Spinal anesthesia

Incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery: a multi- center prospective observational study

BACKGROUND

Failed spinal anaesthesia causes prolonging of operation time, insufficient analgesia for surgery and needs repeating spinal anaesthesia which in turn causes local anaesthesia toxicity, high spinal and total spinal, and conversion to general anaesthesia. However, the problem remains unexplored in Amhara regional state comprehensive specialized hospitals.

OBJECTIVE

To determine incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery in selected Amhara National Regional State comprehensive specialized hospitals, Northwest Ethiopia, 2023.

METHODS

Multi-center prospective observational study was conducted. Data was collected using questionnaire and checklist. All consecutive scheduled emergency and elective patients were included in the study. Data was transformed from Epi data to SPSS and logistic regression analysis was done. Both crude and adjusted odds ratio were used to assess the strength of association. Variables with a p-value of less than 0.05 were considered as statistically significant.

RESULTS

A total of 532 patients were included in this study with a response rate of 98%. Incidence of failed spinal anaesthesia was 22.4% (CI = 19-25.9). Emergency surgery (AOR = 7.01, CI = 4.5-12.7), dose of bupivacaine of ≤ 10 mg (AOR = 3.02, CI = 1.3-10.2), work experience of anaesthetist < 2 years (AOR = 3.1, CI = 1.7-5.72), bloody CSF (AOR = 8.5, CI = 2.53-18.5), hyperbaric local anaesthetic drug (AOR = 3.3, 95% CI = 3.2-8.2) and local anaesthetist without adjuvants (AOR = 5.25, CI = 2.62-14.2) were associated failed spinal anaesthesia.

CONCLUSION AND RECOMMENDATION

The incidence of failed spinal anaesthesia was high in Amhara Region comprehensive specialized hospitals. We suggest that anaesthesia providers should minimize failure by using adjuvants and appropriate dose of local anaesthetic. Additionally, simulation training should be given for anaesthesia trainees to improve their skills and to produce competent professionals.

Safety and effectiveness of prilocaine for spinal anesthesia in day surgery setting: a retrospective study on a sample of 3291 patients

Spinal anesthesia is considered safe and reliable for most surgical procedures involving the lower part of the body, but its use in the ambulatory setting requires drugs with rapid onset and regression of the motor and sensory block-like prilocaine.The purpose of this study is to retrospectively analyze data from 3291 procedures recorded in our institutional database, to better define the safety profile of spinal prilocaine and the incidence of complications and side effects.All clinical data, prospectively collected from 2011 to 2019 in an Italian tertiary hospital, of patients treated with spinal anesthesia performed with 40 mg of hyperbaric 2% prilocaine, according to our internal protocol of day surgery, were analyzed.Surgical procedures included saphenectomy (28.5%, n = 937), knee arthroscopy (26.8%, n = 882), proctologic surgery (15.16%, n = 499), and inguinal canal surgery (14.9%, n = 491).Anesthesia-related complication was represented by urinary retention (1.09%, n = 36), lipotimia (0.75%, n = 25), and postoperative nausea (0.33%, n = 11); arrhythmic events were uncommon (0.18%, n = 6). One case of persistent hypotension and 2 cases of persistent hypertension were reported.Persistent motor or sensory block (lasting more than 5 h) was experienced by 7 patients. One patient (0.03%), who underwent knee arthroscopy, experienced pelvic pain lasting for 6 h, compatible with a transient neurological symptom.Proctologic surgery was a factor associated with unplanned admission due to anesthesia-related complications (OR = 4.9; 95% CI: 2-14%).The number of complications related to the method was low as well as the need for hospitalization. This drug is valid and safe for the most performed day surgery procedures; however, further trials are needed to investigate the incidence of complications in the days following the procedure.

Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection

Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.

