{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T18:29:38Z","timestamp":1772821778873,"version":"3.50.1"},"reference-count":68,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2021,3,2]],"date-time":"2021-03-02T00:00:00Z","timestamp":1614643200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.<\/jats:p>","DOI":"10.3390\/jcm10051013","type":"journal-article","created":{"date-parts":[[2021,3,2]],"date-time":"2021-03-02T10:36:37Z","timestamp":1614681397000},"page":"1013","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Local Anesthetic-Induced Central Nervous System Toxicity during Interscalene Brachial Plexus Block: A Case Series Study of Three Patients"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8915-4588","authenticated-orcid":false,"given":"Daniel","family":"Spitzer","sequence":"first","affiliation":[{"name":"Institute of Neurology (Edinger Institute), University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"},{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katharina J.","family":"Wenger","sequence":"additional","affiliation":[{"name":"Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1793-2918","authenticated-orcid":false,"given":"Vanessa","family":"Neef","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Iris","family":"Div\u00e9","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"},{"name":"Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"},{"name":"University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany"},{"name":"Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany"},{"name":"German Cancer Consortium (DKTK), Partner Site Frankfurt\/Mainz, 60590 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1447-9908","authenticated-orcid":false,"given":"Martin A.","family":"Schaller-Paule","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kolja","family":"Jahnke","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christian","family":"Kell","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christian","family":"Foerch","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6927-0987","authenticated-orcid":false,"given":"Michael C.","family":"Burger","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"},{"name":"Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany"},{"name":"University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany"},{"name":"Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany"},{"name":"German Cancer Consortium (DKTK), Partner Site Frankfurt\/Mainz, 60590 Frankfurt, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,3,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1177\/0310057X0703500103","article-title":"Long-term neurological complications associated with surgery and peripheral nerve blockade: Outcomes after 1065 consecutive blocks","volume":"35","author":"Watts","year":"2007","journal-title":"Anaesth. Intensive Care"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1213\/00000539-199807000-00020","article-title":"Peripheral nerve blocks improve analgesia after total knee replacement surgery","volume":"87","author":"Allen","year":"1998","journal-title":"Anesth. Analg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1053\/rapm.2003.50019","article-title":"Femoral block provides superior analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction","volume":"28","author":"Iskandar","year":"2003","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1031","DOI":"10.1034\/j.1399-6576.2002.460818.x","article-title":"Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery","volume":"46","author":"Laurila","year":"2002","journal-title":"Acta Anaesthesiol. Scand."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1213\/00000539-199807000-00019","article-title":"Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty","volume":"87","author":"Singelyn","year":"1998","journal-title":"Anesth. Analg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"630","DOI":"10.1097\/ALN.0000000000002822","article-title":"Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery: A Systematic Review and Meta-analysis","volume":"131","author":"Hussain","year":"2019","journal-title":"Anesthesiology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1016\/S0952-8180(02)00408-7","article-title":"Perioperative interscalene blockade: An overview of its history and current clinical use","volume":"14","author":"Long","year":"2002","journal-title":"J. Clin. Anesth."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Stav, A., Reytman, L., Stav, M.