isolation, this report illustrates the utility of the real-time raw EEG waveforms that can be obtained from the BIS monitor, and in this situation, prompting a formal EEG evaluation. Matthew Smith, FRCA Patrick Dobbs, FRCA George Eapen, FRCA, FFICM Sheffield Teaching Hospitals Sheffield, UK REFERENCES 1. Hernandez-Fernandez F, Fernandez-Diaz E, Pardal-Fernandez J, et al. Periodic lateral- ized epileptiform discharges as manifestation of pneumococcal meningoencephalitis. Int Arch Med. 2011;4:23. 2. Pedersen G, Rasmussen S, Gyllenborg J, et al. Prognostic value of periodic electroencephalo- graphic discharges for neurological patients with profound disturbances of consciousness. Clin Neurophysiol. 2013;124:44–51. 3. Fishman O, Legatt A. PLEDs following control of seizures and at the end of life. Clin EEG Neurosci. 2010;41:11. Intractable Nausea and Vomiting Following Balloon Occlusion of Carotico-Cavernous Fistula To JNA Readers: A 19-year-old male patient weighing 60 kg presented with prom- inent veins on forehead, protrusion of left eye ball, and tinnitus in the left ear since the past 3 months. He had a his- tory of road traffic accident for which he underwent repair of mandibular and maxillary fracture under anesthesia. The patient was diagnosed to have a left carotico-cavernous fistula (CCF) with venous drainage into ipsilateral cav- ernous sinus and inferior petrosal sinus and a significant steal in ipsilateral middle cerebral artery and anterior cerebral artery territories. He was scheduled for balloon occlusion of the CCF under monitored anesthesia care. In the neuroradiologic suite standard monitors were attached and femoral artery was cannulated for the procedure under local anesthetic infiltration. Two balloons were used for complete occlu- sion of the high-flow CCF (Fig. 1). The patient had stable hemodynamics throughout the procedure, which lasted for 150 minutes and he received 8 mg of intravenous (IV) dexamethasone 30 mi- nutes before completion of the proce- dure. The proptosis was visibly reduced after of the procedure. Ten minutes later, the patient complained of nausea and vomiting. The blood pressure, elec- trolytes, neurological status, and com- puted tomographic scan of the head were normal. Ondansetron (6 mg) was administered intravenously (IV) but without any relief to the episodes of nausea and vomiting. However, these episodes later responded to an injection of propofol 20 mg IV. The patient was then shifted to ICU for observation during which he remained asympto- matic for 4 to 5 hours. This was fol- lowed by recurrence of nausea and vomiting albeit with reduced severity. The patient received second dose of dexamethasone and ondansetron. Next morning, the computed tomography scan and fluoroscopic imaging con- firmed correct position of the balloon. The patient continued to have nausea and vomiting but with each passing day, the severity and frequency was dimin- ished and completely subsided on fifth postprocedural day. Balloon occlusion is one of the therapeutic options for CCF. 1 This case is probably the first report of isolated episodes of nausea and vomiting fol- lowing the procedure. Subanesthetic doses of propofol have been used to treat intractable nausea and vomiting, which was also used in our patient. 2 Nakashima et al 3 reported abducens nerve palsy, headache, vomiting, and convulsion in a patient with high-flow FIGURE 1. Periodic lateralized epileptiform discharges-PLEDs (highlighted) in raw electroencephalogram (EEG) waveform with abnormally high bispectral index of 74. FIGURE 1. X-ray image showing balloon occlusion of carotico-cavernous fistula. The authors have no funding or conflicts of interest to disclose. Dube et al J Neurosurg Anesthesiol  Volume 27, Number 1, January 2015 74 | www.jnsa.com r 2014 Lippincott Williams & Wilkins