Ultrasound mapping of soft tissue vascular anatomy proximal to the larynx: a prospective cohort study

Background

Bleeding incidents during percutaneous dilatational tracheostomy are concerning, and most cases occur in patients with unrecognized and unanticipated anatomical variations in the vascular anatomy. However, the extent of this variation remains unclear. To address this knowledge gap, our study aimed to comprehensively map laryngeal vascular anatomy in a cohort of adult patients.

Methods

Ultrasound assessments of the soft tissue in the neck were performed, spanning from the thyroid cartilage to the third tracheal ring and extending 2 cm laterally on both sidesperformed. We subdivided this area into 12 zones comprising four medial and eight lateral sections. A pre-planned form was used to document the presence of arteries or veins in each zone. The results are reported as odds ratios, 95% CIs, and corresponding P-values.

Results

Five-hundred patients were enrolled from August 14, 2023, to November 13, 2023, at the University Hospital of Padua. Arteries and veins were identified in all investigated zones (varying from a minimum of 1.0%-46.4%). The presence of invessels progressively increased from the cricothyroid membrane to the third tracheal ring and from the midline to the paramedian laryngeal area.

Conclusions

Given the prevalence of arteries and veins, particularly in areas where tracheostomies are commonly performed, we strongly advocate for routine ultrasound assessments before such procedures are performed.

Rehabilitation approaches in West Nile Virus survivors: a systematic review

INTRODUCTION

Periodic increases in West Nile virus (WNV) infections have been documented. Proper rehabilitative management is essential for these patients, who may experience limitations in daily activities even after the resolution of the acute infection. Since there are currently no globally accepted guidelines, our aim is to conduct a best-evidence synthesis on rehabilitative management for patients with neuroinvasive WNV.

EVIDENCE ACQUISITION

We screened the literature with two independent researchers conducting searches on PubMed, Embase, SCOPUS, and Google Scholar databases for WNV-related studies in the field of rehabilitation. Suitable studies were identified and selected through a rigorous process. The review includes original research articles published up to August 15, 2023.

EVIDENCE SYNTHESIS

Despite the potential for bias in the studies, the literature suggests that a comprehensive and interdisciplinary rehabilitation program, which includes physical therapy with neuromotor and respiratory interventions, occupational therapy, neurocognitive interventions, and speech therapy for dysphagia and communication issues, can lead to functional improvement in WNV patients. This program should be tailored to address each patient's specific challenges, and the duration of the rehabilitation program may vary depending on the individual patient's needs.

CONCLUSIONS

Even if additional research with larger cohorts and higher evidence levels is needed for a comprehensive understanding of WNV patient rehabilitation, an early and comprehensive rehabilitation approach addressing respiratory, neuromuscular, and cognitive aspects appears effective for WNV patient recovery.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS)

BACKGROUND

The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.

METHODS

A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.

RESULTS

A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).

CONCLUSIONS

This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Examining gender bias in regional anesthesia academic publishing: a 50-year bibliometric analysis

BACKGROUND

The connection between academic career advancement and publishing research articles is important, as it can impact promotion and compensation decisions. Gender bias in academic publishing is a known issue, with studies showing low numbers in key roles in female representation. This article aims to analyze the ratio of women to men as first and last authors in the Regional Anesthesia & Pain Medicine (RAPM) journal and explore other factors such as the mentorship effect and representation in regional anesthesia associations.

MAIN BODY

We examined the RAPM articles from 1976 to 2023 evaluating the gender of first and last authors. We analyzed the trend over the years and also analyze the subset of original articles. A further analysis was conducted to analyze the relationship between the first and last author's gender. Additionally, regional anesthesia societies were contacted to gather data on the gender of their members. We included 5650 articles; most of them were first authored by men (72.9-87.7%). There was a positive trend over time for female first authorship but not for last authorship. The analysis also revealed a mentorship effect in recent years for both overall articles and the subgroup of original articles. The representation of women within regional anesthesia societies contrasted with the representation of women as last authors in original articles.

CONCLUSIONS

Our findings raise important questions about gender bias in academic publishing highlighting the need for increased representation and opportunities for women in the field of regional anesthesia.

Enhancing study quality assessment: an in-depth review of risk of bias tools for meta-analysis-a comprehensive guide for anesthesiologists

BACKGROUND

Yearly, a multitude of randomized controlled trials are published, overwhelming clinicians with conflicting information; this data saturation leads to confusion and hinders clinicians' everyday decision-making. Hence, it is crucial to assess the quality and reliability of the evidence in order to consolidate it. Through this synthesis, clinicians can guarantee that their decisions are informed by solid evidence. Meta-analysis, a statistical technique, can effectively combine data from multiple studies to furnish accurate and dependable evidence for clinical practice and policy decisions. Nonetheless, the reliability of the obtained results depends on the use of high-quality evidence.

