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A Comparative Analysis of Ipsilateral, Contralateral, and Bilateral Average ONSD in Correlating with Cerebral Midline Shift: Re-framing a Non-Invasive Tool from a Quantitative Predictor to a Clinical Classifier Ramadina Putri Cahyanti Ghofar; Buyung Hartiyo Laksono; Taufiq Agus Siswagama
Archives of The Medicine and Case Reports Vol. 6 No. 4 (2025): Archives of The Medicine and Case Reports
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/amcr.v6i4.823

In traumatic brain injury (TBI), non-invasive proxies for mass effect are crucial. The optic nerve sheath diameter (ONSD) is used to estimate intracranial pressure (ICP), but its correlation with structural outcomes like midline shift (MLS) is poorly defined, particularly regarding the optimal measurement method (unilateral vs. bilateral). We prospectively enrolled 38 adult TBI patients who received both a CT scan and a bedside ONSD ultrasound within 24 hours. Data was re-analyzed to classify ONSD relative to lesion location (Ipsilateral, Contralateral) and to correlate these, plus the Bilateral Average (ONSD-Avg), with CT-measured MLS using Spearman's correlation. We used linear regression to assess quantitative prediction (R-square) and binary logistic regression (ROC curve) to assess clinical classification (AUC) for predicting MLS >5mm. A significant, positive correlation was found between MLS and Ipsilateral-ONSD (rs = 0.450, p = 0.005) and ONSD-Avg (rs = 0.383, p = 0.018). The Contralateral-ONSD correlation was not significant (rs = 0.210, p = 0.206). A Wilcoxon test confirmed Ipsilateral-ONSD was significantly wider than Contralateral-ONSD (p < 0.01). The linear regression model for MLS quantification was statistically significant (p = 0.015) but had a very low predictive power (R-square = 0.153). In contrast, the logistic regression model found ONSD-Avg to be an excellent classifier for detecting surgical MLS (> 5mm), with an Area Under the Curve (AUC) of 0.88 (95% CI 0.75-0.96). In conclusion, ONSD measurement is significantly affected by asymmetric, unilateral TBI pathology. The bilateral average (ONSD-Avg) is the most reliable screening method, as it compensates for unilateral pressure gradients. The low R-square (15.3%) confirms ONSD is a poor quantitative predictor of MLS, reflecting the non-linear pressure-volume relationship. However, the high AUC (0.88) proves ONSD is an excellent clinical classifier for identifying patients with surgical-threshold mass effect. ONSD should not be used to "quantify" MLS, but rather to "classify" patient risk.

Admission GCS, Age, and Pupillary Response as a Multivariable Triad for Predicting Outcomes Following Emergent Surgery for Traumatic Brain Injury Ramadhan Saputro; Aswoco Andyk Asmoro; Buyung Hartiyo Laksono
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.822

Introduction: Early prognostication for patients with moderate-to-severe traumatic brain injury (TBI) requiring emergent surgery and intensive care is critical but complex. While the Glasgow Coma Scale (GCS) is foundational, its standalone predictive power, especially when unadjusted for known confounders, can be misleading. This study aimed to determine the independent predictive value of admission GCS within a multivariable model including other key clinical predictors. Methods: We conducted a retrospective, descriptive-analytic study at a tertiary referral center in Indonesia, analyzing a specific cohort of 150 patients with moderate-to-severe TBI (GCS 3–12) who all underwent the emergent ED-OR-ICU pathway between July and December 2024. Data on admission GCS, patient age, pupillary reactivity, and CT findings (Marshall score) were extracted. We built multivariable logistic regression models to predict two primary outcomes: (1) In-Hospital Mortality and (2) Unfavorable Functional Outcome (a composite of mortality or discharge to a skilled nursing/palliative care facility). Results: A univariate analysis identifying a GCS cut-off of 9.5 produced a statistically unstable odds ratio (OR) for mortality of 104.87, consistent with quasi-complete separation. However, in the multivariable model, this effect was resolved. After adjusting for confounders, GCS remained a significant independent predictor of mortality (Adjusted OR 2.78 per point decrease) and unfavorable outcome (aOR 3.11 per point decrease). Crucially, non-reactive pupils (aOR 5.12 for mortality) and patient age (aOR 1.07 per year for unfavorable outcome) were found to be equally, if not more, powerful independent predictors. Conclusion: Admission GCS is a robust and independent predictor of outcome in high-risk surgical TBI patients, but its true value is only revealed when used as part of a multivariable assessment. The statistical power of univariate GCS is easily inflated by confounding. We conclude that prognostication in this cohort must be a multivariable exercise, incorporating GCS, pupillary response, and age as an essential prognostic triad.