-Y., Portnoy, I., Kantarovsky, A., Galili, O., Luboshitz, S., Sevi, R., and Sternberg, A. (2016). Comparison of the Supraclavicular, Infraclavicular and Axillary Approaches for Ultrasound-Guided Brachial Plexus Block for Surgical Anesthesia. Rambam Maimonides Med. J., 7.","DOI":"10.5041\/RMMJ.10240"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e1726","DOI":"10.1097\/MD.0000000000001726","article-title":"Comparison between Ultrasound-Guided Supraclavicular and Interscalene Brachial Plexus Blocks in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective, Randomized, Parallel Study","volume":"94","author":"Ryu","year":"2015","journal-title":"Medicine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"875","DOI":"10.1097\/00000542-200110000-00015","article-title":"Acute and nonacute complications associated with interscalene block and shoulder surgery: A prospective study","volume":"95","author":"Borgeat","year":"2001","journal-title":"Anesthesiology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1016\/S1098-7339(03)00218-9","article-title":"Relationship between evoked motor response and sensory paresthesia in interscalene brachial plexus block","volume":"28","author":"Bollini","year":"2003","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1097\/ACO.0b013e32834c155f","article-title":"Ultrasound-guided blocks for shoulder surgery","volume":"24","author":"Conroy","year":"2011","journal-title":"Curr. Opin. Anaesthesiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"610","DOI":"10.1007\/s00540-012-1366-x","article-title":"Electrostimulation with or without ultrasound-guidance in interscalene brachial plexus block for shoulder surgery","volume":"26","author":"Salem","year":"2012","journal-title":"J. Anesth."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1213\/ane.0b013e3181a3272c","article-title":"A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms","volume":"109","author":"Liu","year":"2009","journal-title":"Anesth. Analg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1188","DOI":"10.1213\/01.ANE.0000053235.07186.39","article-title":"Seizure after levobupivacaine for interscalene brachial plexus block","volume":"96","author":"Crews","year":"2003","journal-title":"Anesth. Analg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/j.rapm.2003.08.022","article-title":"Lower lobe collapse during continuous interscalene brachial plexus local anesthesia at home","volume":"29","author":"Sardesai","year":"2004","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_17","first-page":"94","article-title":"Hypoxia following interscalene block","volume":"27","author":"Rose","year":"2002","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"904","DOI":"10.1034\/j.1399-6576.2003.00188.x","article-title":"Cardiac arrest after interscalene brachial plexus block with ropivacaine and lidocaine","volume":"47","author":"Reinikainen","year":"2003","journal-title":"Acta Anaesthesiol. Scand."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1097\/00115550-200311000-00011","article-title":"Pleural effusion and chest pain after continuous interscalene brachial plexus block","volume":"28","author":"Souron","year":"2003","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1274","DOI":"10.1097\/00000542-200211000-00034","article-title":"Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service","volume":"97","author":"Auroy","year":"2002","journal-title":"Anesthesiology"},{"key":"ref_21","first-page":"352","article-title":"Ultrasonographic assessment of hemidiaphragm paralysis secondary to interscalene block","volume":"80","year":"2012","journal-title":"Cir. Cir."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1016\/j.bja.2017.11.104","article-title":"Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles","volume":"120","author":"Vorobeichik","year":"2018","journal-title":"Br. J. Anaesth."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"215","DOI":"10.5603\/AIT.a2018.0013","article-title":"Risk factors for the development of Horner\u2019s syndrome following interscalene brachial plexus block using ropivacaine for shoulder arthroscopy: A randomised trial","volume":"50","author":"Stasiowski","year":"2018","journal-title":"Anaesthesiol. Intensive Ther."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1097\/00000542-200308000-00026","article-title":"Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery","volume":"99","author":"Borgeat","year":"2003","journal-title":"Anesthesiology"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1097\/AAP.0b013e31819624eb","article-title":"Upper extremity regional anesthesia: Essentials of our current understanding, 2008","volume":"34","author":"Neal","year":"2009","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_26","first-page":"e4491","article-title":"Total Spinal Anesthesia Following an Interscalene Block Treated with Intravenous Lipid Emulsion","volume":"11","author":"Turner","year":"2019","journal-title":"Cureus"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1166","DOI":"10.1111\/j.1365-2044.2012.07222.x","article-title":"Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia","volume":"67","author":"Yanovski","year":"2012","journal-title":"Anaesthesia"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1128","DOI":"10.1213\/00000539-199711000-00031","article-title":"Convulsions induced by ropivacaine during interscalene brachial plexus block","volume":"85","author":"Korman","year":"1997","journal-title":"Anesth. Analg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1097\/00115550-199924020-00014","article-title":"Anxiety, vocalization, and agitation following peripheral nerve block with ropivacaine","volume":"24","author":"Klein","year":"1999","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"912","DOI":"10.1007\/BF03026796","article-title":"Case report: Ropivacaine neurotoxicity at clinical doses in interscalene brachial plexus block","volume":"54","author":"Dhir","year":"2007","journal-title":"Can. J. Anaesth."