MAIN BODY

Risk of bias is an assessment mandatory while performing a meta-analysis and is used to have an overview of the quality of the studies from which data are extracted. Several tools have been developed and are used to perform the risk of bias assessment. In this statistical round, we will provide an overview of the most used tools for both the randomized (Cochrane Risk of Bias 2 and Jadad) and the nonrandomized (Risk Of Bias In Non-randomized Studies and Newcastle-Ottawa Scale) clinical trials.

CONCLUSION

We provided an overview of the most used risk of bias tools used in meta-analysis.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Pupillary dynamics predict long-term outcome in a cohort of acute traumatic brain injury coma patients

OBJECTIVE

Examining the size and reactivity of the pupils of traumatic brain injury coma patients is fundamental in the Neuro-intensive care unit (ICU). Pupil parameters on admission predict long-term clinical outcomes. However, little is known about the dynamics of pupillary parameters and their potential value for outcome prediction.

METHODS

This study applied a time-course analysis of pupillary signals (size and photo-reactivity) in acute traumatic brain injury coma patients (n = 20) to predict outcome at 6 months.

RESULTS

The time course of pupillary signals was informative in discriminating favorable (F) versus unfavorable (U) outcomes, with the highest correlation within the 1st week notwithstanding pharmacological sedation. Patients with favorable outcome at 6 months showed more consistent in time isochoric and photo-reactive pupils. In contrast, patients with an unfavorable outcome showed more variable measures that tended to stabilize toward pathological values.

INTERPRETATION

Time-dependent tracking of pupils' size and reactivity is a promising application for ICU monitoring and long-term prognosis. These findings support the usefulness of automatic tools for the dynamic, quantitative, and objective measurements of pupils.

Comparison of multiple definitions for ventilator-associated pneumonia in patients requiring mechanical ventilation for non-pulmonary conditions: preliminary data from PULMIVAP, an Italian multi-centre cohort study

OBJECTIVES

To compare intensivist-diagnosed ventilator-associated pneumonia (iVAP) with four established definitions, assessing their agreement in detecting new episodes.

METHODS

A multi-centric prospective study on pulmonary microbiota was carried out in patients requiring mechanical ventilation (MV). Data collected were used to compare hypothetical VAP onset according to iVAP with the study consensus criteria, the European Centre for Disease Control and Prevention definition, and two versions of the latter adjusted for leukocyte count and fever.

RESULTS

In our cohort of 186 adult patients, iVAPs were 36.6% (68/186, 95% confidence interval 30.0-44.0%), with an incidence rate of 4.64/100 patient-MV-days, and median MV-day at diagnosis of 6. Forty-seven percent of patients (87/186) were identified as VAP by at least one criterion, with a median MV-day at diagnosis of 5. Agreement between intensivist judgement (iVAP/no-iVAP) and the criteria was highest for the study consensus criteria (50/87, 57.4%), but still one-third of iVAP were not identified and 9% of patients were identified as VAP contrary to intensivist diagnosis. VAP proportion differed between criteria (25.2-30.1%).

CONCLUSIONS

Caution is needed when evaluating studies describing VAP incidence. Pre-agreed criteria and definitions that capture VAP's evolving nature provide greater consistency, but new clinically driven definitions are needed to align surveillance and diagnostic criteria with clinical practice.

Single-Shot Regional Anesthesia for Bariatric Surgery: a Systematic Review and Network Meta-Analysis

PURPOSE

Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients with obstructive sleep apnea. To promote early recovery, enhanced recovery after surgery guideline advises minimizing opioid use and opting for alternative analgesics. This paper aims to investigate the effect of regional anesthesia techniques through a systematic review and network meta-analysis. Primary outcome is postoperative morphine equivalent consumption at 24 h.

METHODS

Search was conducted in the following databases: PubMed, CENTRAL, Scopus, and EMBASE, from the inception until 10 January 2023. The eligibility criteria were determined by PICOS, including postoperative opioid consumption, pain scores, time to ambulate, use of additional analgesics, and adverse events. The quality assessment was performed using the Risk of Bias 2 Tool, and the certainty of evidence was assessed using the GRADE approach. Funnel plots were used to evaluate publication bias.

RESULTS

We included 22 studies in quantitative synthesis. A review of 12 studies found that all techniques had a lower mean consumption of opioids compared to placebo or no intervention, with TAP block having the greatest reduction. The quality of evidence for postoperative pain, PONV, time to deambulate, and use of rescue analgesics, was rated as moderate, with TAP block being the most effective intervention. There was no publication bias in any outcome.

CONCLUSIONS

TAP block is superior to other regional anesthesia techniques in reducing opioid consumption, pain, PONV, and use of rescue analgesics in bariatric surgery. However, further research is needed.

Erector Spinae Plane Block and Chronic Pain: An Updated Review and Possible Future Directions

Chronic pain is a common, pervasive, and often disabling medical condition that affects millions of people worldwide. According to the Global Burden of Disease survey, painful chronic conditions are causing the largest numbers of years lived with disability worldwide. In America, more than one in five adults experiences chronic pain. Erector spinae plane block is a novel regional anesthesia technique used to provide analgesia with multiple possible uses and a relatively low learning curve and complication rate. Here, we review the erector spinae plane block rationale, mechanism of action and possible complications, and discuss its potential use for chronic pain with possible future directions for research.