Opioid consumption and pain in patients with gynecological cancer who underwent spinal anesthesia vs. general anesthesia for interstitial brachytherapy

AIMS

Interstitial brachytherapy (ISBT) is an effective option for delivering conformal high dose radiation to the target volume with better organ-at risk sparing but is thought to be more invasive and painful than other methods. This study investigated pain levels and opioid consumption in patients who received spinal anesthesia (SA) or general anesthesia (GA) for their ISBT.

MATERIALS AND METHODS

Patients that underwent ISBT from April 2014 to September 2018 were analyzed from a prospective institutional database. The most prevalent malignancies were cervical (45%), recurrent endometrial (27%) and vaginal (20%) cancers. Baseline patient characteristics, radiation treatment details, anesthesia records, and inpatient charts were obtained. Opioid consumption was quantified as oral morphine equivalent per day (OMEq/day) from implantation until removal. Pain score levels were collected by using an 11-point scoring system.

RESULTS

Ninety nine patients received GA and 40 patients received SA as their anesthesia for ISBT. During their first admission, 76 patients (55%) required intravenous opioids. Patients receiving SA had significantly lower mean pain scores on the morning of their procedure 6 (Interquartile range [IQR] 2-8) vs. 0 (IQR: 0-1); p < 0.001]. Pain did not significantly differ between cohorts at any other time. During the first admission, SA patients had a lower median opioid usage of 23 (IQR: 9-47) mg/day compared to GA patients at 38 (IQR: 21-71) mg/day (p = 0.011). No difference in opioid consumption was seen during subsequent admissions.

CONCLUSIONS

In patients undergoing ISBT, SA provides better immediate pain control post insertion compared to GA. Patients who received SA used lower amounts of opioids during their first ISBT insertion.

Randomized controlled study comparing 2-chloroprocaine and bupivacaine for spinal anesthesia in gynecological surgeries

Background:

Ambulatory surgeries are increasing all over. While searching for an ideal anesthetic, the use of lidocaine was linked to a greater rate of transitory neurological symptoms and bupivacaine delays discharge due to a longer duration of motor blockade. 2-chloroprocaine (2CP) with a shorter duration of action is gaining popularity. We aimed to compare intrathecal bupivacaine and 2CP for the subarachnoid block for elective ambulatory gynecological surgeries.

Methods:

A single-blind study was conducted on 90 patients comparing 40 mg 2CP and 10 mg 0.5% bupivacaine heavy measuring pinprick sensation, motor block, time to ambulation, and voiding of urine so as to get ready for discharge.

Results:

In both groups, the beginning of sensory blockage occurred at a similar time, while motor blockade achieved was faster in the 2CP group. The resolution of motor blockade was 1.7 times faster in the 2CP group than in the bupivacaine group. Time taken for ambulation was delayed significantly in the bupivacaine group, i.e., 263.04 ± 29.08 min compared to the 2CP group, i.e., 225.44 ± 29.48 min which was a delay of almost 38 min. Voiding of urine was also delayed in the bupivacaine group by 60 min compared to the 2CP group and was significant finding leading to delay of discharge of patients. Adverse effects were comparable in both groups.

Conclusion:

Intrathecal preservative-free 2CP provides satisfactory surgical block, and has a considerably faster rate of block regression, resulting in earlier ambulation and voiding, allowing the patient to be discharged from the hospital sooner as compared to intrathecal bupivacaine.

Correlation Between Anthropometric Measurements and Sensory Block Level of Spinal Anesthesia for Cesarean Section

Background

When performing spinal anesthesia for cesarean section, it is important to determine the appropriate anesthetic dose as well as to predict the level of spinal anesthesia. In this study, it was hypothesized that some anthropometric measurements may be related to maximum sensory block and hemodynamic changes.

Objectives

The aim of this study are to find maternal anthropometric values that are correlate with the level of spinal anesthesia.

Methods

Maternal anthropometric measurements, including height, weight, supine and standing abdominal circumference (AC), and hip circumference, were recorded before spinal anesthesia for cesarean section. Spinal anesthesia was induced by administering 8 mg of 0.5% hyperbaric bupivacaine and 20 μg of fentanyl at the L3-L4 interspace. The level of sensory block was determined using pin-prick at 1, 5, 10, and 15 minutes after spinal anesthesia. The sensory block level and hemodynamic adverse events were analyzed in relationship to anthropometric measurements.