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1007\/s00540-011-1125-4","article-title":"Successful treatment of ropivacaine-induced central nervous system toxicity by use of lipid emulsion: Effect on total and unbound plasma fractions","volume":"25","author":"Mizutani","year":"2011","journal-title":"J. Anesth."},{"key":"ref_32","first-page":"1998","article-title":"2nd Focal neurologic deficit","volume":"29","author":"Wippold","year":"2008","journal-title":"AJNR. Am. J. Neuroradiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1097\/01376517-199712000-00008","article-title":"Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group","volume":"29","author":"Spilker","year":"1997","journal-title":"J. Neurosci. Nurs. J. Am. Assoc. Neurosci. Nurses"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2957","DOI":"10.1001\/jama.1993.03510240069035","article-title":"A new Simplified Acute Physiology Score (SAPS II) based on a European\/North American multicenter study","volume":"270","author":"Lemeshow","year":"1993","journal-title":"JAMA"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/S0140-6736(74)91639-0","article-title":"Assessment of coma and impaired consciousness. A practical scale","volume":"2","author":"Teasdale","year":"1974","journal-title":"Lancet"},{"key":"ref_36","first-page":"i13","article-title":"Neurological assessment of coma","volume":"71","author":"Bateman","year":"2001","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_37","first-page":"221","article-title":"The EEG of status epilepticus","volume":"23","author":"Kaplan","year":"2006","journal-title":"J. Clin. Neurophysiol. Off. Publ. Am. Electroencephalogr. Soc."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1016\/j.yebeh.2015.05.007","article-title":"Salzburg Consensus Criteria for Non-Convulsive Status Epilepticus--approach to clinical application","volume":"49","author":"Leitinger","year":"2015","journal-title":"Epilepsy Behav."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1007\/s12028-012-9695-z","article-title":"Guidelines for the evaluation and management of status epilepticus","volume":"17","author":"Brophy","year":"2012","journal-title":"Neurocrit. Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"775","DOI":"10.2106\/00004623-200205000-00012","article-title":"Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk","volume":"84","author":"Weber","year":"2002","journal-title":"J. Bone Joint Surg. Am."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1097\/00115550-200005000-00021","article-title":"Complete brachial plexus palsy after total shoulder arthroplasty done with interscalene block anesthesia","volume":"25","author":"Walton","year":"2000","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1213\/00000539-199709000-00028","article-title":"Idiopathic brachial plexitis after total shoulder replacement with interscalene brachial plexus block","volume":"85","author":"Tetzlaff","year":"1997","journal-title":"Anesth. Analg."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1016\/j.jclinane.2004.09.012","article-title":"Cerebral ischemia during shoulder surgery in the upright position: A case series","volume":"17","author":"Pohl","year":"2005","journal-title":"J. Clin. Anesth."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1301","DOI":"10.1213\/ANE.0b013e31823aca46","article-title":"Focal cerebral ischemia after surgery in the \u201cbeach chair\u201d position: The role of a congenital variation of circle of Willis anatomy","volume":"114","author":"Drummond","year":"2012","journal-title":"Anesth. Analg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1016\/j.jstrokecerebrovasdis.2012.12.017","article-title":"Postoperative brain stroke after shoulder arthroscopy in the lateral decubitus position","volume":"23","author":"Zeidan","year":"2014","journal-title":"J. Stroke Cerebrovasc. Dis. Off. J. Natl. Stroke Assoc."},{"key":"ref_46","first-page":"1434","article-title":"False-negative diffusion-weighted MR findings in acute ischemic stroke","volume":"21","author":"Oppenheim","year":"2000","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1212\/CPJ.0b013e318296f288","article-title":"Stroke syndromes associated with DWI-negative MRI include ataxic hemiparesis and isolated internuclear ophthalmoplegia","volume":"3","author":"Watts","year":"2013","journal-title":"Neurol. Clin. Pract."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1212\/WNL.0000000000004120","article-title":"Diagnosis of DWI-negative acute ischemic stroke: A meta-analysis","volume":"89","author":"Edlow","year":"2017","journal-title":"Neurology"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"8910","DOI":"10.1038\/srep08910","article-title":"A retrospective analysis of negative diffusion-weighted image results in patients with acute cerebral infarction","volume":"5","author":"Zuo","year":"2015","journal-title":"Sci. Rep."