General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis

PURPOSE

Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies.

RESULTS

Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months.

CONCLUSIONS

In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion.

TRIAL REGISTRATION

PROSPERO (CRD42022319368); registered 19 April 2022.

Reliability of Third Ventricle Assessment by Transcranial Ultrasound: A Computational Model of the Effect of Insonation Angle

INTRODUCTION

Transcranial sonography (TCS) is a bedside examination which is currently used in multiple neurocritical care settings. Third ventricle ultrasound is usually a simple technique, though a large insonation angle could lead to an overestimation of third ventricular diameter. The aim of this study was to use a mathematical model to evaluate the impact of probe inclination on the false positive rate when using TCS to evaluate third ventricle enlargement.

METHODS

Using R software, we simulated a pool of 100,000 fictitious patients with a normal third ventricle size (diameter from 0 to 9 mm) in daily follow-up for ventricle enlargement for 30 consecutive days using TCS. Each day, a different, random insonation angle (α) was generated and a corresponding measured diameter calculated as: measured diameter=real diameter/cos α. If the measured diameter was >9.0 mm, the simulation registered a "misdiagnosis" episode and the simulation loop was interrupted; otherwise, the simulation continued to its thirtieth iteration.

RESULTS

Of the 100,000 "patient" simulations, 30,905 (30.9%) had an erroneous TCS diagnosis of ventricular enlargement. Angles of insonation >35 degrees contributed to 79.3% of the total misdiagnoses of ventricular enlargement (false positive rate, 3.71%), whereas misdiagnosis was rare when the insonation angle was ≤15 degrees (1.30% of the total misdiagnoses; false positive rate, 0.06%).

CONCLUSION

Using probe inclinations <15 degrees, erroneous diagnosis of third ventricular enlargement was rare. Our results suggest that TCS has a low rate of false positives when the angle of insonation is minimized.

Nasal/orotracheal tube switch to reduce length of mechanical ventilation in neurocritical patients: A propensity score matched analysis

INTRODUCTION AND OBJECTIVES

Nasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation. The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients.

MATERIALS AND METHODS

We conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit.

RESULTS

A total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay.

CONCLUSIONS

In critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)–Part 1

Background

Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm.

Methods

A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted.

Results

Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided.

Conclusions

This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-part 2

BACKGROUND

Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment.

METHODS

A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted.

RESULTS

A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided.

CONCLUSIONS

This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.

Optimizing post anesthesia care unit admission after elective craniotomy for brain tumors: a cohort study

BACKGROUND

Postoperative admission to intensive care unit (ICU) after craniotomy for brain tumor was the routine in the past years. However, there is little evidence supporting this dogma and doubts have been casted by many authors in the last years. Our aim was to identify risk factors for ICU admission after elective brain tumor surgery in order to propose an individualized admission to ICU tailored on patient needs.

METHODS

We conducted a retrospective cohort study including all patients undergoing elective surgery for brain tumor in a neurosurgical post anesthesia care unit of a university hospital over a period of 6 years. In order to identify and validate risk factors for ICU admission, we split the final cohort of patients in a training cohort (two/third of the cohort) and the validation cohort (one/third of the cohort) using a random sequence. Using univariate and multivariate logistic regression, we created a scoring system in the training cohort and tested it with the validation cohort. Moreover, we perform a sensitivity analysis on the overall population.

RESULTS

A total of 420 patients were eligible for this study. ASA-PS, tumor volume, and surgery length entered the scoring system. Sensitivity analysis on the overall population for the scoring system had an AUC of 0.774 (95% CI 0.668-0.880, the best threshold at 12.5) CONCLUSIONS: We created a tool based on ASA-PS, length of surgery, and tumor volume to evaluate the risk for ICU admission after supratentorial tumor resection. Prospective studies are deemed necessary to validate our tool.

Preoperative Dexmedetomidine and intraoperative bradycardia in laparoscopic cholecystectomy: meta-analysis with trial sequential analysis

Background

While laparoscopic surgical procedures have various advantages over traditional open techniques, artificial pneumoperitoneum is associated with severe bradycardia and cardiac arrest. Dexmedetomidine, an imidazole derivative that selectively binds to α²-receptors and has sedative and analgesic properties, can cause hypotension and bradycardia. Our primary aim was to assess the association between dexmedetomidine use and intraoperative bradycardia during laparoscopic cholecystectomy.

Methods

We performed a systematic review with a meta-analysis and trial sequential analysis using the following PICOS: adult patients undergoing endotracheal intubation for laparoscopic cholecystectomy (P); intravenous dexmedetomidine before tracheal intubation (I); no intervention or placebo administration (C); intraoperative bradycardia (primary outcome), intraoperative hypotension, hemodynamics at intubation (systolic blood pressure, mean arterial pressure, heart rate), dose needed for induction of anesthesia, total anesthesia requirements (both hypnotics and opioids) throughout the procedure, and percentage of patients requiring postoperative analgesics and experiencing postoperative nausea and vomiting and/or shivering (O); randomized controlled trials (S).

