Early Neurological Examination Research Articles

Early neurological signs in infants identified through neonatal screening for SMA: do they predict outcome?

Neonatal screening for SMA has allowed the identification of infants who may present with early clinical signs. Our aim was to establish whether the presence and the severity of early clinical signs have an effect on the development of motor milestones. Infants identified through newborn screening were prospectively assessed using a structured neonatal neurological examination and an additional module developed for the assessment of floppy infants. As part of the follow-up, all infants were assessed using the HINE-2 to establish developmental milestones. Only infants with at least 24 months of follow-up were included. Normal early neurological examination (n = 11) was associated with independent walking before the age of 18 months while infants with early clinical signs of SMA (n = 4) did not achieve ambulation (duration follow-up 33.2 months). Paucisymptomatic patients (n = 3) achieved ambulation, one before the age of 18 months and the other 2 between 22 and 24 months. Conclusion: Our findings suggest that early clinical signs may contribute to predict motor milestones development.What is Known:• There is increasing evidence of heterogeneity among the SMA newborns identified via NBS.• The proposed nosology describes a clinically silent disease, an intermediate category (‘paucisymptomatic’) and ‘symptomatic SMA’.What is New:• The presence of minimal clinical signs at birth does not prevent the possibility to achieve independent walking but this may occur with some delay.• The combination of genotype at SMN locus and clinical evaluation may better predict the possibility to achieve milestones.

Risk factors for unfavorable outcome at discharge of newborns with hypoxic-ischemic encephalopathy in the era of hypothermia.

To re-visit short-term outcomes and associated risk factors of newborns with hypoxic-ischemic encephalopathy (HIE) in an era where hypothermia treatment (HT) is widespread. This is a prospective population-based cohort in French neonatal intensive care units (NICU). Neonates born at or after 34 weeks of gestational age with HIE were included; main outcomes were in-hospital death and discharge with abnormal or normal MRI. Associations of early perinatal risk factors, present at birth or at admission to NICU, with these outcomes were studied. A total of 794 newborns were included and HT was administered to 670 (84.4%); 18.3% died and 28.5% and 53.2% survived with abnormal and normal MRI, respectively. Severe neurological status, Apgar score at 5 mn ≤5, lactate at birth ≥11 mMoles/l, and glycemia ≥100 mg/dL at admission were associated with an increased risk of death (relative risk ratios (aRRR) (95% CI) 19.93 (10.00-39.70), 2.89 (1.22-1.62), 3.06 (1.60-5.83), and 2.55 (1.38-4.71), respectively). Neurological status only was associated with survival with abnormal MRI (aRRR (95% CI) 1.76 (1.15-2.68)). Despite high use of HT in this cohort, 46.8% died or presented brain lesions. Early neurological and biological examinations were associated with unfavorable outcomes and these criteria could be used to target children who warrant further neuroprotective treatment. Clinical trial registry, NCT02676063, ClinicalTrials.gov. In this population-based cohort of newborns with HIE where 84% received hypothermia, 46.8% still had an unfavorable evolution (death or survival with abnormal MRI). Risk factors for death were high lactate, low Apgar score, severe early neurological examination, and high glycaemia. While studies have established risk factors for HIE, few have focused on early perinatal factors associated with short-term prognosis. This French population-based cohort updates knowledge about early risk factors for adverse outcomes in the era of widespread cooling. In the future, criteria associated with an unfavorable evolution could be used to target children who would benefit from another neuroprotective strategy with hypothermia.

Procedure-Specific Complications Associated with Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spine Surgery: A Retrospective Analysis of 342 Consecutive Cases.

PurposePresumed benefits of erector spinae plane blocks (ESPB) include an enhanced safety profile and few complications. There are few large series, which report the incidence of complications associated with ESPB on a procedure-specific basis. The objective of this retrospective cohort study was to estimate the incidence of complications of ESPB in a large series of patients undergoing lumbar spine surgery.Patients and MethodsWe included 342 consecutive patients who underwent any primary lumbar spine surgery via posterior approach (November 2018–July 2020). All patients received bilateral ultrasound-guided ESPB. The primary study outcome was the incidence of any perioperative complication, defined a priori as sensory, motor, hematologic, hemodynamic or respiratory complication consistent with plausible contribution from the ESPB. Secondary outcomes included the incidence of numeric rating scale (NRS) pain scores ≥7 in the post anesthesia care unit (PACU) and risk factors associated with NRS ≥7 (age, sex, ASA class, BMI, opioid tolerance, surgical type, and duration).ResultsWe did not identify any pre-specified complications associated with ESPB. There was one unilateral pneumothorax, in one patient, deemed unlikely to have been related to ESPB. NRS ≥7 was found in 17/342 patients (5%) and was independent of any background differences or risk factors assessed.ConclusionUltrasound guided ESPB for lumbar spine surgery was associated with zero complications, no interference with intraoperative neuromonitoring or the early postoperative neurological examination, and low incidence of poorly controlled pain in the PACU. These results help to establish procedure-specific risks and benefits of ESPB for spine surgery.

Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management.

Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.

Early Determination of Prognosis in Neonatal Moderate or Severe Hypoxic-Ischemic Encephalopathy.

Early determination of prognosis is important in neonates with hypoxic-ischemic encephalopathy (HIE). Our objective was to test scoring systems developed earlier (original scoring system) and develop new prognostic models. Secondary analysis of data from the multicenter randomized controlled trial of longer, deeper, or usual care cooling in neonatal HIE (NCT01192776) that enrolled 364 neonates diagnosed with moderate or severe HIE. The primary outcome was death or moderate or severe disability at 18 to 22 months, and secondary outcome was death during initial hospitalization. Testing of early neurologic clinical examination (<6 hours of age) and the original scoring system for prognostic ability was done, followed by development of new scoring systems and classification and regression tree (CART) models by using early clinical variables (<6 hours of age). For death or disability, the original scoring system correctly classified 75% (95% confidence interval: 69%-81%), whereas the new scoring system correctly classified 78% (73%-82%), and the CART model correctly classified 76% (72%-81%). Early neurologic clinical examination also had a correct classification rate of 76% (71%-80%). Depth and duration of cooling did not affect prediction. Only a few components of the early neurologic examination were associated with poor outcome. For death, the original scoring system correctly classified 72% (66%-77%), the new scoring system 68% (63%-72%), the new CART model 87% (83%-90%), and early neurologic evaluation 81% (77%-85%). The 3 models (scoring system, CART, and early neurologic evaluation) were comparable in predicting death or disability. For in-hospital death, CART models were superior to scoring systems and early neurologic examination.

Multilevel Postoperative Cervical Epidural Hematoma: Complete Removal Through Catheter Drainage of the Unexposed Blood Collection

Postoperative spinal epidural hematoma is a rare complication of anterior cervical discectomy and fusion. This condition may rapidly produce severe neurologic deficits, often requiring a prompt surgical decompression. A multilevel extension of the epidural bleeding has been rarely described after anterior cervical procedures. In such cases, the choice of the most suitable surgical approach may be challenging. Herein, we describe an effective surgical decompression of a C2-T1 ventral epidural hematoma following anterior cervical discectomy and fusion at the C5-C6 level. By reopening the previous approach, the C5-C6 intersomatic cage was removed and the surgical field inspected for bleeding. After removal of the spinal epidural hematoma at this level, a lumbar external drainage catheter was inserted into the epidural space to perform multiple irrigations with saline solution until the washing fluid was clear. Immediate postoperative cervical computed tomography and magnetic resonance imaging revealed gross total removal of the epidural hematoma and complete decompression of the spinal cord all along the affected tract. Early postoperative neurologic examination revealed mild lower extremity weakness that fully recovered within hours. Although rare, multilevel epidural hematoma following anterior cervical decompression represents a serious complication. The revision of the previous anterior cervical approach may be considered the first treatment option, allowing to control the primary bleeding site. Catheter irrigation of the epidural space with saline solution may be a useful technique for removal of unexposed residual blood collection, avoiding the need for posterior laminectomy or other unnecessary bone demolition.

Predicting functional outcomes after stroke: an observational study of acute single-channel EEG