Emergency Neuroanesthesia for Spontaneous Subdural Hematoma in a Pediatric Patient with Hemophilia A: A Protocol-Based Multidisciplinary Approach Sulistiyawati; Buyung Hartiyo Laksono; Eko Nofiyanto; Dewi Arum Sawitri
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2026): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1532

Background: Spontaneous subdural hematoma (SDH) in pediatric patients with Hemophilia A is a rare, life-threatening emergency requiring a delicate balance between hemostatic correction and neuroprotective anesthesia. The mortality rate is high without immediate surgical decompression, yet the surgery itself poses catastrophic bleeding risks. Case presentation: We report the case of an 11-year-old male (25 kg) with severe Hemophilia A (Factor VIII <1%) who presented with a three-day history of headache and vomiting, culminating in a sudden loss of consciousness (GCS E2V2M5). Neuroimaging revealed a massive left frontotemporoparietal SDH (8 mm thickness) with a 12 mm midline shift and non-communicating hydrocephalus. The patient had discontinued prophylaxis five months prior. Management involved a strict multidisciplinary protocol. Preoperatively, aggressive Factor VIII replacement was initiated to achieve 100% activity. Intraoperatively, a total intravenous anesthesia (TIVA) strategy utilizing propofol, fentanyl, and dexmedetomidine was employed to maintain cerebral perfusion pressure (CPP) while strictly controlling intracranial pressure (ICP). Tranexamic acid was used as an adjunct. The patient underwent successful craniotomy and hematoma evacuation with minimal blood loss. Postoperative care focused on serial factor VIII replacement and neurological monitoring, resulting in a favorable discharge outcome. Conclusion: Successful management of spontaneous SDH in hemophilia requires a target-controlled approach to both hemostasis and hemodynamics. The integration of preoperative factor loading, neuroprotective anesthesia with dexmedetomidine, and postoperative vigilance is critical for survival.

Emergency Neuroanesthesia for Spontaneous Subdural Hematoma in a Pediatric Patient with Hemophilia A: A Protocol-Based Multidisciplinary Approach Sulistiyawati; Buyung Hartiyo Laksono; Eko Nofiyanto; Dewi Arum Sawitri
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2026): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1532

Background: Spontaneous subdural hematoma (SDH) in pediatric patients with Hemophilia A is a rare, life-threatening emergency requiring a delicate balance between hemostatic correction and neuroprotective anesthesia. The mortality rate is high without immediate surgical decompression, yet the surgery itself poses catastrophic bleeding risks. Case presentation: We report the case of an 11-year-old male (25 kg) with severe Hemophilia A (Factor VIII <1%) who presented with a three-day history of headache and vomiting, culminating in a sudden loss of consciousness (GCS E2V2M5). Neuroimaging revealed a massive left frontotemporoparietal SDH (8 mm thickness) with a 12 mm midline shift and non-communicating hydrocephalus. The patient had discontinued prophylaxis five months prior. Management involved a strict multidisciplinary protocol. Preoperatively, aggressive Factor VIII replacement was initiated to achieve 100% activity. Intraoperatively, a total intravenous anesthesia (TIVA) strategy utilizing propofol, fentanyl, and dexmedetomidine was employed to maintain cerebral perfusion pressure (CPP) while strictly controlling intracranial pressure (ICP). Tranexamic acid was used as an adjunct. The patient underwent successful craniotomy and hematoma evacuation with minimal blood loss. Postoperative care focused on serial factor VIII replacement and neurological monitoring, resulting in a favorable discharge outcome. Conclusion: Successful management of spontaneous SDH in hemophilia requires a target-controlled approach to both hemostasis and hemodynamics. The integration of preoperative factor loading, neuroprotective anesthesia with dexmedetomidine, and postoperative vigilance is critical for survival.

Efficacy of Particulate versus Non-Particulate Corticosteroids as Adjuvants for Popliteal Sciatic Nerve Block: A Randomized Controlled Superiority Trial Erma Rosita; Taufiq Agus Siswagama; Rudy Vitraludyono; Buyung Hartiyo Laksono
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.853

