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Spontaneous pneumomediastinum is a rare diagnosis. A thirty-five-year-old female who was admitted to our hospital with fever, cough and breathlessness and positive RT-PCR for COVID -19 was diagnosed with spontaneous pneumomediastinum and pneumothorax. She was managed with symptomatic approach and oxygen therapy. Small pneumomediastinum usually requires close monitoring and follows an uneventful course.

Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH).The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters.We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated.After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients.SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.

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.

Context: Scalp infiltration and scalp block are being used to manage postcraniotomy pain. Dexmedetomidine has been successfully used as an adjuvant in regional anesthesia. The study was intended to compare whether addition of dexmedetomidine prolonged the duration of analgesia as well as to compare the two techniques. Aims: The primary objective was to assess whether addition of dexmedetomidine to bupivacaine prolonged the duration of analgesia. The secondary objective was to compare between scalp nerve block and scalp infiltration as techniques for pain relief. Settings and Design: The randomized control study was conducted in a tertiary care center from November 2013 to October 2014. Materials and Methods: A total of 150 American Society of Anesthesiologists Physical Status I–II patients, aged 18–70 years undergoing elective craniotomy were included. Patients were randomized into three groups of 50 patients, i.e., Group BI (bupivacaine infiltration), Group BDI (bupivacaine and dexmedetomidine infiltration), and Group BDNB (bupivacaine and dexmedetomidine scalp nerve block). Patient's pain score, pain-free interval, rescue analgesic requirement, and hemodynamic and respiratory parameters were noted for 48 h. Patients were followed up at 1 and 3 months to assess postcraniotomy pain. Results: Pain-free period was significantly longer in Group BDNB than Groups BDI and BI (P < 0.0001) and pain control was better in dexmedetomidine containing groups than in bupivacaine group (BI) (P < 0.0001). The rescue analgesic requirement was significantly lower in Group BDNB and Group BDI compared to Group BI. Conclusion: The addition of dexmedetomidine (1 µg/kg) to bupivacaine prolonged the pain-free period. Scalp nerve block is a superior technique than scalp infiltration.

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.

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.