ABSTRACTBackground: Early and objective prediction of functional outcome after stroke is an important issue in rehabilitation. Electroencephalography (EEG) has long been utilized to describe and monitor brain function following neuro-trauma, and technological advances have improved usability in the acute setting. However, skepticism persists whether EEG can provide the same prognostic value as neurological examination.Objective: The current cohort study examined the relationship between acute single-channel EEG and functional outcomes after stroke.Methods: Resting-state EEG recorded at a single left pre-frontal EEG channel (FP1) was obtained from 16 adults within 72 h of first stroke. At 30 and 90 days, measures of disability (modified Rankin Scale; mRS) and involvement in daily activities (modified Barthel Index; mBI) were obtained. Acute EEG measures were correlated with functional outcomes and compared to an early neurological examination of stroke severity using the National Institute of Health Stroke Scale (NIHSS). Classification of good outcomes (mRS ≤1 or mBI ≥95) was also examined using Receiver Operator Curve analyses.Results: One-third to one-half of participants experienced incomplete post-stroke recovery, depending on the time point and measure. Functional outcomes correlated with acute theta values (rs 0.45–0.60), with the strength of associations equivalent to previously reported values obtained from conventional multi-channel systems. Acute theta values ≥0.25 were associated with good outcomes, with positive (67-83%) and negative predictive values (70-90%) comparable to those obtained using the NIHSS.Conclusions: Acute, single-channel EEG can provide unique, non-overlapping clinical information, which may facilitate objective prediction of functional outcome after stroke.

Subdural contrast effusion during endovascular therapy: case report

Accumulation of contrast medium in the subdural space after diagnostic intraarterial contrast administration is a rare observation. The authors report the case of a subdural contrast effusion (SCE) presenting during endovascular treatment of an intracranial dural arteriovenous fistula (DAVF) mimicking an acute subdural hematoma. Differentiation between the two by computed tomography (CT) or intraprocedural Dyna CT and early neurological examination can be crucial for patient management. We believe that repeated large-volume contrast injections via large-bore intermediate catheters into the territory of an (even partly) occluded DAVF may induce leakage of contrast medium into the extravascular subdural space thereby causing a SCE.

Early Neurological Assessment in Infants with Hypoxic Ischemic Encephalopathy Treated with Therapeutic Hypothermia.

Early neurological assessment in infants with hypoxic ischemic encephalopathy (HIE) treated with hypothermia has not been systematically explored. The aims of the present study were to assess whether the Hammersmith Infant Neurological Examination (HINE) is a good tool to predict later neurodevelopmental outcomes at 2 year from birth in this population of infants. A total of 41 term born infants with HIE treated with hypothermia performed the HINE at 12 months and a neurodevelopmental assessment at 24 months. All the infants who had a global HINE score between 67 and 78 were able to walk independently at 2 years and reported a normal developmental quotient; language disorders were observed in a limited number of infants. HINE scores <67 were always associated with motor impairment. In conclusion, the HINE confirms its role as one of the early neurological examination tools for the diagnosis of high risk infants, even in infants with HIE treated with hypothermia. These results can be useful for clinicians involved in the follow up of these infants for early identification of motor disabilities and in planning appropriate intervention.

Efficacy of Early Neurological Examination in Determining Survival in Post Cardiac Arrest Patients who Underwent Hypothermia Protocol (P2.9-067)

Efficacy of Early Neurological Examination in Determining Survival in Post Cardiac Arrest Patients who Underwent Hypothermia Protocol (P2.9-067)

Big data of clinical manifestations combined with neuroelectrophysiologic features in the early diagnosis of motor neuron disease

Motor neuron disease/amyotrophic lateral sclerosis (ALS) is an adult-onset neurodegenerative disorder characterised by loss of upper motor neurons (including the Betz cells of the motor cortex), and lower motor neuron, anterior horn cells of the spinal cord and brainstem nuclei. 5–10% in ALS is hereditary and sporadic, with an incidence of 2–3 per 100,000. ALS is a fatal disease. The average survival of patients is 3–5 years. So far, the pathogenesis of ALS has been unclear. Although there are many drugs in the trial, there is no reversible treatment for motor neurons that are already degenerating. Although more and more researchers are investing a lot of energy in research, the time for identifying this disease is still very long. In the diagnosis of ALS patients, in order to obtain appropriate treatment and care, it is great significance of the concept of “the earlier the better” to diagnose. The purpose of this study was to explore factors for possible early diagnosis and potential therapeutic agents by reviewing the literature and collecting case data and discuss their potential for improvement. We retrospectively analyzed ALS patients from 23427 patients in department of neurology in Xi’an Gaoxin Hospital between December 2006 and March 2017. The conclusion displayed that early neurological electrophysiological examination combined with clinical features can improve the diagnosis of ALS.

Effect of dexmedetomidine on recovery profile of patients undergoing anterior cervical discectomy and fusion.