Results

Fifteen studies were included in the meta-analysis (980 patients). Compared to patients that did not receive dexmedetomidine, those who did had a higher risk of developing intraoperative bradycardia (RR: 2.81, 95% CI [1.34, 5.91]) and hypotension (1.66 [0.92, 2.98]); however, they required a lower dose of intraoperative anesthetics and had a lower incidence of postoperative nausea and vomiting. In the trial sequential analysis for bradycardia, the cumulative z-score crossed the monitoring boundary for harm at the tenth trial.

Conclusions

Patients undergoing laparoscopic cholecystectomy who receive dexmedetomidine during tracheal intubation are more likely to develop intraoperative bradycardia and hypotension.

Risk Factors for General Anesthesia Conversion in Anterior Circulation Stroke Patients Undergoing Endovascular Treatment

BACKGROUND AND PURPOSE

No current consensus exists on the best anesthetic management of ischemic stroke patients undergoing mechanical thrombectomy. Both conscious sedation (CS) and general anesthesia (GA) are currently considered valid anesthetic strategies, yet patients managed under CS may require emergent conversion to GA, which has been associated with worse outcomes. The aim of this study was to analyze the conversion rate and potential risk factors for GA conversion during mechanical thrombectomy.

METHODS

Two-hundred and twenty-seven patients with consecutive acute anterior circulation ischemic stroke treated with mechanical thrombectomy and initiated under CS or local anesthesia were included in this retrospective analysis. Conversion rate to GA was calculated, while univariate and multivariate analysis were used to identify risk factors.

RESULTS

Twenty patients (8.8%) were switched to GA. Multivariate analysis identified procedure duration (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.00-1.02, p value 0.028), tandem stroke (OR 8.57, 95% CI 2.06-35.7, p value 0.003), Sequential Organ Failure Assessment (SOFA) (OR 1.76, 95% CI 1.19-2.61, p value 0.005), and number of pharmacological agents used (OR 5.76, 95% CI 2.49-13.3, p value <0.001) as independently associated with conversion to GA.

CONCLUSION

In our study, tandem occlusion, longer endovascular procedures, SOFA, and number of pharmacological agents used predicted the risk of emergent conversion to GA in stroke patients undergoing endovascular treatment. Prospective studies investigating optimal CS strategies are deemed necessary.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)

Background

The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance.

Methods

A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted.

Results

A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided.

Conclusions

Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.

A practical guide to patient position and complication management in neurosurgery: a systematic qualitative review

PURPOSE

Adequate patient positioning is of paramount importance in neurosurgery. Complications related to the position are common and make up for more than 16% of the claims towards anaesthesiologists and neurosurgeons. This paper aims to provide the anaesthesiologist with a practical guide to avoid common pitfalls related to the patient positioning process.

METHOD

We performed a systematic review of the medical literature for the identification, screening, and inclusion of articles. The bibliographic search was conducted on June 1st, 2021 by two of the authors. In this review, we included articles indexed by MEDLINE, Cochrane Library, or Google Scholar.

RESULTS

We retrieved a total of 5706 unique papers from our initial search. However, after the initial screening, 5363 papers were removed is not related to our research leaving a total of 343 papers. We examined the full text of all the 343 articles including 68 of them in the final qualitative analysis.

DISCUSSION

In this review we examine the most common neurosurgical positions: supine, sitting, lateral, park-bench, prone, jack-knife, and knee-chest. For each of them, the proper positioning and related complications are described. Particular attention is given to the prevention and management of these complications, providing a practical guide for clinicians.

Inattentional blindness in anesthesiology: A gorilla is worth one thousand words

INTRODUCTION

People are not able to anticipate unexpected events. Inattentional blindness is demonstrated to happen not only in naïve observers engaged in an unfamiliar task but also in field experts with years of training. Anaesthesia is the perfect example of a discipline which requires a high level of attention and our aim was to evaluate if inattentional blindness can affect anesthesiologists during their daily activities.

MATERIALS AND METHODS

An online survey was distributed on Facebook between May 1, 2021 and May 31, 2021. The survey consisted of five simulated cases with questions investigating the anesthetic management of day-case surgeries. Each case had an introduction, a chest radiography, an electrocardiogram, preoperative blood testing and the last case had a gorilla embedded in the chest radiography.

RESULTS

In total 699 respondents from 17 different countries were finally included in the analysis. The main outcome was to assess the incidence of inattentional blindness. Only 34 (4.9%) respondents were able to spot the gorilla. No differences were found between anesthesiologists or residents, private or public hospitals, or between medical doctors with different experience.

DISCUSSION

Our findings assess that inattentional blindness is common in anesthesia, and ever-growing attention is deemed necessary to improve patient safety; to achieve this objective several strategies should be adopted such as an increased use of standardized protocols, promoting automation based strategies to reduce human error when performing repetitive tasks and discouraging evaluation of multiple consecutive patients in the same work shifts independently of the associated complexity.