Results

The supine AC/height ratios significantly correlate with the maximal sensory block level at 5, 10, and 15 minutes after the injection of spinal anesthetic (P = 0.001, P < 0.001 and P < 0.001, respectively). Further, there were significant correlations between body mass index (BMI) and sensory block level at every assessment (P = 0.041, P = 0.002, P = 0.001 and P < 0.001, respectively). When comparing the groups with and without hypotension, BMI, weight, and supine AC/height ratio were found to be significantly higher in the group with hypotension (P = 0.002, P = 0.004 and P = 0.006, respectively).

Conclusions

We conclude that BMI and AC/height ratio correlate with the sensory block level of spinal anesthesia for cesarean section.

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.

Comparison of Anesthetic Efficacy of Lidocaine and Bupivacaine in Spinal Anesthesia in Chickens

Lidocaine is used for epidural and spinal anesthesia in various animal species. The ideal drug for epidural and spinal anesthesia should have a long effective duration in addition to a fast onset of action, and adequate analgesia and muscle relaxation. Despite the delayed onset of action, bupivacaine provides a longer duration of anesthesia than lidocaine. The purpose of this study was to compare the onset to effect and duration of action between lidocaine and bupivacaine for spinal anesthesia in broiler chickens. Thirty-two, 8-week-old, female Ross broiler chickens were randomly divided into 4 groups of 8: 1) 2 mg/kg lidocaine (L); 2) 0.1 mg/kg bupivacaine (B0.1); 3) 0.25 mg/kg bupivacaine (B0.25); and 4) 0.5 mg/kg bupivacaine (B0.5). After aseptic preparation, a 23-gauge spinal needle was inserted into the synsacrococcygeal space of the chickens with correct needle placement confirmed by a sudden loss of resistance. Spinal anesthesia was performed with the aforementioned doses of lidocaine and bupivacaine. The respiratory rate and cloacal temperature were measured every 10 minutes in each chicken until the anesthetic effect was no longer present. The onset to effect and the duration of action were calculated for each bird based on the pinch test at predetermined time intervals. The results are demonstrated as mean ± SD. The onset of action for bupivacaine (9 ± 1.41, 4.33 ± 1.15, and 3.33 ± 1.23 minutes in B0.1, B0.25, and B0.5 groups, respectively) was significantly delayed compared with that of lidocaine (1.37 ± 0.52 minutes). The duration of action of B0.5 (54 ± 6.08 minutes) was significantly longer than that of any other group (17.87 ± 3.18, 11 ± 1.41, and 18 ± 4.36 min in L, B0.1, and B0.25 groups, respectively). The results showed that a spinal injection of 0.5 mg/kg bupivacaine produces approximately 55 minutes of spinal anesthesia in these broiler chickens, which is much longer than the 18 minutes of anesthesia provided by 2 mg/kg lidocaine. Considering the various disease conditions that affect the cloacal area of birds, one can use each of these anesthetic drugs for either short-term or long-term spinal anesthesia in chickens and possibly other avian species.

A Prospective Open-Label Randomized Controlled Trial to Compare Intrathecal 1% 2-Chloroprocaine Versus 0.5% Bupivacaine in Ambulatory Elective Surgeries

Background:

For an outpatient surgery, an ideal anesthetic drug should have a faster onset and shorter duration of action and minimal side effects. Although Bupivacaine is a drug of choice in spinal anesthesia but is not suitable for ambulatory surgeries. We aimed to compare 1% 2-chloroprocaine (2-CP) which is considered to be a short-acting agent with 0.5% hyperbaric bupivacaine as a spinal anesthetic agent in ambulatory surgeries.

