patients: A Prospective, Observational, Blinded Study.

Background: Hypotension after anesthesia induction is a common problem and is partly related to patient volume status. The present study aimed to investigate the correlation between blood pressure change and pulse pressure variation (PPV), and percentage of weight loss while determining threshold for hypotension by receiver operating characteristic analysis. Methods: We analyzed 231 neurosurgery patients. In all patients, propofol was used for standard anesthesia induction. Patient demographics, medical histories, fasting duration, percentage weight loss, baseline blood pressure, and PPV during normal tidal volume breathing and that during forced inspiratory breathing (PPVfi) were recorded. Hemodynamic changes within 10 minutes of intubation were observed. Patients developing hypotension and severe hypotension were determined; lowest mean arterial pressure (MAP) and systolic arterial pressure (SAP) values were recorded, and their differences relative to baseline values were calculated. Results: The incidence of hypotension was 18.6%. Both percentage weight loss and PPVfi were correlated with the changes in MAP and SAP. A PPVfi>14 identified all observed hypotensive episodes with 86% sensitivity and 86.2% specificity, whereas percentage weight loss >1.75% identified all observed hypotensive episodes with 81.4% sensitivity and 70.7% specificity. Furthermore, PPVfi>16.5 identified severe hypotension with 85% sensitivity and 90.5% specificity, whereas percentage weight loss >1.95% identified severe hypotension with 85% sensitivity and 73% specificity. Conclusions: Percentage weight loss and PPVfi are good predictors of hypotension after anesthesia induction and, thus, may allow anesthesiologists to adopt preventative measures and ensure safer anesthesia induction.

Evaluation of risk factors and development of acute kidney injury in aneurysmal subarachnoid hemorrhage, head injury, and severe sepsis/septic shock patients during ICU treatment

BACKGROUND There are few studies examining development of acute kidney injury (AKI) in the various types of patients in intensive care units (ICUs). Presently described is evaluation of risk factors and development of AKI in different groups of ICU patients. METHODS Present study was performed in 3 different ICUs. Development of AKI was measured using Acute Kidney Injury Network (AKIN) classification system. Total of 300 patients who were treated in trauma, neurosurgery, or general ICU departments (due to head injury, aneurysmal subarachnoid hemorrhage [aSAH], or severe sepsis/septic shock, respectively) were assessed for incidence, risk factors, and development of AKI. RESULTS AKI did not develop in aSAH patients when evaluated based on serum creatinine level; however, it was observed in 5% of aSAH patients according to volume adjusted creatinine (VACr) level. AKI developed in 76% of sepsis group, and in 20% of head injury group, based on AKIN classification, according to both serum and VACr levels. Incidence of AKI was significantly higher in sepsis group (p<0.001). Only use of vasopressor was significantly related to AKI development in sepsis and head injury groups. Mortality rate was 8%, 22%, and 42% in aSAH, head injury, and sepsis groups, respectively. AKI development and vasopressor use were significantly related to mortality in sepsis group. CONCLUSION Despite similar characteristics and risk factors, there were fewer instances of AKI in aSAH group. Hypertension or hydration therapy used to treat vasospasm and polyuria due to cerebral salt-wasting syndrome may prevent aSAH patients from developing AKI.