Trial Sequential Analysis explained using a post-hoc analysis of meta-analyses published in Korean Journal of Anesthesiology

Background

Trial sequential analysis (TSA) is a recent cumulative meta-analysis method used to weigh type I and II errors and to estimate when the effect is large enough to be unaffected by further studies. The aim of this study was to illustrate possible TSA scenarios and their significance using meta-analyses published in the Korean Journal of Anesthesiology (KJA) as working material.

Methods

We performed a systematic medical literature search for meta-analyses published in the KJA. TSA was performed on each main outcome, estimating the required sample size on the calculated effect size for the intervention, considering a type I error of 5% and a power of 90% or 99%.

Results

Six meta-analyses with a total of ten main outcomes were included in the analysis. Seven TSAs confirmed the results of the meta-analyses. However, only three of them reached the required sample size. In the two TSAs, the cumulative z-lines were not statistically significant. One TSA boundary for effect was reached with the 90% analysis, but not with the 99% analysis.

Conclusions

In TSA, a meta-analysis pooled effect may be established to assess if the cumulative sample size is large enough. TSA can be used to add strength to the conclusions of meta-analyses; however, pre-registration of the TSA protocol is of paramount importance. This study could be useful to better understand the use of TSA as an additional statistical tool to improve meta-analysis quality.

Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.

Ultrasound as a Useful Tool in Hydrocephalus Management During Pregnancy: A Case Report

A 38-year-old pregnant woman in her 24th week of gestation was admitted to our neurosurgical intensive care unit with a 5-cm cerebellar hemangioblastoma and acute hydrocephalus. Initial management included the placement of an external ventricular drain to prevent neurological deterioration. Five days after the initial diagnosis, the patient successfully underwent a neurosurgical intervention to remove the lesion. Transcranial ultrasound was used to determine the optimal ventricular drain level and facilitate weaning, bypassing the need for cerebral computed tomography and cerebral magnetic resonance imaging, which would have otherwise been necessary in postoperative follow-up.

Effect of dexmedetomidine on hemodynamic responses to tracheal intubation: A meta-analysis with meta-regression and trial sequential analysis

STUDY OBJECTIVE

An uncontrolled adrenergic response during tracheal intubation may lead to life-threatening complications. Dexmedetomidine binds to α2-receptors and may attenuate this response. The primary aim of our meta-analysis is to investigate dexmedetomidine efficacy in attenuating sympathetic response to tracheal intubation, compared with placebo or no dexmedetomidine, in terms of heart rate and blood pressure at intubation.

DESIGN

Meta-analysis with meta-regression and trial sequential analysis.

SETTING

Systematic search from inception until December 1, 2020 in the following databases: Pubmed, Scopus, the Cochrane Central Register of Controlled Trials, EMBASE and Google Scholar.

INTERVENTIONS

All randomized controlled trials investigating intravenous dexmedetomidine as premedication in adult patients undergoing tracheal intubation were included in our study. Studies were included without any language or publication date restriction. A trial sequential analysis and a post-hoc meta-regression were performed on the main outcomes.

MEASUREMENTS

Hemodynamic parameters and heart rate at tracheal intubation, dose of anesthetic needed for induction of anesthesia, total anesthetic requirement throughout the operative procedure, postoperative pain and percentage of patients requiring analgesics at 24 postoperative hours, postoperative nausea and vomiting, intraoperative and postoperative bradycardia, hypotension, dizziness, shivering and/or respiratory depression.

MAIN RESULTS

Ninety-nine included studies randomized 6833 patients. During laryngoscopy, all hemodynamic parameters were significantly greater in the no dexmedetomidine group. In particular, in the dexmedetomidine group, systolic blood pressure differed by -21.8 mm Hg (95% CI -26.6 to -17.1, p-value < 0.001, I² 97%), mean arterial pressure by -12.8 mm Hg (95% CI -15.6 to -10.0, p-value < 0.001, I² 98%), and heart rate by -16.9 bpm (95% CI -19.8 to -13.9, p-value < 0.001, I² 98%).

CONCLUSIONS

Patients receiving premedication with dexmedetomidine for tracheal intubation, compared with no dexmedetomidine, have a lower blood pressure and heart rate, however, the risk of bradycardia and hypotension is relevant and its use during daily practice should be cautiously evaluated for each patient.

Serratus anterior plane block for video-assisted thoracoscopic surgery: A meta-analysis of randomised controlled trials

BACKGROUND

The serratus anterior plane block (SAPb) is a promising interfascial plane technique able to provide profound thoracic analgesia. As only a few studies with quite small patient samples are presently available, the analgesic efficacy of adding SAPb to general anaesthesia in video-assisted thoracoscopic surgery (VATS), compared with general anaesthesia only, remains unclear.

OBJECTIVES

Our primary aim was to assess the analgesic efficacy of SAPb for VATS peri-operative pain control. The secondary aims were to evaluate differences in postoperative opioid use, intra-operative hypotension, postoperative side-effects and complications, time to chest tube removal, length of hospital stay.