Materials and Methods:

The study includes a prospective analysis of 60 patients who underwent ambulatory surgeries of <60 min and were randomly divided into two groups of 30 each: Group I – intrathecal injection of preservative-free formulation of 1% 2-CP 40 mg (4 mL) given and Group II – intrathecal injection of 0.5% hyperbaric bupivacaine 10 mg (2.0 mL) given time to reach surgical anesthesia, time for resolution of motor block, time for end of anesthesia, time to requirement of first postoperative analgesic, time to unassisted ambulation, time for micturition, and time to reach discharge readiness criteria, which were recorded.

Results:

We observed that in the CP group, onset time is early and there was more fast regression of surgical anesthesia in the CP group resulting in less time required for unassisted ambulation and less time for discharge from the hospital.

Conclusion:

We concluded that 2-CP can be used for spinal anesthesia in shorter duration surgeries with early recovery from anesthesia and hence early discharge from the hospital.

Spinal myoclonus following neuraxial anesthesia: a literature review

Spinal myoclonus (SM) is a rare neurologic movement disorder following neuraxial anesthesia (NA). SM following NA (SM-NA) has insufficient clinical information and its pathogenesis remains to be elucidated. The aim of this review article was to summarize the past cases and consider SM-NA pathophysiology. Based on our PubMed search, it was revealed that SM-NA develops within several hours after neuraxial local anesthetic (LA) administration and resolves in a day without leaving neurologic compilations. It occurs primarily in the lower extremities, but can sometimes spread upward and affect the upper extremities and trunk. Although statistical adjustments are indispensable, analysis of the previous cases provided important facts that seem to be related with the mechanism of SM-NA. The frequently used LAs for spinal anesthesia were hyperbaric. SM-NA occurrence was more frequent in women. After initiation of spinal anesthesia, intrathecal hyperbaric LA distributes cephalad. In the LA elimination process, the large concentration differences in intrathecal LA may induce the partially functioning spinal neurons, resulting in myoclonus generation. The morphological features of the lumbar spine in women can predispose to a higher LA concentration difference. SM-NA is an unpredictable and rare neural complication following NA and should be confirmed by basic experiments and large-scale researches.

The Effects of the Quincke Spinal Needle Bevel Insertion on Postdural Puncture Headache and Hemodynamics in Obstetric Patients

Aim

Spinal anesthesia is a widely used procedure in modern anesthesia. Although it is a reliable and frequently used anesthetic procedure, it involves complications, including postdural puncture headache caused by arachnoid punctured, which significantly affects postoperative well-being. In this study, we aimed to observe headache frequency with 26-G Quincke spinal needle in either transverse or sagittal planes.

Materials and Methods

One hundred patients with American Society of Anesthesiologists status classes I and II who were scheduled for elective cesarean delivery with no contraindications for performing spinal anesthesia were randomly divided into two groups: Group I (transverse n = 50) and Group II (sagittal n = 50). Spinal anesthesia was performed with a 26-G Quincke needle, using 1.5-2.0 ml 0.75% hyperbaric bupivacaine. The anesthesiologists' experience, number of attempts for spinal anesthesia, volume of fluid administered preoperatively and intraoperatively, intervertebral space where spinal anesthesia was administered, and patient movements during the attempts were recorded. Mean arterial pressure and peak heart rates were recorded for 60 min intraoperatively and postoperatively. Headache and back pain complications were observed for 1 week postoperatively. Chi-square tests and statistical comparisons of the rates (statistical significance, P < 0.05) were used for assessments.

Results and Conclusions

No significant differences were observed with respect to age, height, weight, headache, or incidence of back pain. No significant differences were observed for the number of spinal attempts, intervertebral space where spinal anesthesia was administered, experience of the anesthesiologists, patient movements during the attempts, volumes of fluid administered preoperatively and intraoperatively, or low back pain incidence. Significant reductions in mean arterial pressure were observed between groups after 10, 15, 30, 40, and 50 min. No significant differences were observed in headache or back pain frequency with 26-G Quincke spinal needle in either transverse or sagittal planes. Hypotension was frequently observed in the transverse group.

