The central and peripheral nervous systems are the primary target organs during anaesthesia. At the time of the inception of the British Journal of Anaesthesia, monitoring of the central nervous system comprised clinical observation, which provided only limited information. During the 100 yr since then, and particularly in the past few decades, significant progress has been made, providing anaesthetists with tools to obtain real-time assessments of cerebral neurophysiology during surgical procedures. In this narrative review article, we discuss the rationale and uses of electroencephalography, evoked potentials, near-infrared spectroscopy, and transcranial Doppler ultrasonography for intraoperative monitoring of the central and peripheral nervous systems.

Background: Traumatic brain injury (TBI) is a common healthcare problem related to disability. An easy-to-use trauma scoring system informs physicians about the severity of trauma and helps to decide the course of management. The purpose of this study is to use the combination of both physiological and anatomical assessment tools that predict the outcome and develop a new modified prognostic scoring system in TBIs. Patients and methods: A total of 181 subjects admitted to the emergency department (ED) of Sanglah General Hospital were documented for both Marshall CT scan classification score (MCTC) and Revised Trauma Score (RTS) upon admission. Glasgow Outcome Scale (GOS) was then documented at six months after brain injury. A new Modified Revised Trauma–Marshall score (m-RTS) was developed using statistical analytic methods. Results: The total sample enrolled for this study was 181 patients. The mean RTS upon admission was 10.2±1.2. Of the 181 subjects, 110 (60.8%) were found to have favorable GOS (GOS score >3). Best Youden’s index results were obtained with any of the RTS of ≤10 with area under receiver operating characteristic (ROC) curve of 0.2542 and with risk ratio of 2.9 (95% CI=1.98−4.28; P=0.001); and Marshall score ≤2 with area under ROC curve of 0.2249 with risk ratio of 3.9 (95% CI=2.52−5.89; P=0.001). The RTS–Marshall combination has higher sensitivity with risk ratio of 4.5 (CI 95%=2.55−8.0; P=0.001) for screening tools of unfavorable outcome. The Pearson’s correlation between RTS and Marshall classification is 0.464 (P<0.001). Conclusion: Combination of physiological and anatomical score improves the prognostic of outcome in moderate and severe TBI patients, formulated in this accurate, simple, applicable and reliable m-RTS prognostic score model.

Background: Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients’ outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury. Patients and Methods: A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spearman’s rank correlation coefficient was used to determine whether GCS correlated with BIS value. Results: In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p<0.01). The BIS values increased with an increasing GCS. Mean BIS values of mild, moderate, and severe head injury were 88.1±5.6, 72.1±11.1, and 60.4±11.7, respectively. Conclusion: In this study, a significant correlation existed between GCS and BIS. This finding suggests that BIS may be used for assessing GCS in patients with traumatic brain injury. However, the scatters of BIS values for any GCS level may limit the BIS in predicting GCS accurately.

Background: Maintaining brain oxygenation status is the main goal of treatment in severe traumatic brain injury (TBI). Jugular venous oxygen saturation (SjvO₂) monitoring is a technique to estimate global balance between cerebral oxygen supply and its metabolic requirement. Full Outline of Responsiveness (FOUR) score, a new consciousness measurement scoring, is expected to become an alternative for Glasgow Coma Scale (GCS) in evaluating neurologic status of patients with severe traumatic head injury, especially for those under mechanical ventilation. Methods: A total of 63 patients with severe TBI admitted to emergency department (ED) were included in this study. SjvO₂ sampling was taken every 24 hours, until 72 hours after arrival. The assessment of FOUR score was conducted directly after each blood sample for SjvO₂ was taken. Spearman’s rank correlation was used to determine the correlation between SjvO₂ and FOUR score. Regression analysis was used to determine mortality predictors. Results: From the 63 patients, a weak positive correlation between SjvO₂ and FOUR score (r=0.246, p=0.052) was found upon admission. Meanwhile, strong and moderate negative correlation values were found in 48 hours (r=-0.751, p<0.001) and 72 hours (r=-0.49, p=0.002) after admission. Both FOUR score (p<0.001) and SjvO₂ (p=0.04) were found to be independent mortality predictors in severe TBI. Conclusion: There was a negative correlation between the value of SjvO₂ and FOUR score at 48 and 72 hours after admission. Both SjvO₂ and FOUR score are independent mortality predictors in severe TBI.

Background: Erectile dysfunction (ED) after a prostate-transurethral resection (P-TUR) is one of the problems in the treatment of benign prostatic hyperplasia (BPH) that may affect the quality of life in middle-aged and older men. The aim of this study was to investigate the impact of P-TUR on ED in BPH patients. Methods: This study was conducted on 83 patients suffering from BPH that underwent a P-TUR. Clinically, testosterone levels, prostatic-specific antigen (PSA) levels, and prostate volume were measured before the P-TUR. Erectile function was measured prior to the P-TUR, as well as at 1 and 3 months after the P-TUR using the International Index of Erectile Function (IIEF). Suitability test of the model was done in a structural equation. Data were analyzed using the chi-square (χ^2,) test by Analysis of Moment Structure (AMOS) software version 21. Results: The effects of PSA to IIEF before, 1 month after, and 3 months after P-TUR were 0.116, 0.084, and 0.097, respectively. The effects of body mass index to IIEF before, 1 month after, and 3 months after P-TUR were 0.180, 0.066, and 0.164, respectively. The effects of prostate volume to IIEF before, 1 month after, and 3 months after P-TUR were 0.049, 0.004, and 0.011, respectively. The effects of testosterone to IIEF before, 1 month after, and 3 months after P-TUR were –0.029, –0.453, and –0.415, respectively. The effects of age to IIEF before, 1 month after, and 3 months after P-TUR were –0.444, 0.921, and 0.911, respectively. Conclusion: There was a significant improvement of erectile function in patients that underwent P-TUR who previously had preoperative ED, especially 3 months after the surgery.

The surgical outcome of orbital cavernous hemangiomas has been reported either by ophthalmologists, who preferred anterior approach, or by neurosurgeons, who favored transcranial approach. In this series, we reported the surgical outcome of ten patients with orbital cavernous hemangioma. The clinical findings varied from obvious axial proptosis in all patients (100%), visual impairment (60%), limited ocular movement (50%), and orbital pain (60%). The surgical outcomes were determined at their last follow-up and examination, where 80% of the cases had a good outcome, one patient had permanent visual damage and partial ptosis (poor), and another patient had an unchanged visual function (fair). Transcranial approach is still an appropriate surgical approach for most orbital cavernous hemangioma with good and acceptable surgical outcomes. Generally, lateral orbitotomy is indicated for a lesion located at the lateral compartment of the orbit that does not affect orbital apex.