Background and Aim:Smooth and rapid emergence and extubation, with minimal coughing, is desirable after cervical spine surgery to facilitate early neurological examination. The present study investigated the effect of dexmedetomidine as an intraoperative anesthetic adjuvant on postoperative extubation and recovery profile in patients undergoing anterior cervical discectomy and fusion (ACDF) surgery.Material and Methods:Sixty-four, American Society of Anesthesiologist I or II adult patients (age 18–60 years) were randomized in this placebo-controlled, double-blind study. In group D, dexmedetomidine was started at 0.2 μg/kg/h after a loading dose of 1 μg/kg before induction and in group P, volume and infusion rate-matched normal saline was used. Perioperative hemodynamics, intraoperative anesthetic consumption, and postoperative recovery profile were observed.Results:Thirty-one patients in each group successfully completed the study. Time to emergence (6.9 min vs 10 min, P < 0.001), time to extubation (8.5 min vs 12.2 min, P = 0.002), and time to achieve modified Aldrete score ≥9 (5 min vs 10 min, P < 0.001) were earlier in group D compared to group P, respectively. Pain score at extubation was lower (0 vs 20) and time for first analgesic was longer (50 min vs 15 min) in group D compared to group P. Coughing at extubation was comparable in both the groups. One patient in group D had severe postextubation bradycardia.Conclusions:Intraoperative use of dexmedetomidine at the lowest recommended dosage in adults undergoing ACDF surgery results in a favorable recovery profile with reduced emergence/extubation time and postoperative pain, but similar incidence of coughing.

Comparison of the effect of intravenous dexmedetomidine and lignocaine spray instilled into the endotracheal tube on extubation response in patients undergoing spine surgery

Abstract Background: In spine surgery rapid emergence and extubation with haemodynamic stability is crucial for early neurological examination. Here, we have studied the effect of α2 agonist – dexmedetomidine intravenous (IV) and lignocaine spray instilled into the endotracheal tube at the end of the procedure to attenuate the extubation responses. Methods: A total of 45 patients undergoing spine surgery were randomly allocated in three groups. After the return of spontaneous respiration, Group-D: Dexmedetomidine 0.3 mcg/kg IV, Group-L: 10% lignocaine spray 1.5 mg/kg through endotracheal route and Group-P: Normal saline IV given over 60 s. Haemodynamic responses (systolic blood pressure, diastolic blood pressure, mean arterial pressure [MAP], heart rate [HR] and SpO2) were recorded before and after administration of drugs and also duration of emergence, extubation, quality of extubation and post-operative sedation level were evaluated. Results: The increase in MAP and HR during extubation was significantly less in Group-D than Group-L and Group-P, 2 min after administration of the respective drugs (P &lt; 0.05). There were no significant differences in the grade of a cough after extubation and post-operative sedation level. Conclusion: Dexmedetomidine (0.3 mcg/kg) attenuates haemodynamic response better than lignocaine spray (1.5 mg/kg) during emergence and extubation. It also provides smooth extubation and easy recovery without any post-operative sedative effect.

Early neurologic examination is not reliable for prognostication in post–cardiac arrest patients who undergo therapeutic hypothermia

BackgroundRecent advances in post–cardiac arrest (CA) care including therapeutic hypothermia (TH) have improved survival and favorable neurologic outcomes for survivors of CA. Survivors often present with deep coma and lack of brainstem reflexes, which are generally associated with adverse outcomes in many disease processes. Little is known regarding the role of initial emergency department (ED) neurological examination and its potential for prognostication. ObjectivesThe purpose of this study is to determine if components of a standardized neurologic examination are reliable prognosticators in patients recently resuscitated from CA. We hypothesize that lack of neurologic function does not reliably predict an adverse outcome and, therefore, should not be used to determine eligibility for TH. MethodsA standardized neurologic examination was performed in the ED on a prospective, convenience cohort of post-CA patients presenting to a CA resuscitation center who would undergo a comprehensive postarrest care pathway that included TH. Data such as prior sedation or active neuromuscular blockade were documented to evaluate for the presence of possible confounders. Examination findings were then compared with hospital survival and neurologic outcome at discharge as defined by the cerebral performance category (CPC) score as documented in the institutional TH registry. ResultsForty-nine subjects were enrolled, most of whom presented comatose with a Glasgow Coma Scale of 3 (n=41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not have evidence of active neuromuscular blockade at the time of the examination; 2 of 9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only 1 of the 17 subjects who survived was discharged with poor neurologic function with a CPC score=3, whereas all others who survived had good neurologic function, CPC score=1. ConclusionIn this cohort of patients treated in a comprehensive postarrest care pathway that included TH, absence of neurologic function on initial ED presentation was not reliable for prognostication. Given these findings, clinicians should refrain from using the initial ED neurological examination to guide the aggressiveness of care or in counseling of family members regarding anticipated outcome.

