Abstract Multimodal neuromonitoring plays a pivotal role in the prevention of perioperative stroke during microsurgical occlusion of an aneurysm. Several modalities are available for the same, and by appropriately combining them, depending on the vascular territory of interest, their diagnostic precision can be maximized. Any intraoperative change in evoked potentials during aneurysm clipping should be addressed immediately. A root cause analysis using a checklist can identify and rectify reversible causes, avoiding morbidity. In this report, we present a case of surgical clipping of a right middle cerebral artery aneurysm where the intraoperative somatosensory-evoked potential changes occurred secondary to an ipsilateral extradural hemorrhage. This is the first report describing such a rare phenomenon, and addressing it promptly led to a complete neurological recovery.

Abstract Phytochemicals or herbal medicines (HMs) with neuroprotective and nootropic properties are being increasingly utilized in various neurological conditions owing to their antioxidative, anti-inflammatory, and antiapoptotic properties, as well as their role in immune regulation, hormonal regulation, and modulation of neurotransmitters and ion channels. While HMs are often regarded as safe, they are not without risks. The aim of this review was to know the various neurological and non-neurological side effects of long-term consumption of neuroprotective and nootropic phytochemicals. An electronic search was conducted using the following databases from January 2000 to December 2023: PubMed, PubMed Central, Embase, Scopus, and Science Citation Index (Web of Science). Only studies published in the English language were considered. The search used key terms such as “Herbs,” “Phytochemicals,” “India,” “Asia,” “Neuroprotection,” “Neurological diseases,” and “Complications.” The sources included research articles, systematic reviews and meta-analyses, narrative reviews, and editorials. Letters to the editor, commentaries, abstracts only, and unpublished data were excluded. While HMs are increasingly being used therapeutically for various neurological and non-neurological conditions, they also carry the risk of adverse effects due to contamination, adulteration, direct effects of metabolites, herb–drug interactions, interindividual susceptibility, and other factors. In addition, widespread availability, over-the-counter sale, and unsupervised dosing are the key reasons for their unregulated prolonged use. As such, correct identification of HMs and consequent assessment of their toxicological profile are deemed extremely crucial. Neurotoxicity testing for HMs is challenging considering the limitations of traditional methods (morphological, microscopic, and chemical); nevertheless, in the recent years, several novel procedures have been developed. Large studies are warranted to establish the safety profile of consuming HMs either alone or in combination in humans.

Abstract Transfusion-associated hypotension (TAH) is a rare but potentially serious complication characterized by a sudden onset of hypotension during or shortly after the initiation of a blood transfusion. Once other causes have been excluded, the hypotension resolves upon cessation of the transfusion. We report the case of a 49-year-old female scheduled for excision of a central neurocytoma via an interhemispheric approach. Intraoperatively, the patient developed unexplained hypotension unresponsive to inotropic support during tumor resection. After systematic exclusion of other differential diagnoses, TAH was considered as the most likely cause. Discontinuation of the transfusion led to the resolution of hypotension, confirming the diagnosis. This case highlights the importance of considering TAH as a differential diagnosis for intraoperative hypotension, particularly when unresponsive to standard management and temporally associated with transfusion. Prompt recognition and appropriate management are crucial to avoid unnecessary interventions and improve patient outcomes.

Abstract Management of intracranial hemorrhage in a patient with hemophilia A and high-titer inhibitors presents a significant challenge to the neurointensivist. The decision between conservative and surgical approaches involves a delicate risk–benefit balance. While conservative management is costly and carries the risk of sudden deterioration, surgical intervention is often complicated by the high likelihood of rebleeding. We report the successful critical care management of a 50-year-old male with hemophilia A and high-titer factor VIII inhibitors who presented with an acute-on-chronic subdural hematoma. His factor VIII levels were markedly low, and conventional factor VIII replacement therapy was ineffective. The bleeding manifestations and laboratory parameters did not improve with standard treatment. The patient was successfully managed using sequential or combined bypassing agent therapy.

Abstract Conventional electroencephalogram (EEG) has been the most common method to detect and manage seizure episodes. Limitations to its use in the intraoperative period during neurosurgical cases have made detecting intraoperative seizure almost impractical, especially in the presence of a neuromuscular blocking agent. Using an EEG-based monitor like bispectral index (BIS) can add a new dimension to intraoperative neuromonitoring in patients at risk of seizure. Apart from other indices, it also displays the real-time raw EEG waveform, which can be valuable in diagnosing an intraoperative seizure and guide the therapeutic achievement of burst suppression. An increase in the BIS value has also been reported during intraoperative seizures. Here, we present the cases of three patients posted for excision of intracranial space-occupying lesions who developed intraoperative seizures, which were diagnosed and managed with the aid of a BIS monitor. This case series highlights the utility of BIS in detecting and managing intraoperative seizures, apart from its role in depth of anesthesia monitoring.

Abstract Pneumocephalus following spinal surgery is a rare but significant complication, particularly in procedures involving durotomy. Its nonspecific presentation can be mistaken for anesthesia-related effects, delaying diagnosis. We report a 70-year-old female who underwent D4 laminectomy and excision of a D3–D4 intradural extramedullary tumor. In the immediate postoperative period, she developed progressively worsening frontal headache and nausea, unresponsive to standard analgesia. A computed tomography scan on postoperative day 1 revealed pneumocephalus in the basal cisterns and Sylvian fissures. Despite no evident cerebrospinal fluid leak after watertight closure or intraoperative nitrous oxide use, factors such as subtle dural microleaks, intraoperative head elevation, and the use of a subfascial drain may have contributed to intracranial air entry. Vacuum activation of the drain, though not confirmed, could not be ruled out. Conservative management with supine positioning, oxygen therapy, analgesics, and early drain removal led to full symptom resolution. This case highlights the need for early recognition of pneumocephalus in patients with severe postoperative headache particularly as headache severity has been shown to correlate with the extent of pneumocephalus. Heightened awareness and preventive intraoperative strategies are essential to mitigate this risk.