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Arteriovenous malformations (AVMs) are defined as an abnormal collection of dysplastic blood vessels wherein the arterial blood flows directly into the draining veins without any intervening neural parenchyma or capillary beds. These are usually congenital lesions with a lifelong risk of hemorrhage of about 2–4% per year. These lesions tend to enlarge with age and may progress from low-flow AVMs at birth to medium- or high-flow and high-pressure AVMs in adulthood. Grossly, it appears as a “tangle” of vessels with a well-circumscribed center called nidus. Intracranial AVMs are classified as parenchymal and dural depending, upon the location of AVMs. Intracranial AVMs in pediatric patients might present with congestive heart failure (CHF) in neonates, seizures or hemorrhage, and varying degrees of ischemic symptoms. Anesthetic management in this group of patients is quite challenging as surgical interventions are associated with massive blood loss. The pediatric population has a low cardiopulmonary reserve and poorly tolerates such losses. This chapter describes the anesthetic management of patients with intracranial AVMs posted for various interventions.

Background: The short term outcome of patients undergoing surgery for Moyamoya disease can be affected by various perioperative factors. However, due to lesser prevalence of this disease in our country, data relating the effect of perioperative factors on the overall neurological outcomes of these patients is lacking. Aims: To analyze the effect of perioperative factors on the duration of postoperative hospital stay in patients undergoing surgery for Moyamoya disease. Settings and Design: It is a retrospective study analyzing various perioperative factors influencing the overall outcome of patients undergoing surgery for Moyamoya disease at a tertiary care centre in North India. Methods and Material: The medical records of all patients who underwent revascularization surgeries for Moyamoya disease from 2007 to till January 2014 were included for retrospective analysis. Various preoperative, intraoperative, and postoperative data were recorded. The data was statistically compared for short and prolonged hospital stay for various perioperative factors. The duration of post operative hospital stay was categorized as short (5 days). Statistical Analysis: Kolmogrov Smirnov test was applied to see the normality of continuous data. The association of various categorically classified data with 2 groups was found using Fisher Exact test. The trends in intraoperative hemodynamics were analysed using 2 way repeated measure Anova test. T-test was used for comparing two group means for various parameters. Results: A total of 15 patients were included in the study. One patient underwent surgery twice on two different occasions. Thirteen patients belonged to paediatric age group (

Negative pressure pulmonary oedema (NPPO) is a life-threatening complication occurring due to large negative intrathoracic pressures created by inspiration against a closed glottis. Timely diagnosis and management is important to prevent any fatal outcome. Although it presents acutely most of the time, its presentation may rarely be delayed. We present a case of a 21-year-old female weighing 40 kg who developed NPPO 1.5 h after warding in the post-anaesthesia care unit. Despite the delayed presentation, she was diagnosed in a timely manner and managed successfully. This case emphasises the need for extended monitoring of all patients with any respiratory difficulty in the perioperative period for delayed development of NPPO.

Cerebral vasospasm leading to delayed cerebral ischaemia is one of the major concerns following subarachnoid haemorrhage (SAH). Various modalities are present for evaluation and detection of cerebral vasospasm that occurs following SAH. They include transcranial Doppler (TCD), computed tomographic angiography (CTA), computed tomographic (CT) perfusion and digital subtraction angiography (DSA). The recent guidelines have advocated the use of TCD and have described it as a reasonable technique for monitoring the development of vasospasm. This review describes the functioning of TCD, the cerebral haemodynamic changes during vasospasm and TCD-based detection of vasospasm. The review shall highlight as to how the TCD derived values are relevant in the settings of neurocritical care. The data in the review have been consolidated based on our search of literature from year 1981 till 2016 using various data base.

Postoperative nausea and vomiting (PONV) is a significant complication for neurosurgical patients. PONV affects patient satisfaction, prolongs hospital stay, and increases the economic burden and morbidity. In addition to these problems, there are certain consequences of PONV specific to the craniotomy, including increased intracranial pressure and increased risk of tumor bed hematoma formation. Expert panels have suggested that, if the consequences of PONV are deleterious to the patients, then prophylaxis should be instituted. This article describes the pathophysiology, risk factors, prevention, and management of PONV in neurosurgery patients as per the recent guidelines.

Background and Aims: Pre-emptive analgesia using caudal epidural technique is an underutilized technique in lumbosacral spine surgery patients. We intend to study if pre-emptive analgesia with a single caudal epidural injection of ropivacaine is an effective method of postoperative analgesia by assessing the quality and duration of pain relief and intraoperative opioid requirement. Material and Methods: Eighty patients undergoing lumbosacral spine surgeries by the posterior approach were randomized to ropivacaine (R) group (n = 40) and saline (S) group (n = 40). Patients in R group received caudal epidural injection of 20 ml of 0.2% ropivacaine for surgeries at or below L5 lumbar spine and 25 ml of 0.2% ropivacaine for surgeries between L2 and L5 lumbar spine. Patients in S group received similar amounts of normal saline. Patients were monitored in the immediate postoperative period and at 4, 8, 12, and 24 hours for pain using visual analogue scale (VAS) scale. Time to rescue analgesia and intraoperative fentanyl requirement were noted. Results: The demographics, duration of anesthesia, and hemodynamic variables were comparable in both groups. The mean intraoperative fentanyl requirement (P = 0.001) and mean VAS scores were significantly lower in the R group in the immediate postoperative period, (P < 0.001), 4 hours (P < 0.001), 8 hours (P = 0.009), 12 hours (P = 0.007), and 24 hours (P = 0.046) postoperatively. The mean time to rescue analgesia was significantly longer in the R group (P < 0.001) compared to S group. No hemodynamic or neurological side-effects were observed in the groups. Conclusion: Pre-emptive analgesia with caudal epidural injection of ropivacaine is a safe and effective method of postoperative analgesia.