Use of the Hammersmith Infant Neurological Examination in infants with cerebral palsy: a critical review of the literature.

The Hammersmith Infant Neurological Examination (HINE) has been proposed as one of the early neurological examination tools for the diagnosis of cerebral palsy (CP). The aim of the present study was to critically review the existing literature and our experience with the use of the HINE in infants at risk of CP. The published papers confirm that the HINE can play an important role in the diagnosis and prognosis of infants at risk of developing CP, and provide information on aspects of neurological findings impaired in different forms of CP and brain lesions.

Comparison of dexmedetomidine and lignocaine on attenuation of airway and pressor responses during tracheal extubation

Abstract Background: Haemodynamic stability and rapid emergence after general anaesthesia used in spinal surgery is a common practice, the goal of which is to permit early neurological motor and sensory examination. Extubation is almost always associated with hypertension, increased airway response and arrhythmias. We have compared the effects of the α-2 agonist Dexmedetomidine and Lignocaine given at the end of the procedure on attenuation of airway and pressor responses following tracheal extubation. This study is a randomised, placebo-controlled, double-blinded study. Materials and Methods: Sixty ASA I-III patients, aged 18-70 years, scheduled to undergo spinal surgery at the level of thoracic, lumbar or sacral region were randomly divided into three groups. Balanced general anaesthesia comprising standard procedures and drugs were used for monitoring, induction and maintenance. At the last skin suture, inhalation anaesthetic was discontinued. After turning the patient supine and return of spontaneous efforts, in Group D Dexmedetomidine 0.5 μg/kg, in Group L Lignocaine 1.5 mg/kg and in Group P normal saline (10 ml) were administered as bolus intravenously over 60 seconds. Systolic, diastolic and mean arterial pressures and heart rate were recorded before intravenous administration and also every minute for 3 minutes, at 5, 10 and 15 minutes post-extubation. Duration of emergence and extubation were noted and attenuation of airway response and quality of extubation was evaluated on cough grading. Results: Mean arterial pressures and heart rate were higher in Group L and Group P than in Group D but not statistically significant. The duration of emergence, extubation and recovery were comparable in all the groups (P &gt; 0.05). Extubation Quality Scores was 1 in 80%, 2 in 20% in Group D; in Group L, the quality scores were 1 for 55%, 2 for 45% and I Group P 1 for 35%, 2 for 45% and 3 for 20% of the patients. The requirement of rescue analgesia was also less and after prolonged time in Group D than in Group L and Group P (P &lt; 0.05). None of the patients in all three groups showed respiratory depression, allergic reactions, nausea, vomiting or shivering. There was occurrence of hypertension for the initial 3 minutes of administration of drug in 10 (50%) of patients in Group D (Dexmedetomidine) group. Conclusion: Without interfering in emergence and extubation times, attenuation of pressor response is comparable between Dexmedetomidine 0.5 μg/kg and Lignocaine 1.5 mg/kg but airway response is much better controlled allowing a smooth easy extubation providing a more comfortable recovery and early neurological examination following spinal surgeries.

Delayed Tetraplegia After Thoracolumbar Scoliosis Surgery in Stuve-Wiedemann Syndrome

ObjectiveWe present 2 patients with Stuve-Wiedemann syndrome (SWS) who suffered delayed tetraparesis following posterior spinal surgery for scoliosis. Background SummaryDelayed tetraparesis after a syndromic thoracic scoliosis correction has never been reported. A cord injury distant from the surgical site is rare, and intraoperative neuromonitoring should be used to detect and prevent neurologic impairment. MethodsReview of medical charts. ResultsTwo patients with SWS suffered delayed tetraparesis 20 and 40 hours respectively after thoracolumbar posterior surgery. In one patient distal motor evoked potentials fell and recovered partially during surgery. In both patients, early postoperative neurologic examination was normal (in one of them except for the extensor hallucis 2/5). CT scan showed correct instrumentation placement and no compressive haematoma. MRI ruled out cord anomalies, but revealed in both patients identical cervical edema that was most likely secondary to ischemia. Angiogram revealed an absence of anterior cord vascular supply. ConclusionsCorrection of severe deformities in syndromic patients may lead to stretch injuries of the spinal cord and its vascular supply. This in turn may lead to a neurological deficit extending beyond the limits of the spinal instrumentation. Abrupt postoperative neck pain may be an alert to this impending development. Close surveillance in the early postoperative period should be maintained in patients with SWS because a delayed neurological deficit can be present even hours afterwards and may be cranial to the surgical level.