DESIGN

Systematic review of randomised controlled trials (RCTs) with meta-analyses.DATA SOURCES PubMed, Web of Science, Google Scholar and the Cochrane Library, searched up to 6 December 2019.ELIGIBILITY CRITERIA RCTs including adult patients undergoing VATS who received single shot SAPb (cases), compared with general anaesthesia (controls).

RESULTS

Seven RCTs, with a total of 489 patients were included. SAPb reduced pain scores peri-operatively, compared with controls: 6 h [mean difference -1.86, 95% confidence interval (CI) -2.35 to -1.37, P < 0.001]; 12 h (mean difference -1.45, 95% CI -1.66 to -1.25, P < 0.001); 24 h (mean difference -0.98, 95% CI -1.40 to -0.56, P < 0.001). SAPb also reduced the use of postoperative opioids (mean difference: -4.81 mg of intravenous morphine equivalent, 95% CI -8.41 to -1.22, P < 0.03) and decreased the incidence of nausea and vomiting (risk ratio 0.53, 95% CI 0.36 to 0.79, P < 0.002).

CONCLUSION

Compared with general anaesthesia only and if no other locoregional techniques are used, SAPb significantly reduces postoperative pain and nausea and vomiting in patients undergoing VATS. Grading of Recommendations Assessment, Development and Evaluation rating are, nonetheless, quite low, due to high heterogeneity. Well designed and properly powered RCTs are necessary to confirm these preliminary findings.

General Anesthesia Compared to Spinal Anesthesia for Patients Undergoing Lumbar Vertebral Surgery: A Meta-Analysis of Randomized Controlled Trials

Vertebral lumbar surgery can be performed under both general anesthesia (GA) and spinal anesthesia. A clear benefit from spinal anesthesia (SA) remains unproven. The aim of our meta-analysis was to compare the early analgesic efficacy and recovery after SA and GA in adult patients undergoing vertebral lumbar surgery. A systematic investigation with the following criteria was performed: adult patients undergoing vertebral lumbar surgery (P); single-shot SA (I); GA care with or without wound infiltration (C); analgesic efficacy measured as postoperative pain, intraoperative hypotension, bradycardia, length of surgery, blood loss, postoperative side effects (such as postoperative nausea/vomiting and urinary retention), overall patient and surgeon satisfaction, and length of hospital stay (O); and randomized controlled trials (S). The search was performed in Pubmed, the Cochrane Central Register of Controlled Trials, and Google Scholar up to 1 November 2020. Eleven studies were found upon this search. SA in vertebral lumbar surgery decreases postoperative pain and the analgesic requirement in the post anesthesia care unit. It is associated with a reduced incidence of postoperative nausea and vomiting and a higher patient satisfaction. It has no effect on urinary retention, intraoperative bradycardia, or hypotension. SA should be considered as a viable and efficient anesthetic technique in vertebral lumbar surgery.

Retrospective Analysis of a Modified Organizational Model to Guarantee CT Workflow during the COVID-19 Outbreak in the Tertiary Hospital of Padova, Italy

At the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) outbreak in Italy, the cluster of Vò Euganeo was managed by the University Hospital of Padova. The Department of Diagnostic Imaging (DDI) conceived an organizational approach based on three different pathways for low-risk, high-risk, and confirmed Coronavirus Disease 19 (COVID-19) patients to accomplish three main targets: guarantee a safe pathway for non-COVID-19 patients, ensure health personnel safety, and maintain an efficient workload. Thus, an additional pathway was created with the aid of a trailer-mounted Computed Tomography (CT) scanner devoted to positive patients. We evaluated the performance of our approach from February 21 through April 12 in terms of workload (e.g., number of CT examinations) and safety (COVID-19-positive healthcare workers). There was an average of 72.2 and 17.8 COVID-19 patients per day in wards and the Intensive Care Unit (ICU), respectively. A total of 176 high-risk and positive patients were examined. High Resolution Computed Tomography (HRCT) was one of the most common exams, and 24 pulmonary embolism scans were performed. No in-hospital transmission occurred in the DDI neither among patients nor among health personnel. The weekly number of in-patient CT examinations decreased by 27.4%, and the surgical procedures decreased by 29.5%. Patient screening and dedicated diagnostic pathways allowed the maintenance of high standards of care while working in safety.

Predictors of deep-vein thrombosis in subarachnoid hemorrhage: a retrospective analysis

BACKGROUND

Subarachnoid hemorrhage is a severe subtype of hemorrhagic stroke, and deep-vein thrombosis is a frequent complication detected in these patients. In addition to other well-established risk factors, the early activation of coagulation systems present in patients with subarachnoid hemorrhage could potentially play a role in the incidence of deep-vein thrombosis. This study aims to identify possible predictors for deep-vein thrombosis related to subarachnoid hemorrhage.

