An electrical storm is usually associated with catecholaminergic surge following myocardial ischaemia and manifest as recurrent ventricular arrhythmias, requiring frequent DC shocks. Delivering repeated DC shocks induces myocardial damage and further worsens the arrhythmias, which are resistant to the antiarrhythmic drugs. Cardiac sympathetic blockade abates the excessive catecholaminergic drive and help pacifying the malignant ventricular arrhythmias. We treated the electrical storm in a 52-year-old male with ultrasound-guided left sympathetic ganglion block followed by surgical left cardiac sympathetic denervation. The patient remained symptom-free without any incident of ventricular arrhythmias for 8 months after the surgery. The ultrasonography during blockade of the stellate ganglion enhances the success rate of the technique, reduces the quantity of local anaesthetic required to produce desired effects and prevents technical complications. Supraclavicular surgical access to the upper thoracic sympathetic chain obviates the necessity for one lung ventilation and lateral decubitus during surgery, when the patient is in hemodynamically unstable condition. Sympathectomy can be performed under general anaesthesia taking cautions to avoid sympathetic stimulation in intraoperative period.

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Asleep-awake-asleep technique of anesthesia is used during awake craniotomy with or without securing airway. We assessed this technique using laryngeal mask airway (LMA) in two patients. Patients underwent awake craniotomy for epilepsy surgery and the removal of a frontotemporal glioma. After anesthesia induction, airway was secured using LMA. Anesthesia was maintained using oxygen, nitrous oxide and sevoflurane, supplemented with an infusion of propofol and remifentanil. Twenty minutes before corticography, anesthesia was discontinued and LMA removed. Both patients were awake and cooperative during the neurological assessment and surgery on eloquent areas. The LMA was reinserted before the closure of the dura and remained in place until the end of surgery. Both patients had no recall of events under anesthesia, although experienced mild pain and discomfort during awake phase of surgery. Both expressed complete satisfaction over the anesthetic management. Asleep-awake-asleep technique using LMA offers airway protection. The painful aspect of surgery can be performed under anesthesia, hence minimizing the duration of stress and pain. Patients remained awake and cooperative throughout the time of neurological testing.

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The authors describe two patients who suffered carotid artery injury during transsphenoidal resection of a pituitary tumor. Anesthesiologists were involved in resuscitation after initial hemorrhage, in securing the airway, in initiating cerebral protection strategies, and in transporting these patients. Anesthesia was provided for resection of the tumors, removal of packs from the pituitary fossae, and diagnostic and therapeutic radiologic procedures. In each case hemostasis was achieved by packing the sella turcica, sphenoid sinus, and nostrils. Both patients were electively ventilated. In one patient, a pseudoaneurysm of the carotid artery was detected by angiography in the operating room. It was treated by trapping the internal carotid artery. The other patient developed a carotid-cavernous fistula, which was treated by balloon embolization. Both patients were discharged after dealing with these complications.

Aneurysms of sinus of Valsalva, usually a rare presentation, account for 0.1%-3.5% of congenital heart defects. They rarely present unless rupture occurs. There are very few cases of unruptured sinus of Valsalva aneurysms that presented with myocardial ischemia, symptomatic cardiac dysfunction, and conduction abnormalities. We present a case of multiple unruptured sinus of Valsalva aneurysms with particular emphasis on the transesophageal echocardiography.

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