Pediatric Hemispherotomy: Unique Perioperative Challenges

Keywords

pediatric epilepsy - hemispherotomy - neuroanesthesia

Introduction: About 30 to40% of pediatric patients with epilepsy remain refractory to medical management and require surgery. Disconnective procedures, such as hemispherotomy, can be challenging for the neurosurgeon as well as the anesthesiologist considering the longer duration of surgery, possibility of sudden massive blood loss, and some unique postoperative complications.

Methodology/Description: A 7-year-old female patient had a history of continuous left partial seizures since 1 year of age. She remained refractory to antiepileptics and was diagnosed as epilepsia partialis continua. She was posted for a functional right hemispherotomy. Her developmental age was of 3 years and 4 months with an IQ of 52 (moderate mental retardation). On the day of surgery, her antiepileptics were continued. Intravenous induction was done with propofol, followed by vecuronium as relaxant. Patient was in-tubated using flexometallic tube. Invasive BP monitoring was done and two large-bore IV lines were secured. Anesthesia was maintained with isoflurane and fentanyl. Injection mannitol and dexamethasone were given to decrease ICP. Temperature was maintained with air warming blankets. Blood loss around 250 mL was replaced with packed RBCs. Patient was extubated on table. Intravenous levetiracetam was given before extubation. Postoperatively patient remained seizure-free, alert, and oriented for 24 hours after which she became sleepy but arousable for next 5 days. She had fever on postoperative day 5 which subsided the next day with steroids and was discharged on the seventh day.

Conclusion: Pediatric patients present challenges to neurosurgeons as well as anesthesiologists. The intraoperative concerns include possibility of sudden massive blood loss, longer duration of surgery, and interaction of muscle relaxants with antiepileptic drugs, hypothermia, and delayed recovery. Increased sleepiness after 48 hours due to contralateral edema of the cerebrum or obstructive hydrocephalus increases postoperative ICU stay. A noninfectious fever mostly on day 4 or 5 is caused by chemical ventriculitis, and usually responds to steroids. Thus, a team approach including neurosurgeon, neurophysician, anesthesiologist and intensivist helps in making pediatric hemispherotomy a successful and safe surgery for intractable epilepsy

• References

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• 2 Sheshadri V, Raghavendra S, Chandramouli BA. Perioperative anaesthetic concerns during paediatric epilepsy surgeries: a retrospective chart review.. J Neuroanaesth Crit Care 2016; 3: 110-114