METHODS

We conducted a retrospective cohort study on patients with a diagnosis of subarachnoid hemorrhage who presented to our institution between 1 January 2014 and 1 August 2018. We reviewed electronic medical records and analyzed several parameters such as Fisher scale, World Federation of Neurosurgical Surgeons scale, aneurysm site, surgical or endovascular treatment, decompressive craniectomy, vasospasm, infection (meningitis and pneumonia), presence of motor deficit, length of stay in the ICU, length of hospital stay, number of days under ventilator support, d-dimer at hospitalization, and the time to thromboprophylaxis (days).

RESULTS

The univariate analysis showed that intraparenchymal cerebral hemorrhage, d-dimer at hospitalization, the time to thromboprophylaxis, motor deficit, and aneurysm located at the internal carotid artery were statistically significant factors. Intraparenchymal cerebral hemorrhage (OR 2,78 95%CI 1.07-7.12), motor deficit (OR 3.46; 95%CI 1.37-9.31), and d-dimer at hospitalization (OR 1.002 95% CI 1.001-1.003) were demonstrated as independent risk factors for deep-vein thrombosis. Length of hospital stay was also found to be significantly longer in patients who developed deep-vein thrombosis (p value 0.018).

CONCLUSION

Elevated d-dimer level at the time of hospitalization, motor deficit, and the presence of an intraparenchymal hemorrhage are independent risk factors for deep-vein thrombosis. Patients with DVT also had a significantly longer hospital stay. Even though further studies are needed, patients with elevated d-dimer at hospitalization and intraparenchymal cerebral hemorrhage may benefit from a more aggressive screening strategy for deep-vein thrombosis.

Pharmacokinetics of lidocaine after bilateral ESP block

INTRODUCTION

Erector spinae plane (ESP) block is an emerging interfascial block with a wide range of indications for perioperative analgesia and chronic pain treatment. Recent studies have focused their attention on mechanisms of action of ESP block. However, the pharmacokinetics of drugs injected in ESP is, as of now, uninvestigated. The aim of this brief report is to investigate the pharmacokinetics of lidocaine in a series of 10 patients.

METHODS

We are reporting a case series of 10 patients undergoing bilateral ESP block for multilevel lumbar spine surgery.ESP was performed with 3.5 mg/kg of lidocaine based on ideal body weight. Lidocaine concentration was dosed at 5, 15, 30 min and at 1, 2 and 3 hours.

RESULTS

T_max was 5 min for all the patients. C_max ranged from 1.2 to 3.8 mg/L (mean: 2.59 mg/L). AUC_0-3 was high (76%, on average) suggesting an almost complete bioavailability. Age had a negative correlation with T½ of lidocaine.

CONCLUSIONS

Lidocaine pharmacokinetic after ESP block is well-described by a two-compartment model with a rapid and extensive rate of absorption. Nevertheless, its peak concentrations never exceeded the accepted toxicity limit. Elimination half-life was slightly prolonged, probably due to the advanced age of some patients.

A brief introduction to propensity score for anesthesiologists

Intergroup comparability is of paramount importance in clinical research since it is impossible to draw conclusions on a treatment if populations with different characteristics are compared. While an adequate randomization process in randomized controlled trials (RCTs) ensures a balanced distribution of subjects between groups, the distribution in observational prospective and retrospective studies may be influenced by many confounders.<br/> Propensity score (PS) is a statistical technique that was developed more than 30 years ago with the purpose of estimating the probability to be assigned to a group. Once evaluated, the PS could be used to adjust and balance the groups using different methods such as matching, stratification, covariate adjustment, and weighting. The validity of PS is strictly related to the confounders used in the model, and confounders that are either not identified or not available will produce biases in the results. RCTs will therefore continue to provide the highest quality of evidence, but PS allows fine adjustments on otherwise unbalanced groups, which will increase the strength and quality of observational studies.

Continuous stellate ganglion block in delayed cerebral ischemia: A possible supplementary approach to traditional therapy?

Delayed Cerebral Ischemia (DCI) is a major contributor to morbidity and mortality after SAH. Currently the prevention of vasospasm and DCI relies on nimodipine administration and on maintaining an adequate cerebral perfusion pressure. We report a patient with initial DCI after SAH in which stellate ganglion block (SGB) was performed after nimodipine administration. Firstly the procedure was characterized by a iv and intra-arterial nimodipine administration which did not result into a normal perfusion pattern. Therefore a single-shot stellate ganglion block was performed, as suggested in literature. Because of the not sufficient but promising perfusion improvement, we decided to deliver a continuous ganglion block (cSGB) for 5 days. Consequently a further improvement of the cerebral perfusion on CTPerfusion and Real Time Angiographic Perfusion Assessment was registered. In order to treat cerebral vasospasm, SGB is known to be a further valuable treatment, despite its temporary effect. However the continuous use of SGB during initial DCI has never been described before.

Combined Fluorescence Using 5-Aminolevulinic Acid and Fluorescein Sodium at Glioblastoma Border: Intraoperative Findings and Histopathologic Data About 3 Newly Diagnosed Consecutive Cases

OBJECTIVE

Fluorescence-guided glioblastoma surgery is an intraoperative technique developed in recent years. Two main compounds have been used so far: 5-amilovelulinic acid (5-ALA) and fluorescein sodium (Fl-Na). Despite a large amount of literature on both techniques, few data are available on the use of both compounds in the same patient.