A multicenter study of the analgesic effects of epidural chloroprocaine after lower limb orthopedic surgery

STUDY OBJECTIVE

To investigate the effects and optimal concentration of chloroprocaine for epidural analgesia after lower limb orthopedic surgery.

DESIGN

Prospective, randomized, observational, multicenter clinical study.

SETTING

Operating room, postoperative recovery area, university hospital.

PATIENTS

One hundred and twenty patients from 4 hospitals were enrolled and randomized into 5 groups after lower limb orthopedic surgery under epidural anesthesia with lidocaine.

INTERVENTIONS

Epidural chloroprocaine mixed with 0.4μg/mL fentanyl was administered via a patient-controlled analgesia pump at the concentration of 0.6%, 0.8%, 1.0%, 1.2%, or 1.4% after the surgery.

MEASUREMENTS

Systolic blood pressure, heart rate, visual analog score at rest and during activity, as well as the Bromage score at 0 minute, 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, 24 hours, and 48 hours after the surgery were recorded and compared. Use of morphine and incidence of adverse effects were also recorded.

MAIN RESULTS

Patients given 1.2% chloroprocaine showed the lowest visual analog score compared with other groups. There was no significant difference in the Bromage score among 5 groups. The Bromage score returned to 0 in 89.7% of the patients 48 hours after surgery. No difference in postoperative morphine usage, blood pressure, or heart rate was found among 5 groups.

CONCLUSIONS

Epidural 1.2% chloroprocaine with 0.4μg/mL fentanyl could generate proper analgesic effects with little influence on mobility in patients undergoing lower limb orthopedic surgery. In addition, it could generate a good sense and movement separation, facilitating the early functional training.

Vasoconstrictive effects of levobupivacaine on the basilar artery in the rabbit

INTRODUCTION

Spinal anesthesia is a widely used technique of the modern practice of anesthesia. Spinal cord ischemia is a rare but catastrophic complication of spinal anesthesia which may be caused by a direct vasoconstrictive effect of the local anesthetic. Although the vasoconstrictive effects of levobupivacaine have been widely studied, the vasoconstrictive effects of this drug on the intradural arteries have never been studied. The aim of this study is to evaluate whether levobupivacaine has vasoconstrictive effects on the basilar artery in rabbits.

MATERIAL AND METHODS

Thirty male New Zealand white rabbits were divided randomly into three groups of ten rabbits each: group 1 (control); group 2 (0.125% levobupivacaine); group 3 (0.25% levobupivacaine). The cisterna magna was punctured as described below, then 1 ml of saline or 0.125% or 0.25% levobupivacaine was injected into the cisterna magna in 10 min by an infusion pump in groups 1, 2 and 3 respectively. All animals were euthanized by perfusion-fixation 30 min after the procedure. The luminal area and the size of the cross-sectional area for each basilar artery were measured.

RESULTS

Both 0.125% and 0.25% levobupivacaine infusion caused significant vasoconstriction. Vasoconstriction was more significant for the 0.125% concentration.

CONCLUSIONS

The results of this study indicated that both 0.125% and 0.25% concentrations of levobupivacaine caused significant vasoconstriction of the basilar artery when administered into the subarachnoid space. This may constitute proof that subarachnoid administration of levobupivacaine may diminish the spinal cord blood flow, causing ischemia.

Inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle

STUDY DESIGN

Case report and review of the literature.

OBJECTIVE

To report the first case of inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle.

SUMMARY OF BACKGROUND DATA

Rare complications from cervical transforaminal epidural corticosteroid injection have resulted in infarction of the spinal cord and brain. The most often-hypothesized mechanism is inadvertent intra-arterial injection of particulate corticosteroids with a resulting embolus and infarction.

METHODS

Retrospective review of a patient's history and fluoroscopic imaging.

RESULTS

A 30-year-old man with a diagnosed cervical radiculopathy underwent a right C6-C7 transforaminal epidural corticosteroid injection, using a 25-gauge 3.5-inch Whitacre spinal needle. Simultaneous epidural and radicular artery spread were observed under live fluoroscopy. The patient suffered no complications from the procedure.

