Syringomyelia discovered in the course of peridural anesthesia

Neurological symptoms after epidural anaesthesia suggest complications due to anaesthetic procedure. We report the case of a child who underwent perineal surgery in a gynaecological position under general and epidural anaesthesia, who experienced the day after surgery hypoesthesia of the whole left lower limb without any motor deficit. Magnetic resonance imaging excluded spinal compression, but revealed syringomyelic cavity extending from T9 to T11. Electromyogram evaluation was normal. Clinical signs completely vanished within 24 hours. This case emphasizes that the apparition of neurological signs after central nerve blocks is not only a complication of regional anaesthesia, but may reveal unknown neuropathy or result from surgical position or surgical procedure. Meticulous neurological examination, magnetic resonance imaging and electromyogram are immediately required.     

The prolonged Q-T syndrome presenting as a focal neurological lesion

A patient with a prolonged electrocardiographic Q-T interval suddenly developed left hemiplegia after an episode of ventricular fibrillation. A CT scan showed a cerebral infarction in the right internal capsule. The prolonged Q-T interval, by virtue of its association with cardiac arrhythmias, may cause cerebral hypoperfusion that commonly results in generalized neurological deficits. The lack of evidence for embolization in this patient suggests that decreased cerebral perfusion was responsible for the genesis of her neurological signs and symptoms. The prolonged Q-T interval is an easily overlooked cardiac abnormality that must be considered in a patient who exhibits a focal neurological deficit.     

Endogenous Aspergillus Endophthalmitis Occurring After Liver Transplantation: A Case Report

Endogenous Aspergillus endophthalmitis (AE) is a rare complication of invasive aspergillosis in transplant patients. In this report, we have described a patient who underwent liver transplantation because of drug-induced cholestatic cirrhosis and developed AE at 2 weeks after the surgery. The patient was a 22-year-old man who received a right liver lobe from his father. The operation was uneventful but the patient developed signs and symptoms of small-for-size syndrome after the second day of surgery. The patient received intense immunosuppression with methylprednisolone for 3 days, tacrolimus and mycophenolate mofetil from the first day after the operation, with ceftriaxone and metronidazole as prophylactic antibiotics. Because of signs of respiratory distress with pneumonia, vancomycin and amphotericin B were added empirically to his regimen. Polymerase chain reaction for aspergillus DNA in the blood was positive. The patient received one course of methylprednisolone pulse therapy for signs of acute rejection at day 10, and tacrolimus was changed to sirolimus because of a rising serum creatinine and convulsions. After 2 weeks, the patient's symptoms improved and liver function tests were normal, but the complained of sudden intense pain in the left eye with unilateral blurred vision, redness, and other signs of endophthalmitis upon examination by an ophthalmologists. After 24 hours, visual acuity decreased to light perception. AE was confirmed by microscopy and culture of the vitreous fluid and retinal biopsy. Despite changing amphotericin to intravitreal injection of voriconazole followed by intravenous voriconazole and transient resolution of the symptoms, no improvement was seen in visual acuity. Pain and signs of inflammation in the eye recurred after 2 weeks. At last the patient underwent enucleation for resistant infection and fear of involvement of the other eye by aspergillosis or sympathetic ophthalmia.     

Isolated cerebral vasculitis associated with rheumatoid arthritis

Central nervous system involvement in rheumatoid arthritis is infrequent. Inflammatory lesions described in the literature are limited to rheumatoid nodules and vasculitis. We report on a 71-year-old woman who presented with a 1-month history of headache and dysarthria, and who had suffered seropositive rheumatoid arthritis without extra-articular complications, for 15 years. Magnetic resonance imaging showed a high-intensity image in FLAIR-weighted sequences in the right cerebral hemisphere, with meningeal gadolinium enhancement. A brain biopsy revealed necrotizing and lymphocytic vasculitis in the meninges as well as cerebral parenchyma. The patient received treatment with high-dose intravenous methylprednisolone with radiological improvement at 6-month follow-up. She remained neurologically asymptomatic in subsequent years. Three years after the onset of neurological symptoms, she was admitted to the hospital with choluria and jaundice. On the fiftieth day of hospitalization, she died from bronchopneumonia. The autopsy showed no signs of vasculitis. Cerebral vasculitis is an infrequent complication in RA. High-doses of intravenous corticosteroids may be an effective treatment.     

