Chirurgie arthroscopique de l’épaule et complications ischémiques cérébrales

The authors report three cases in which cerebral ischemia occurred during arthroscopic shoulder surgery performed in beach chair position under general anaesthesia and interscalene plexus block. Several similar cases have been published in the literature. This rare but extremely severe complication is related to the decrease in cerebral perfusion pressure (CPP). Monitoring of CPP in the beach chair position using the measurement of arterial pressure and taking into account the hydrostatic gradient is essential. Prevention includes correction of preoperative hypovolaemia, treatment of postural arterial hypotension, adequate installation of the patient's head, aggressive treatment of perioperative arterial hypotension (whatever the cause) and avoidance of deliberate perioperative arterial hypotension. Routine use of non-invasive monitoring of cerebral oxygenation has been advocated to avoid this accident but its usefulness has to be confirmed by clinical studies.     

Complications cardiovasculaires de l’agression cérébrale

The clinical importance of cardiovascular consequences resulting from cerebral injury has long been recognized. However, interactions between the brain and the cardiovascular system remain poorly defined and their importance for the management of patients suffering from acute brain injury is largely underestimated. This should have profound consequences on treatment strategies during anaesthesia and intensive cares of these patients, taking into account not only brain perfusion, but also cardiovascular optimisation. This report summarizes the main data available regarding the cardiovascular consequences of brain death, traumatic brain injury, stroke and epilepsy.     

Intérêt du monitorage de l’index bispectral (BIS) pour la détection précoce des hypoperfusions cérébrales

Objectives

The goal of the study was to assess whether clinically significant cerebral hypoperfusion in awake patients would be associated with some alterations in the values of the bispectral index (BIS) monitoring.

Study design

Observational study.

Population and methods

We monitored the BIS during endovascular carotid artery occlusion testing in awake patients.

Results

Twenty-eight patients were included. Twenty-one adequately tolerated the procedure. Their BIS value remained stable throughout the procedure. Four patients had poor angiographic tolerance, but no clinical symptoms. Their BIS value slightly decreased during the test (minimal BIS: 83 [79–87]). Three patients had poor clinical and angiographic tolerance of the occlusion. They all experienced an immediate and dramatic decrease in their BIS value (minimal BIS: ipsilateral to clamping: 50 [45–60]; contralateral to clamping: 48 [45–52]). In all patients, the clinical symptoms and the BIS normalized after deflating the occlusion balloon.

Conclusion

In awake patients, the observed values of the BIS monitoring seem to be associated with clinically relevant cerebral hypoperfusion.     

Œdème cérébral : nouvelles pistes thérapeutiques

Cerebral oedema (CO) after brain injury can occur from different ways. The vasogenic and cytotoxic oedema are usually described but osmotic and hydrostatic CO, respectively secondary to plasmatic hypotonia or increase in blood pressure, can also be encountered. Addition of these several mechanisms can worsen injuries. Consequences are major, leading quickly to death secondary to intracerebral hypertension and later to neuropsychic sequelae. So therapeutic care to control this phenomenon is essential and osmotherapy is actually the only way. A better understanding of physiopathological disorders, particularly energetic ways (lactate), aquaporine function, inflammation lead to new therapeutic hopes. The promising experimental results need now to be confirmed by clinical data.     

Défaillance cardiaque et neurologique secondaire à une intoxication accidentelle par l’hydrogène sulfuré : à propos d’un cas

We report the case of a patient who was victim of a hydrogen sulphide poisoning. This poisoning took place following a fall in sewers. The initial clinical presentation was dominated by an acute respiratory failure caused by an acute pulmonary oedema. In this context, non cardiogenic pulmonary oedema is usually evoked in the literature. Our observation supports a left ventricular systolic dysfunction as a possible cause of this cardiorespiratory complication. The initial presentation was also marked by a coma which is often associated with severe poisonings by hydrogen sulphide. Evolution was favourable under symptomatic treatment. We discuss the mechanism of heart and neurological failure.     

Hémorragie cérébrale chez un enfant asthmatique ventilé : mécanismes multifactoriels

We report the case of a 7-year-old boy with acute status asthmaticus requiring mechanic ventilation in the pediatric intensive care unit. He developed a brain hemorrhage during the course of his illness. We discuss the mechanisms that may have precipitated this neurological complication.     

Hémorragie intracérébrale spontanée secondaire à un déficit congénital en facteur XIII

Deficiency of coagulation factor XIII is a rare anomaly. The risk of intracranial haemorrhage is particularly high at any age, either spontaneously or during minor trauma. We report a case of spontaneous intracerebral haemorrhage in a child carrying a known deficiency of factor XIII.     

Chirurgie éveillée des gliomes cérébraux : plaidoyer pour un investissement accru des anesthésistes

The recent development of awake surgery in neuro-oncology allowed a conceptual change, i.e. the realization of resection for invasive brain tumors according to functional and not anatomic boundaries. This paradigmatic shift enabled a significant improvement of results in surgery for gliomas, by opening the door to resections within eloquent areas classically considered as “inoperable”, while preserving and even improving the quality of life of patients. In addition, the extent of resections has been maximized, leading to an increase of median survival – especially in low-grade gliomas. Strong relationships between the different teams (surgeons, neuropsychologists, anaesthesiologists) are crucial for the development and improvement of awake surgery. Thus, it seems important that anesthesiologists can benefit from a clear and accurate knowledge of the real contribution of this procedure, in order to better evaluate the balance between the theoretical risks of surgery under local anesthesia versus the actual risk of not performing resection with a maximum of safety and efficiency for the patients. The purpose of this plea is to advocate the spread of awake surgery in routine practice, due to its major impact on both functional and survival outcomes, by nonetheless keeping in mind that a multidisciplinary staff is mandatory for selection of patients as well as into the operating room. In this state of mind, anaesthesiologists have to play a central role, through an increased involvement in this field.     