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1179\/174313208X340969","article-title":"Rate of arterial occlusion in patients with acute ischemic stroke","volume":"30","author":"Zubkov","year":"2008","journal-title":"Neurol. Res."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"2323","DOI":"10.1161\/STROKEAHA.118.022253","article-title":"Large Vessel Occlusion in Acute Stroke","volume":"49","author":"Beume","year":"2018","journal-title":"Stroke"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1159\/000090791","article-title":"Is hypoperfusion an important cause of strokes? If so, how?","volume":"21","author":"Caplan","year":"2006","journal-title":"Cerebrovasc. Dis."},{"key":"ref_53","first-page":"321","article-title":"Regional anesthesia and local anesthetic-induced systemic toxicity: Seizure frequency and accompanying cardiovascular changes","volume":"81","author":"Brown","year":"1995","journal-title":"Anesth. Analg."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.ijoa.2004.04.008","article-title":"Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: A retrospective analysis of 19,259 deliveries","volume":"13","author":"Pan","year":"2004","journal-title":"Int. J. Obstet. Anesth."},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Alsukhni, R.A., Ghoubari, M.S., Farfouti, M.T., and Aboras, Y.A. (2016). Status epilepticus following local anesthesia in a previously healthy adult. BMC Res. Notes, 9.","DOI":"10.1186\/s13104-016-2100-9"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1017\/S0265021502000911","article-title":"Lidocaine-induced cell death in a human model of neuronal apoptosis","volume":"19","author":"Friederich","year":"2002","journal-title":"Eur. J. Anaesthesiol."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1097\/AAP.0b013e3181d2310b","article-title":"Clinical presentation of local anesthetic systemic toxicity: A review of published cases, 1979 to 2009","volume":"35","author":"Neal","year":"2010","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"10","DOI":"10.2344\/0003-3006(2006)53[98:EOLAP]2.0.CO;2","article-title":"Essentials of local anesthetic pharmacology","volume":"53","author":"Becker","year":"2006","journal-title":"Anesth. Prog."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1093\/bja\/76.2.300","article-title":"Ropivacaine","volume":"76","author":"McClure","year":"1996","journal-title":"Br. J. Anaesth."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1184","DOI":"10.1097\/00000542-200411000-00019","article-title":"Mitochondrial injury and caspase activation by the local anesthetic lidocaine","volume":"101","author":"Johnson","year":"2004","journal-title":"Anesthesiology"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"1788","DOI":"10.1080\/21691401.2019.1594858","article-title":"The role of DRP1 in ropivacaine-induced mitochondrial dysfunction and neurotoxicity","volume":"47","author":"Chen","year":"2019","journal-title":"Artif. Cells Nanomed. Biotechnol."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1093\/bja\/aep236","article-title":"Apoptosis induction by different local anaesthetics in a neuroblastoma cell line","volume":"103","author":"Werdehausen","year":"2009","journal-title":"Br. J. Anaesth."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1213\/ane.0b013e31819385e1","article-title":"Cytotoxicity of local anesthetics in human neuronal cells","volume":"108","author":"Patel","year":"2009","journal-title":"Anesth. Analg."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"1537","DOI":"10.1097\/00000542-200012000-00031","article-title":"Transient neurologic symptom (TNS) following intrathecal ropivacaine","volume":"93","author":"Ganapathy","year":"2000","journal-title":"Anesthesiology"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"784","DOI":"10.1093\/bja\/87.5.784","article-title":"Grand mal convulsion and plasma concentrations after intravascular injection of ropivacaine for axillary brachial plexus blockade","volume":"87","author":"Litz","year":"2001","journal-title":"Br. J. Anaesth."},{"key":"ref_66","first-page":"133","article-title":"Ropivacaine induced acute neurotoxicity after epidural injection","volume":"11","author":"Anastasi","year":"2007","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1097\/00000542-198811000-00030","article-title":"Cerebral and hemodynamic effects of lidocaine accidentally injected into the carotid arteries of patients having carotid endarterectomy","volume":"69","author":"Perkins","year":"1988","journal-title":"Anesthesiology"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1038\/209207a0","article-title":"Blocking of cortical inhibitory synapses by intravenous lidocaine","volume":"209","author":"Tanaka","year":"1966","journal-title":"Nature"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/5\/1013\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:31:28Z","timestamp":1760160688000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/5\/1013"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,2]]},"references-count":68,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2021,3]]}},"alternative-id":["jcm10051013"],"URL":"https:\/\/doi.org\/10.3390\/jcm10051013","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,2]]}}}