Mitral valve prosthetic endocarditis: development of left ventricular-coronary sinus fistula following replacement

We report the history and course of a patient in whom a left ventricular-coronary sinus fistula developed following mitral valve replacement due to prosthetic endocarditis. Six months after the intervention the patient suddenly presented with deterioration of her symptoms, holosystolic murmur and signs of congestive heart failure. Transesophageal echocardiography showed a left-to-right shunt but did not show its exact location. At surgery, exploration of the right atrium revealed a left ventricular-coronary sinus communication due to discontinuation of the left ventricular free wall next to the coronary sinus; repair of the defect was successfully performed by direct suture. The postoperative course was uneventful and the patient recovered quickly. This case is reported to stress that debridement of the mitral annulus and removal of an old prosthesis must be very carefully performed and to facilitate the diagnosis of this rate but severe complication of repeated mitral valve replacement.     

Epidural hematoma caused after epidural catheterization for the coronary artery bypass graft: a case report

Epidural hematoma is a rare complication of epidural anesthesia, but once this severe complication has occurred, without early decompressive procedure, it may cause permanent neurologic disorder. Especially, the patients with hemostatic disorder have a higher risk of epidural hematomas. We report a patient who recovered immediately from neurological symptoms resulting from epidural hematoma formed by epidural catheterization on the day before coronary artery bypass. Epidural hematoma as a complication of epidural anesthesia is discussed.     

Thoracic vertebral body fracture after total hip replacement in diffuse idiopathic skeletal hyperostosis

This article describes the critical clinical sequelae of a patient with diffuse idiopathic skeletal hyperostosis who sustained an acute iatrogenic thoracic vertebral body fracture with subsequent spinal cord injury after a total hip replacement, with a final lethal course.A 57-year-old woman was referred to the authors' institution after undergoing a total hip replacement in the supine position for secondary osteoarthritis. Postoperatively, the patient had symptoms of an incomplete paraplegia. Computed tomography scan and magnetic resonance imaging revealed diffuse idiopathic skeletal hyperostosis and an acute unstable fracture of T11 with spinal contusion. A posterior spinal fusion of T10-L1 with laminectomy of T11 was performed immediately on admission. Postoperatively, no improvement of the neurological deficit was observed. After developing multiorgan failure while in intensive care, the patient died 2 months after the total hip replacement.The morphological and functional symptoms of diffuse idiopathic skeletal hyperostosis with the typical ossification of the longitudinal ligaments and the associated loss of bending forces of the spine were detected postoperatively. This severe case demonstrates that the surgeon must be alert to possible complications due to intraoperative maneuvers in patients with stiffened spinal disorders undergoing total hip replacement.     

Tocolysis with ritodrine worsens cerebral oedema in a patient with brain injury

In a 33-weeks pregnant patient with a head injury, neurological status severely deteriorated after introduction of tocolytic treatment with ritodrine. On admission to the intensive care unit she scored 10 points on the Glasgow coma scale. She gradually recovered and on day 7 there was no neurological deficit, apart from slight confusion. The same day tocolytic treatment with ritodrine was recommended because of imminent premature labour. Fourteen hours after ritodrine infusion was started, the neurological status deteriorated severely. Urgent CT scan showed signs of transtentorial herniation. Ritodrine infusion was stopped and therapy for brain oedema was introduced. The patient made a good neurological recovery. A caesarean section was performed on day 11, because of placenta praevia, and a healthy girl was delivered. The patient was discharged without neurological sequelae. The clinical course and CT findings imply that tocolytic treatment with ritodrine can worsen brain oedema in a patient with a disrupted blood-brain barrier, as in head injury. The mechanism is probably analogous to the one by which ritodrine causes pulmonary oedema, a well-known complication.     

