Thiopental-Based Neuroprotective Anesthesia for Emergency Craniotomy in an Adolescent with Multifocal Epidural Hematoma and Impending Herniation: A Case Report

Abstract

Background. Multifocal traumatic epidural hematoma with pneumocephalus and impending herniation is a neurosurgical emergency in which anesthetic management can limit or add to secondary brain injury. Reports in adolescents are few.

Objective. To describe the anesthetic management and physiological course of an adolescent who underwent emergency decompressive craniotomy and facial reconstruction under a thiopental-based protocol.

Methods. A 17-year-old male (50 kg, Glasgow Coma Scale 12, ASA 4E) was admitted after a high-velocity injury. Computed tomography showed epidural hematomas (66 and 43 mL), pneumocephalus, a 15-mm midline shift and early transtentorial herniation. Anesthesia was induced with fentanyl 2 mcg/kg, thiopental 4 mg/kg and atracurium 0.5 mg/kg and maintained with sevoflurane without nitrous oxide, with invasive arterial monitoring and targets of mean arterial pressure (MAP) 85–95 mmHg and end-tidal CO₂ 30–35 mmHg. Intracranial pressure was estimated, not measured.

Results. MAP fell from 104 to 86 mmHg (−17.3%) at induction and stayed at 85–95 mmHg thereafter; the response to intubation was blunted. Estimated cerebral perfusion pressure was 58–80 mmHg. Blood loss was 600 mL, replaced with 1,200 mL of crystalloid, without transfusion. The patient was extubated on postoperative day 2 and left the intensive care unit on day 5 with a Glasgow Coma Scale score of 15 and a Glasgow Outcome Scale score of 5.

Conclusion. A titrated thiopental-based induction with strict pressure and ventilation targets and no nitrous oxide was followed by stable hemodynamics and a good early recovery. One case cannot show that thiopental protected the brain.