CONCLUSION

This case demonstrates that the use of pencil-point (Whitacre) needles does not eliminate the risk of inadvertent arterial injection during cervical transforaminal epidurals. Further investigation is required to determine whether the incidence of inadvertent vascular injection is reduced with pencil-point needles compared with sharp-beveled needles.

Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial

BACKGROUND

We have always been searching for the ideal local anesthetic for outpatient spinal anesthesia. Lidocaine has been associated with a high incidence of transient neurological symptoms, and bupivacaine produces sensory and motor blocks of long duration. Preservative-free 2-chloroprocaine (2-CP) seems to be a promising alternative, being a short-acting agent of increasing popularity in recent years. This study was designed to compare 2-CP with bupivacaine for spinal anesthesia in an elective ambulatory setting.

METHODS

A total of 106 patients were enrolled in this randomized double-blind study. Spinal anesthesia was achieved with 0.75% hyperbaric bupivacaine 7.5 mg (n = 53) or 2% preservative-free 2-CP 40 mg (n = 53). The primary endpoint for the study was the time until reaching eligibility for discharge. Secondary outcomes included the duration of the sensory and motor blocks, the length of stay in the postanesthesia care unit, the time until ambulation, and the time until micturition.

RESULTS

The average time to discharge readiness was 277 min in the 2-CP group and 353 min in the bupivacaine group, a difference of 76 min (95% confidence interval [CI]: 40 to 112 min; P < 0.001). The average time for complete regression of the sensory block was 146 min in the 2-CP group and 329 min in the bupivacaine group, a difference of 185 min (95% CI: 159 to 212 min; P < 0.001). Times to ambulation and micturition were also significantly lower in the 2-CP group.

CONCLUSION

Spinal 2-chloroprocaine provides adequate duration and depth of surgical anesthesia for short procedures with the advantages of faster block resolution and earlier hospital discharge compared with spinal bupivacaine. (ClinicalTrials.gov number, NCT00845962).

[Catastrophes caused by neurologic diagnostic procedures]

Serious complications (catastrophes) resulting from diverse neurological diagnostic procedures can be caused by erroneous indication and omission, as well as by delay and erroneous execution or interpretation. Headache, caused by cerebrospinal fluid (CSF) hypotension, is a frequent complication of lumbar puncture; hematic patch is a therapeutic option for severe cases. The most serious complication is cerebral herniation and, for its prevention, computed tomography (CT) or cerebral magnetic resonance imaging (MRI) must always be performed before lumbar puncture: a lesion with evident mass effect is a contraindication. Some cases of minor subarachnoid hemorrhages can produce sentinel headache: when the findings of CT scans are normal, lumbar puncture must be performed for diagnosis and prevention of a catastrophic recurrence. Edrophonium testing can be complicated with bradycardia and/or asystole. The lack of indication of this procedure is a cause of under-diagnosis of myasthenia gravis, especially in older people. Electromyography produces few complications (rare cases of paraspinal hematomas and pneumothorax). Ultrasound, CT angiography and MR angiography examinations have decreased the indications for cerebral angiography, whose main complications -in addition to contrast reactions, hemorrhage and infection at the injection site- are neurological deficits caused by vascular dissection or atheromatous embolus. Video-electroencephalogram (EEG) recording with medication suppression can be used in the presurgical evaluation of epilepsy, which can precipitate repeated seizures with the risk of injuries and status epilepticus. The possible complications of studies performed with invasive electrodes are infections and intracranial hemorrhages. Cerebral biopsy is indicated when treatable disease is suspected but the therapeutic options (radiotherapy, chemotherapy) have potential serious adverse effects. Furthermore, cerebral biopsy can aggravate previous neurological deficits or produce new deficits. Genetic testing is not indicated in healthy children when an untreatable disease is suspected. In adults, genetic testing is appropriate in selected cases, but detailed previous information should be gathered and the possibility of triggering serious emotional reactions should always be considered.