Anesthetic Management of a 3-Month-Old Infant Undergoing Emergency Hemispherotomy Following Recent Cardiac Arrest: A Complex Perioperative Challenge

Dear Editor, Hemimegalencephaly is a rare congenital hamartomatous malformation of one cerebral hemisphere resulting in drug-resistant epilepsy, requiring hemispherotomy or hemispherectomy.[1,2] Early-onset epilepsies adversely affect neurodevelopment.[3] Emergency hemispherotomy in early infancy is challenging due to limited physiological reserve. Here, we report the anesthetic management of an infant with hemimegalencephaly and drug-refractory seizures undergoing emergency functional hemispherotomy following a recent cardiac arrest. A 3-month-old female infant weighing 2.92 kg presented with refractory status epilepticus and progressive encephalopathy. She had seizures since day 3 of life (15–20/day) despite multiple anticonvulsants. She deteriorated with bradycardia followed by cardiac arrest, was resuscitated, intubated, and shifted to the pediatric intensive care unit. Magnetic resonance imaging suggested hemimegalencephaly [Figure 1]. Continuous electroencephalography (EEG) showed persistent epileptiform activity despite four anti-seizure medications, necessitating midazolam infusion. Emergency functional hemispherotomy was planned.Figure 1: Magnetic resonance imaging of the brain suggestive of left-sided dysplastic hemimegalencephalyIn the operating theater, a right femoral arterial line and right internal jugular venous access were secured. Anesthesia was induced with propofol (2 mg/kg), fentanyl (2 µg/kg) and maintained with oxygen–air–sevoflurane, atracurium, and fentanyl boluses. Ringer’s lactate with 1% dextrose was administered. Glucose levels fluctuated (82–240 mg/dL), requiring frequent monitoring and titration. Blood loss was 90 mL (approximately 35%–40% of blood volume) and was replaced with packed red blood cells and fresh frozen plasma. Active warming prevented hypothermia. Hemodynamic variations required fluid titration and dopamine infusion (10 µg/kg/min). Postoperatively, she was extubated on postoperative day (POD-1) but developed poor sensorium and airway compromise on POD-3, necessitating re-intubation and tracheostomy. Due to significant blood loss, completion of callosotomy and frontobasal disconnection was staged. Subsequent EEG showed burst suppression with neurological recovery, metabolic stability, successful decannulation, and adequate oral intake. Anesthetic goals were to preserve cerebral perfusion by maintaining normothermia, normoglycemia, normocapnia, normoxia, and electrolyte balance.[4] The major concern was a recent cardiac arrest with possible myocardial stunning, altered hemodynamics, and autoregulation. Altered pharmacokinetics due to multiple antiepileptics, physiological immaturity, rapid drug redistribution, and blood loss posed significant challenges. Goal-directed transfusion guided by invasive monitoring helped maintain hemodynamic stability. Intraoperative hyperglycemia from stress response required frequent monitoring and titration. Delayed neurological recovery and re-intubation may be multifactorial, including anticonvulsant toxicity, cerebral edema, and metabolic disturbances. Anticipation of complications, timely intervention, and management of metabolic disturbances contributed to the favorable neurological recovery of the child. This case study highlights the anesthetic challenges in emergency hemispherotomy in infancy following recent cardiac arrest, emphasizing meticulous physiological control, hemodynamic monitoring, and metabolic optimization for optimal outcomes. Ethical policy and Institutional Review Board statement As it is a letter to the editor, ethics approval is not required. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Author contributions MK: Conception and design of the work; supervision; manuscript drafting; final approval; agreement to be accountable for all aspects of the work. DS: Data acquisition and literature review; drafting of the manuscript; revising the manuscript; final approval; agreement to be accountable for all aspects of the work. MA: Patient management and clinical aspects of the work; critical revision of the manuscript; final approval; agreement to be accountable for all aspects of the work. LS: Patient care and clinical data; manuscript review and revision; final approval; agreement to be accountable for all aspects of the work.