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LETTER TO THE EDITOR

Valsalva’s Maneuver to Assist Delivery of a Neurocysticercosis Cyst from the Fourth Ventricle

Department of Neuroanaesthesiology (Prabhakar, Ali) Department of Neurosurgery; All India Institute of Medical Sciences; New Delhi, India; prabhakarhemanshu{at}rediffmail.com (Sharma)

To the Editor:

Valsalva’s Maneuver (VM) may be employed in patients undergoing intracranial surgery to confirm venous hemostasis and facilitate tumor resection during transsphenoidal pituitary surgery. We used this technique to help deliver a neurocysticercosis cyst from the fourth ventricle of the brain in a 15-yr-old boy. Under general endotracheal anesthesia, the fourth ventricle was opened. VMs were performed three times to maintain airway pressure of 20 cm H₂O greater than the peak airway pressure for 10–15 s. The cyst began to bulge out and after the fourth VM, 3/4th of the cyst was out but the surgeon was not able to grasp it. The surgeon passed a catheter over the cyst to reach behind and gently irrigated with saline to release the adhesions. The combination of VM and irrigation helped deliver the cyst complete.

Studies show that VM increases intrathoracic pressure, which may significantly alter systemic and cerebral circulation.1,2 Wendling et al.3 and Prabhakar et al.4 demonstrated an increase in intracranial pressure following VM in anesthetized neurosurgical patients. In our case, application of VM resulted in extrusion of the intracranial contents through the dural defect, facilitating the delivery of the fourth ventricular cyst.

REFERENCES

1. Leishout JJ Van, Weiling W, Karemaker JM, Secher NH. Syncope, cerebral perfusion, and oxygenation. J App Physiol 2003;94:833–48[Abstract/Free Full Text]
2. Zhang R, Crandall CG, Levine BD. Cerebral hemodynamics during the Valsalva maneuver–Insights from the ganglion blockade. Stroke 2004;35:843–7[Abstract/Free Full Text]
3. Wendling W, Sadel S, Jimenez D, Rosenwasser R, Buchheit W. Cardiovascular and cerebrovascular effects of the applied Valsalva maneuver in neurosurgical patients. Eur J Anaesthesiol 1994;11:81–7[Web of Science][Medline]
4. Prabhakar H, Bithal PK, Suri A, Rath GP, Dash HH. Intracranial pressure changes during Valsalva manoeuvre in patients undergoing neuroendoscopic procedure. Minim Invasive Neurosurg 2007;50:98–101[Web of Science][Medline]

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