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      Anesthetic Management of a Patient With Arnold Chiari Malformation and Syringomyelia During Laparoscopic Surgery With Neurologic Monitoring: A Case Report

      case-report
      , MD, PhD * , , , , MD , , MD, PhD
      A&a Practice
      Lippincott Williams & Wilkins

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          Abstract

          We describe a patient with severe Arnold Chiari Malformation and syringomyelia who underwent gynecological laparoscopy in an emergency context; no brain imaging was available. We here report the successful use of optic nerve sheath diameter (ONSD) and middle cerebral artery (MCA) velocity measurements as surrogate monitoring for cerebral blood flow and intracranial pressure, respectively. MCA velocity was low when assessed after peritoneal insufflation and ONSD increased to 6.3 mm after Trendelenburg positioning. This noninvasive Ultrasound and Doppler neurological monitoring helped adapt the anesthetic management and the patient recovered both normal ONSD and MCA velocity values.

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          Most cited references14

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          Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries.

          In this report the authors describe a noninvasive transcranial method of determining the flow velocities in the basal cerebral arteries. Placement of the probe of a range-gated ultrasound Doppler instrument in the temporal area just above the zygomatic arch allowed the velocities in the middle cerebral artery (MCA) to be determined from the Doppler signals. The flow velocities in the proximal anterior (ACA) and posterior (PCA) cerebral arteries were also recorded at steady state and during test compression of the common carotid arteries. An investigation of 50 healthy subjects by this transcranial Doppler method revealed that the velocity in the MCA, ACA, and PCA was 62 +/- 12, 51 +/0 12, and 44 +/- 11 cm/sec, respectively. This method is of particular value for the detection of vasospasm following subarachnoid hemorrhage and for evaluating the cerebral circulation in occlusive disease of the carotid and vertebral arteries.
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            Noninvasive assessment of intracranial pressure using ocular sonography in neurocritical care patients

            Introduction Invasive devices are the 'gold standard' for measurement of intracranial pressure (ICP). Their placement, however, can be challenging (coagulation disorders, lack of surgical availability). Noninvasive sonography of the optic nerve sheath diameter (ONSD) has been proposed to detect elevated ICP [1,2]. However, this method needs further validation. This study was performed to assess the relationship between the ONSD and ICP in neurocritical care patients. Methods After approval from the local ethics committee, 37 adult patients with severe traumatic brain injury (n = 22), subarachnoidal hemorrhage (n = 6), intracranial hematoma (n = 8) and stroke (n = 1) requiring sedation and ICP monitoring (intraparenchymal probe in the frontal lobe; Codman, Johnson & Johnson) were included. For each optic nerve, two measurements of ONSD were made using a 7.5 MHz linear probe (HP Sonos 5500®; Hewlett Packard) (2D mode, 3 mm behind the globe, one measure in the sagittal and one in the transverse plane). The mean value for both eyes was retained. The ONSD and ICP were measured simultaneously once a day during the first 2 days after ICP probe placement and in cases of important changes in ICP. Results There was a significant linear relationship between the ONSD and ICP (Spearman correlation ρ = 0.75, P 20 mmHg was 5.8 mm (area under ROC curve = 0.91). The negative likelihood ratio of this cutoff was 0.07. Figure 1 Relationship between intracranial pressure (ICP) and the optic nerve sheath diameter (ONSD). Conclusion There is a significant relationship between the ONSD and ICP in neuro-ICU patients. Changes in ICP are accurately detected by the ONSD. The probability of having high ICP when the ONSD is below 5.8 mm is very low. This noninvasive method could be used to check the absence of raised ICP.
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              Transcranial Doppler pulsatility index: what it is and what it isn't.

              Transcranial Doppler (TCD) pulsatility index (PI) has traditionally been interpreted as a descriptor of distal cerebrovascular resistance (CVR). We sought to evaluate the relationship between PI and CVR in situations, where CVR increases (mild hypocapnia) and decreases (plateau waves of intracranial pressure-ICP). Recordings from patients with head-injury undergoing monitoring of arterial blood pressure (ABP), ICP, cerebral perfusion pressure (CPP), and TCD assessed cerebral blood flow velocities (FV) were analyzed. The Gosling pulsatility index (PI) was compared between baseline and ICP plateau waves (n = 20 patients) or short term (30-60 min) hypocapnia (n = 31). In addition, a modeling study was conducted with the "spectral" PI (calculated using fundamental harmonic of FV) resulting in a theoretical formula expressing the dependence of PI on balance of cerebrovascular impedances. PI increased significantly (p < 0.001) while CVR decreased (p < 0.001) during plateau waves. During hypocapnia PI and CVR increased (p < 0.001). The modeling formula explained more than 65% of the variability of Gosling PI and 90% of the variability of the "spectral" PI (R = 0.81 and R = 0.95, respectively). TCD pulsatility index can be easily and quickly assessed but is usually misinterpreted as a descriptor of CVR. The mathematical model presents a complex relationship between PI and multiple haemodynamic variables.
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                Author and article information

                Journal
                A A Pract
                A A Pract
                ACC
                A&a Practice
                Lippincott Williams & Wilkins (Hagerstown, MD )
                2575-3126
                20 January 2025
                January 2025
                : 19
                : 1
                : e01908
                Affiliations
                From the [* ]Service d’Anesthésie, Clinique les Martinets, Groupe Ramsay Santé, Rueil-Malmaison, France
                []Département d’Anesthésie, Hôpital Antoine Béclère, APHP.Université Paris-Saclay, Clamart, France.
                Author notes
                Address correspondence to Mickaël Soued, MD, PhD, Service d'Anesthésie, Clinique les Martinets, 97 Ave Albert 1er, Rueil Malmaison 92500, France. Address e-mail to mickaelsoued@ 123456gmail.com .
                Article
                XAA-D-24-00236 00027
                10.1213/XAA.0000000000001908
                11761015
                39831716
                0bff39de-acca-48c4-9817-c704645a85dc
                Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 13 December 2024
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