Distribution and severity of hypoxic–ischaemic lesions on brain MRI following therapeutic cooling: selective head versus whole body cooling

BackgroundWhole body cooling (WBC) cools different parts of the brain uniformly, and selective head cooling (SHC) cools the superficial brain more than the deeper brain structures. In this study, the...

A47 Does Morphine prolong Emergence in Neurosurgical Patients

Background and Goal of Study: One of the major concerns in neurosurgical patients is emergence. The idea is to allow early neurological examination and reintervention if necessary. More than two decades of quest for an ideal anaesthetic agents to fast track recovery has not yielded conclusive results. Long acting opoids like morphine are not popular for use in neurosurgical patients and the acceptability is for short acting opioids. However there is paucity of data which compares morphine and short acting opioids with regards to their emergence profile in neurosurgical patients. This study was done to evaluate the emergence characteristics of morphine when compared to fentany in patients undergoing elective neurosurgery. Methods: The data of two major tertiary health care institutes of India were compared . One institute predominantly uses morphine while the other uses fentanyl for perioperative analgesia in patients undergoing neurosurgery. The patients who underwent elective supratentorial craniotomy and followed similar emergence technique (low dose propofol along with nitrous oxide in oxygen) were included in the study. The dose of opioids were based on the protocol of individual institution. The patients of morphine group (Group M) received single dose morphine 0.1mg/kg prior to induction. The fentany group (Group F) received 2 ug/kg of fentanyl at induction, 1ug/kg prior to skin incision and at beginning of dural closure. In both groups Fentanyl 1ug/kg was given as additional dose if required. Following surgery, the trachea was extubated after reversal of residual neuromuscular blockade once the patients opened eyes or responded to verbal commands. The emergence chararacteristic among the two groups were compared. Results: A total of eighty four patients qualified for inclusion in the study. There were thirty-seven patients in Group M while Group F had forty-seven patients. The mean time to emergence (time from cessation of anaesthesia to extubation) was 8.5 ± 3.7 minutes in group M and 7.8 ± 5.1 minutes in group F ( p = 0.11). The patients who had early emergence (< 15 minutes following cessation of anaesthesia) were 35 (94%) in group M while it were 43(91%) in group F (p= 0.69). Conclusion: When used judiciously, morphine appears acceptable and similar to fentany for facilitating early emergence in patients undergoing elective supratentorial craniotomy.

Impact of Clinically Identifiable Intrapartum Sentinel Events on Short Term Outcome After Therapeutic Hypothermia in Infants with Hypoxic-Ischemic Encephalopathy

Objective: To determine the impact of intrapartum sentinel events on short term outcome following therapeutic hypothermia. Methods: Medical records of 77 infants ≥ 36 weeks' gestation, who received hypothermia were reviewed. Some of these infants were delivered after a clinically identifiable intrapartum sentinel event (IISE). All surviving infants had brain MRI at 7 to 10 days of life. The primary outcome of neonatal death related to hypoxic-ischemic encephalopathy (HIE) with worsening multiorgan dysfunction despite maximal treatment was compared between infants born after an IISE (n= 39) and infants who did not (non-IISE, n= 38). The pattern of MRI abnormalities consistent with hypoxic-ischemic brain injury was also compared. Logistic regression analysis was used to determine which of the variables predicts the primary outcome. Results: The two groups had similar Apgar scores, initial blood pH, and early neurologic examination. Base deficit was more severe in the IISE group. Neonatal death and global injury on brain MRI with basal nuclei, cortical, and subcortical white matter lesions extending beyond the watershed areas in infants surviving beyond the neonatal period were also more frequent in infants from this group (IISE 23% versus non-IISE 2.6%, p=0.014, OR 11.1, 95% CI 1.3-92.6 and IISE 33% versus non-IISE 11%, p=0.034, OR 4.1, 95% CI 1.1-14.9 respectively). Multivariate analysis identified IISE (p=0.023, OR 12.2, 95% CI 1.4-105.8) to be independently associated with neonatal death. Conclusions: An IISE is associated with an increase in neonatal death and more severe injury on brain MRI, even after hypothermia.