L’oxymétrie cérébrale transcutanée en anesthésie pédiatrique

Cerebral oximetry allows continuous real-time and non-invasive monitoring of cerebral oxygen saturation (cSO₂), by measuring oxyhaemoglobin and deoxyhaemoglobin near infrared light absorption, similarly to pulse oximetry. cSO₂ measurement predominantly reflects brain venous compartment, and is correlated with jugular venous saturation. As jugular venous saturation, cSO₂ must therefore be interpreted as a measure of balance between transport and consumption of O₂ in the brain. Cerebral oximetry should be used as a trend monitoring, because its accuracy is insufficient to be considered as reliable measure of absolute value of ScO₂. In adult, correction of intraoperative cerebral desaturation reduces hospital stay, heavy morbidity and mortality, and serious postoperative neurocognitive impairment after cardiac and major abdominal surgery. In children, the occurrence of intra- and postoperative cerebral desaturations during congenital heart surgery is associated with increased neurological morbi-mortality. Cerebral oximetry could be a useful monitoring during anaesthesia of (ex) preterm neonates, due to the risk of impaired cerebral blood flow autoregulation in these patients.     

Hypothermie et protection cérébrale après traumatisme crânien. Influence des gaz du sang

The usefulness of therapeutic hypothermia is highly debated after traumatic brain injury. A neuroprotective effect has been demonstrated only in experimental studies: decrease in cerebral metabolism, restoration of ATP level, better control of cerebral edema and cellular effects. Despite negative multicenter clinical studies, therapeutic hypothermia is still used to a better control of intracranial pressure. However, important issues need to be clarified, particularly the level and duration of hypothermia, the depth and modalities of sedation. A clear understanding of blood gases variations induced by hypothermia is needed to understand the cerebral perfusion and oxygenation changes. It is essential to recognize and to use hypothermia-induced physiological hypocapnia and alkalosis under strict control of cerebral oxygen balance (jugular venous saturation or tissue PO₂) and also to take into account the increased affinity of hemoglobin for oxygen. Management of post-traumatic intracranial hypertension using hypothermia, directed by intracranial pressure level, and consequently for long duration, is potentially beneficial but needs further clarification.     

Embolie gazeuse cérébrale compliquant une pleurodèse au talc : à propos d’un cas

Cerebral air embolism is a severe complication which can occur during many invasive medical procedures. Its prognosis depends on early diagnosis and hyperbaric oxygen therapy. We report a case of cerebral air embolism which occurred during a talc pleurodesis within a chest tube, in chest postoperative period. After early and appropriate treatment, we observed a significant functional recovery.     

Oxygénothérapie hyperbare et gaz inertes dans l’ischémie cérébrale et le traumatisme crânien

Cerebral ischemia is a common thread of acute cerebral lesions, whether vascular or traumatic origin. Hyperbaric oxygen (HBO) improves tissue oxygenation and may prevent impairment of reversible lesions. In experimental models of cerebral ischemia or traumatic brain injury, HBO has neuroprotective effects which are related to various mechanisms such as modulation of oxidative stress, neuro-inflammation or cerebral and mitochondrial metabolism. However, results of clinical trials failed to prove any neuroprotective effects for cerebral ischemia and remained to be confirmed for traumatic brain injury despite preliminary encouraging results. The addition of inert gases to HBO sessions, especially argon or xenon which show neuroprotective experimental effects, may provide an additional improvement of cerebral lesions. Further multicentric studies with a strict methodology and a better targeted definition are required before drawing definitive conclusions about the efficiency of combined therapy with HBO and inert gases in acute cerebral lesions.     

Association d’une rééducation sous analgésie péri-nerveuse continue et d’une capsulo-distension de l’épaule dans le traitement du syndrome épaule-main rebelle

Objective

Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoulder under general anaesthesia and on active rehabilitation under regional analgesia using infraclavicular brachial plexus catheter.

Material and methods

It was a retrospective study of twenty-five consecutive patients with severe shoulder-hand syndrome treated between 2007 and 2012. Besides their persistent pain, these patients presented a functional disability of their shoulder, wrist and hand. Treatment was initiated at least three months after diagnosis. All were assessed at the admission and six months later.

Results

After treatment, pain was reduced by at least three points at the NS in 64% of the patients. Twelve patients described a complete recovery of their shoulder function; eleven patients described a normal hand function recovery and six patients a partial recovery allowing regular life. Nineteen patients evaluated their functional improvement of more than 50%. Only two patients with more than one year of chronic pain reported no improvement after treatment.

Conclusion

After failure of the physiotherapy and analgesic treatment, there are no clear consensual procedures and guidelines remains discussed. The current study combined different approaches with a significant improvement of this complex regional pain syndrome called shoulder-hand syndromes.