Multiple system atrophy (MSA) is a rare adult-onset neurodegenerative disease. Symptoms vary from autonomic dysfunction to Parkinsonism and cerebellar ataxia, in any combination. MSA affects many organ systems with many possible complications and makes perioperative management of a patient with this condition very challenging. Successful management of a patient with MSA posted for laparoscopic nephrectomy under general anaesthesia is reported.

A pituitary tumor scheduled for surgical excision can eventuate with a myriad of challenges. A 49-year-old acromegalic patient was admitted to our hospital for trans-nasal trans-sphenoidal pituitary surgery. Magnetic resonance imaging (MRI) of his brain revealed a well-defined lesion involving right half of the anterior lobe of pituitary. In the operating room, we encountered difficulty in management of the airway. The trachea could be intubated using fiberoptic bronchoscope via a proseal laryngeal mask airway after five attempts of failed intubation. Intraoperatively, the right internal carotid artery (ICA) was injured during excision of lateral part of the tumor with a blood loss of 3.5 L. Adenosine use to aid hemostasis was unsuccessful. Endovascular coil embolization was done to treat the pseudoaneurysm developed in the right ICA, to restore the blood flow. During this process, the patient developed medial rectus palsy and ptosis in the right eye, which improved gradually. The above amalgamation of maladies commanded an integrated and well-coordinated team approach to manage the catastrophic complications. AbstractKeywords ► airway management ► endotracheal intubation ► pituitary adenoma ► acromegaly ► pseudoaneurysm

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Hydrogen peroxide (H2O2) irrigation is commonly utilised in neurosurgical and non-neurosurgical procedures for its bactericidal and haemostatic effects. Tension pneumocephalus and venous air embolism are potentially disastrous neurological complications mostly seen after intracranial surgery in sitting position and trauma. We present a case of oxygen embolus and tension pneumocephalus after H2O2 irrigation during craniotomy in supine position.

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