Introduction: Single-shot ultrasound-guided popliteal sciatic nerve blocks are the gold standard for distal lower limb analgesia but are limited by a finite duration, often necessitating adjuvants. While dexamethasone (non-particulate) is the standard of care, methylprednisolone (particulate) theoretically offers a depot effect for sustained release. This study aimed to determine if perineural methylprednisolone provides superior analgesic duration compared to dexamethasone. Methods: In this prospective, double-blind, randomized controlled trial, 36 ASA I-III patients undergoing distal lower limb surgery were randomized (1:1) to receive 20 mL of 0.5% Ropivacaine with either Dexamethasone 8 mg (Group D) or Methylprednisolone 40 mg (Group M). To ensure blinding, solutions were prepared by an independent pharmacist and administered via opaque syringes. The primary outcome was the duration of analgesia (time to Numeric Rating Scale [NRS] greater than 3), analyzed using Kaplan-Meier survival curves and Log-Rank tests. Secondary outcomes included cumulative opioid consumption, rebound pain severity, and block onset time. The study was powered for superiority with a clinically significant difference of 4 hours. Results: Thirty-six patients completed the study. Demographic and surgical characteristics were comparable. The median duration of analgesia was 18.4 (SD 3.2) hours in Group D and 19.1 (SD 3.5) hours in Group M (p = 0.58; Log-Rank p = 0.61). Pain scores at 12, 24, and 48 hours showed no significant difference, with both groups demonstrating a floor effect due to multimodal analgesia (Median NRS less than 2). No adverse events, including neurotoxicity or infection, were observed. Conclusion: Perineural methylprednisolone failed to demonstrate superior analgesic duration compared to dexamethasone in this cohort. The theoretical depot advantage did not translate to clinical superiority, likely due to vascular clearance in the popliteal fossa. Given the comparable efficacy but superior safety profile of non-particulate agents, dexamethasone remains the preferred adjuvant. Methylprednisolone serves as a viable alternative only when non-particulate options are unavailable.

Neuroprotective Anesthetic Management Using Thiopental in a 17-Year-Old with Multifocal Epidural Hematoma and Impending Brain Herniation: A Case Report Sutan Malik Maulana Syah; Buyung Hartiyo Laksono; Eko Nofiyanto; Dewi Arum Sawitri
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.862

Introduction: Epidural hematoma resulting from severe traumatic brain injury demands immediate neuroanesthetic intervention. Multifocal lesions accompanied by pneumocephalus and impending brain herniation present profound perioperative challenges requiring targeted cerebral perfusion management. Case presentation: A 17-year-old male weighing 50 kg sustained severe polytrauma, presenting with a Glasgow Coma Scale of 12 and active auditory canal bleeding. Imaging revealed multifocal epidural hematomas in the right frontotemporal (66 cc) and right parietal (43 cc) regions, alongside pneumocephalus, a 1.5 cm subfalcine herniation, and downward transtentorial herniation. The patient, classified as ASA physical status 4E, required an emergent decompressive craniotomy and concurrent facial reconstruction. A neuroprotective anesthetic strategy was deployed utilizing thiopental, fentanyl, and atracurium to minimize the cerebral metabolic rate and control intracranial pressure. Anesthesia was maintained with sevoflurane. Hemodynamics were strictly titrated to ensure optimal cerebral perfusion pressure. Following successful surgical hematoma evacuation, the patient was admitted to the intensive care unit and demonstrated an excellent neurological recovery after a five-day admission. Conclusion: Thiopental serves as a highly effective neuroprotective induction agent for severe traumatic brain injury with intracranial hypertension. Meticulous hemodynamic control and targeted reduction of cerebral metabolism are critical in preventing secondary ischemic cascades and improving functional outcomes in polytrauma patients.

A Rare Complication of Vasovagal Syncope Induced by Pulsed Radiofrequency in a Patient with Cervical Spondylosis and Occipital Neuralgia: A Case Report Fajar Ristranda; Buyung Hartiyo Laksono; Taufiq Agus Siswagama
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.869

Introduction: Pulsed radiofrequency is widely utilized as a minimally invasive neuromodulation technique for managing chronic neuropathic pain, including cervical radicular pain and occipital neuralgia. While pulsed radiofrequency is generally celebrated for its robust safety profile and absence of thermal tissue destruction, unexpected autonomic complications remain poorly characterized in the literature. Case presentation: A 41-year-old female with a six-month history of chronic cervical root syndrome (C3-C6) and refractory occipital neuralgia presented for interventional pain management. Following a comprehensive clinical and radiological evaluation, the patient underwent fluoroscopy-guided pulsed radiofrequency of the bilateral C3 and C4 dorsal root ganglia and the greater and lesser occipital nerves. The procedure was technically successful and uneventful. However, approximately 24 hours post-procedure, the patient experienced a sudden, profound episode of vasovagal syncope, characterized by acute hypotension, bradycardia, and a precipitous drop in consciousness (Glasgow Coma Scale: E3V3M6). Immediate resuscitation, including intravenous fluid boluses and continuous hemodynamic monitoring, led to a full neurological recovery. At follow-up, the patient reported significant attenuation of both radicular and occipital pain scores. Conclusion: This report documents a rare and severe episode of delayed vasovagal syncope following upper cervical and occipital pulsed radiofrequency neuromodulation. The temporal association suggests a complex neuro-autonomic reflex, potentially mediated by the trigeminocervical complex and sudden withdrawal of chronic sympathetic tone. Clinicians performing cervical pulsed radiofrequency must remain vigilant regarding delayed autonomic dysregulation, necessitating extended postoperative observation protocols in susceptible individuals.

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