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Awake craniotomy in a child with chronic extradural hematoma and uncorrected tetralogy of fallot

 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission18-Jul-2020
Date of Decision03-Oct-2020
Date of Acceptance22-Oct-2020
Date of Web Publication19-Jul-2021

Correspondence Address:
Saurav Singh,
Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_188_20


How to cite this URL:
Singh S, Verma S, Manasa K. Awake craniotomy in a child with chronic extradural hematoma and uncorrected tetralogy of fallot. J Pediatr Neurosci [Epub ahead of print] [cited 2023 Dec 1]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=321784


Extradural hematoma (EDH) accounts for 1%–4% of all head injuries, with an overall mortality of 5%.[1] Clinical presentation of Tetralogy of Fallot (TOF), the most common of all congenital cyanotic heart disease (CCHD), varies with age and severity of the right ventricular outflow tract obstruction.[2] General anesthetic management poses various challenges[3]; however, awake craniotomy is safe, feasible, and well tolerated in children, and it is a viable option if the child is cooperative and concomitant anxiety is managed preoperatively.[4],[5]

A 12-year-old, cooperative male child weighing 25 kgs with a history of chronic EDH in the right parietotemporal region was posted for craniotomy and evacuation of hematoma [Figure 1]. Neurological examinations were normal, with a left parasternal heave on palpation, grade V ejection systolic murmur at left sternal border, grade III clubbing, and oxygen saturation (SpO2) of 76% on room air. An echocardiogram revealed a large subaortic ventricular septal defect, a double outlet right ventricle, and pulmonary stenosis; electrocardiogram and chest x-ray showed signs of right ventricular hypertrophy. Baseline blood investigation showed hemoglobin 23.75 gm/dl, hematocrit 72.6%; whereas ABG on room air revealed pH of 7.318, PaCO2 of 34.7 mm Hg, and PaO2 of 44.9 mm Hg.
Figure 1: Noncontrast computed tomography scan of head showing large extradural hematoma in the right parietotemporoal region

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Routine ASA monitors were attached, 20G and 18G IV cannulas were secured, and midazolam 1mg IV was administered once the child had been taken into the operation theater. Scalp block was given by using 16ml of 0.5% bupivacaine and 2% lignocaine. Sedation was achieved with an intermittent bolus dose of injection ketamine 10mg IV and 0.25mg IV midazolam. Injection paracetamol 15mg/kg IV and injection phenytoin 500mg IV were administered over 20 minutes. Oxygen was provided @ 4L/min via nasal cannula, with SpO2 remaining close to the baseline intraoperatively. Blood pressure was maintained within 20% of the baseline to avoid hypotension and reversal of the shunt. Blood loss was 200–300ml, and 500ml of isotonic normal saline was infused. The intraoperative period was uneventful and the patient was shifted in the conscious state, oriented and with stable vitals, which mirrored in the postoperative period.

The anesthetic goals in TOF are to prevent right-to-left shunting by maintaining or increasing the systemic vascular resistance (SVR) and minimizing pulmonary vascular resistance (PVR).[6] Tachycardia, hypoxia, hypovolemia, and sympathetic stimulation by pain were avoided to prevent a decrease in pulmonary blood flow.[3],[5] Normothermia was maintained, and meticulous care was taken to avoid infusion of air through IV tubings to prevent paradoxical air embolism.[3],[6] Ketamine was chosen as an anesthetic agent, as it causes minimal myocardial depression, maintains the SVR, and provides analgesia.[5] Moreover, an intermittent bolus dose of ketamine does not seem to increase intracranial pressure (ICP) in patients with head injury when used with a background sedative.[4] Successful anesthetic management for EDH in patients with TOF depends on understanding the pathophysiology of TOF and maintaining the intracranial dynamics. Minimizing anesthesia-related alterations in hemodynamics to maintain the baseline parameters is crucial in such scenarios. As such, scalp block with sedation and vigilant monitoring in this child served both our purpose and the patients’ purpose. Hence, awake craniotomy may offer an alternative approach over general anesthesia in pediatric age group patients with traumatic brain injury associated with underlying heart defects if the conditions permits us to do so.

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   References Top

Rizvi T, Wintermark M. Modern neuroradiology relevant to anesthetic and perioperative management. In: Cottrell JE, Patel P, editors. Cottrell and Patel’s Neuroanesthesia. 6th ed. Philadelphia: Elsevier; 2017. p. 101.  Back to cited text no. 1
Diaz-Frias J, Guillaume M. Tetralogy of Fallot. StatPearls. Treasure Island (FL): StatPearls Publishing; 2019.  Back to cited text no. 2
Gupta P, Rahul JS, Barik AK, Gupta G. An adolescent with large extradural hematoma and undiagnosed congenital cyanotic heart disease at wee hours: An anesthetist’s nightmare. Indian Anaesth Forum 2020;21:66-9.  Back to cited text no. 3
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Lohkamp LN, Mottolese C, Szathmari A, Huguet L, Beuriat PA, Christofori I, et al. Awake brain surgery in children-review of the literature and state-of-the-art. Childs Nerv Syst 2019;35:2071-7.  Back to cited text no. 4
Mohindra R, Beebe DS, Belani KG. Anaesthetic management of patients with congenital heart disease presenting for non-cardiac surgery. Ann Card Anaesth 2002;5:15-24.  Back to cited text no. 5
[PUBMED]  [Full text]  
Stoelting RK, Hines RL, Marschall KE. Pediatric disease. In: Diu MW, Mancuso TJ, editors. Stoelting’s Anesthesia and Co-existing Disease. 6th ed. Philadelphia: Elsevier Saunders; 2012. p. 58-9.  Back to cited text no. 6


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