METHODS

Three consecutive patients affected by a newly diagnosed glioblastoma underwent surgical resection using both 5-ALA and Fl-Na. 5-ALA was orally administered 3 hours before induction of anesthesia at a dosage of 20 mg/kg, whereas fluorescein was intravenously administered at induction of anesthesia at a dosage of 4 mg/kg. Tumor resection was carried out combining these fluorophores. At tumor borders, multiple samples were collected, and fluorescent pattern of each sample was registered. Samples were then analyzed by a neuropathologist blinded for intraoperative fluorescence findings.

RESULTS

Eighteen samples were analyzed. At tumor margin, bright pink fluorescence was highly indicative of residual tumor (positive predictive value [PPV], 94%), and it was superior to faint pink and fluorescein (PPVs, 89% and 87%, respectively). The gradual reduction of pink fluorescence warned of the risk of gradually entering healthy tissue (specificity of 67% compared with 33% with fluorescein). Using 5-ALA, detecting no fluorescence was highly suggestive of healthy tissue (negative predictive value of 100% compared with 50% with fluorescence).

CONCLUSIONS

In our experience with 3 patients, the 2 techniques presented different advantages and limitations in specific steps of tumor resection, showing complementary properties. Larger studies are mandatory to investigate the synergistic use of both techniques.

Cardiopulmonary By-pass in a Patient with Acquired C1 Inhibitor Deficiency

C1 inhibitor (C1-INH) regulates, complement, contact system, coagulation and fibrinolysis. Bleeding complications during cardiopulmonary bypass (CPB) have been described in a deficient patient. We report a 72 year old man affected with acquired C1-INH deficiency who successfully underwent CPB.

Italian COnsensus in Neuroradiological Anesthesia (ICONA)

Anesthetic management of patients undergoing endovascular procedures for treating intracranial aneurysms or cerebrovascular malformations must consider a number of specific challenges, in addition to those associated with anesthesia for other specialties. In addition to maintenance of physiological stability, manipulation of systemic and cerebral hemodynamic parameters may be required to treat any sudden unexpected catastrophic neurological events. A multidisciplinary group including neuro- and pediatric anesthesiologists, interventional neuroradiologists, neurosurgeons, and a clinical methodologist contributed to this document. This consensus working group from 21 Italian institutions identified open questions regarding the best practices for management of anesthesia during endovascular neuroradiological procedures for intracranial aneurysms and cerebrovascular malformations, and addressed these by formulating practical consensus statements. At the first meeting in November 2015, nine key areas were identified regarding choice of anesthetic, patient monitoring, hemodynamic targets, postoperative care, and the management of neuromuscular blockade, anticoagulant and/or antiplatelet therapy, and special considerations for pediatric patients. Nine subgroups were established and a medical librarian performed literature searches in the Cochrane and MEDLINE/PubMed databases for each group. Groups drafted literature summaries and provisional responses in the form of candidate consensus statements based on evidence, when possible, and clinical experience, when this was lacking. Final wording was agreed at a meeting in April 2016 and where possible evidence was graded using United States Preventive Services Task Force criteria. Consensus (defined as >90% agreement) was based on evidence, clinical experience, clinician preference, feasibility in the Italian healthcare system, and cost/benefit considerations.

Intraoperative functional mapping of calculation in parietal surgery. New insights and clinical implications

BACKGROUND

Parietal areas play a crucial role in calculation processing. The purpose of this study is to report our experience in the assessment of calculation processing during awake surgery in parietal areas, focusing on clinical implications and new insights provided by this approach.

METHODS

We retrospectively reviewed clinical and surgical data of 13 patients who underwent parietal surgery with calculation mapping. Cortical and sub-cortical areas (in 13 and five patients, respectively) involved in single-digit multiplications and additions were identified using bipolar electro-stimulation.

RESULTS

Cortical stimulation data showed that the inferior parietal lobule and the intraparietal sulcus were specifically related to calculation in all cases, regardless of the side (100% of cases, in both sides). Conversely, the superior parietal lobule was inconstantly involved in calculation processing (40% of cases in the left and 75% in the right side), whereas the somatosensory area was never involved. Sub-cortical stimulation was able to detect functional areas for calculation in all patients: in 90% of cases the sub-cortical sites positive for calculation were in close anatomical connection with the cortical sites mapping for the same function. The intraoperative preservation (-or damaging-) of functional sites correlated with the absence (- or occurrence-) of post-operative calculation processing impairment.

CONCLUSIONS

Our findings support the specificity of the reported technique in the intraoperative identification of sites functional for calculation. Our data show the bilateral involvement of parietal cortex, especially of the inferior lobule, in calculation processing. Furthermore, our study suggests the existence of a sub-cortical pathway specific for calculation, whose better understanding might be crucial for the clinical outcome of patients.