Acute motor-sensory axonal neuropathy after cervical spine surgery

The authors report the case of a 55-year-old man who presented with acute motor-sensory axonal neuropathy (AMSAN), a variant of Guillain-Barré syndrome with a poor prognosis, immediately after surgery for resection of a cervical chondroma. A misdiagnosis of spinal cord shock due to an acute surgical or vascular postoperative complication was initially made in this patient. Nevertheless, there was continuous transient improvement that was followed by progressive worsening, and further investigation was necessary. The diagnosis of AMSAN, associated with acute colitis caused by Helicobacter pylori, was made based on neurophysiological examinations and colonoscopy. Interestingly, the patient also developed nephrotic syndrome, which was thought to be a further complication of the autoimmune reaction. Delayed administration of immunoglobulins (400 mg/kg/day), mesalazine (800 mg 3×/day), and meropenem (3 g/day) was used to treat the Helicobacter infection and the autoimmune reaction, leading to restoration of renal function and slight neurological improvement. The patient's general condition and neurological status improved slightly, but he remained seriously disabled (Frankel Grade C). This case demonstrates that a new onset of neurological symptoms in the early postoperative period after spine surgery could be related to causes other than iatrogenic myelopathy, and that an early diagnosis can reduce neurological sequelae, leading to a better outcome.     

Catheter-related epidural abscesses -- don't wait for neurological deficits

Epidural abscess is a rare but serious complication of epidural anesthesia for peri- and postoperative analgesia. It is feared because of possible persistent neurological deficits. Epidural abscess presents mostly with a classic triad of symptoms: back pain, fever and variable neurological signs and symptoms. When neurologic signs or symptoms develop, MRI scanning is the diagnostic procedure of choice. The therapy of choice is intravenous antibiotics for more than 4 weeks with or without a laminectomy or drainage. In the present paper we describe three patients with epidural abscesses presented during a time period of 1 year in our hospital. In each case, patients developed local signs of infection and systemic signs, but no neurological symptoms. Based on these cases and a review of the literature, we propose that MRI scanning should be strongly considered when patients present with systemic and local signs, even in the absence of neurological deficits.     

Neuraxial hematoma after combined regional anesthesia: conservative resolution

Epidural hematoma is a rare but serious neurological complication of neuraxial anesthesia. We report the case of a woman in whom this complication presented after knee replacement surgery under combined neuraxial anesthesia. No adverse events occurred during surgery. In the early postoperative period thromboembolic prophylaxis and continuous perfusion of ropivacaine were started through the epidural catheter. Lumbar pain along with sensorimotor alterations in the lower limbs developed on the first day after surgery. Epidural hematoma was suspected and the perfusion of local anesthetic was suspended. A computed tomography scan confirmed the presence of a hematoma with poorly defined margins. The patient was transferred to another hospital for dorsolumbar magnetic resonance, which revealed an extensive hematoma. Surgery was ruled out in favor of conservative treatment. Neurological symptoms resolved slowly over the following days and the patient was discharged partially recovered 51 days after surgery and recovery was complete within 6 postoperative months. We discuss the prevalence, etiology, and treatment of neuraxial hematoma related to local or regional anesthesia.     

Mitral valve re-replacement in a patient with occlusion of the left internal carotid artery

An 83-year-old female patient, who had previously undergone mitral valve replacement using bioprosthesis at 15 years ago, presented symptoms of congestive heart failure. Mitral valve regurgitation was caused by structural deterioration of the bioprosthetic valve, and replacement of the bioprosthesis was indicated. Digital subtraction angiography revealed occlusion of the left internal carotid artery, which put this patient at high risk to cerebral complications during heart valve surgery. Administration of acetazolamide induced a marked decrease in the blood flow in the left cerebral hemisphere. Re-replacement of the mitral valve was successfully performed under high-flow cardiopulmonary bypass. Intra-aortic balloon pumping produced pulsatile blood flow with a peak pressure of 90-100 mmHg during the cardiopulmonary bypass. She recovered after surgery with no neurological complication. We believe the pulsatile cerebral perfusion produced by the intra-aortic balloon pumping with high-flow cardiopulmonary bypass was effective for preventing cerebral complications in this patient with internal carotid artery occlusion.     

Invasion of the cavernous sinus by medial sphenoid meningioma —“Radical” surgery and recurrence

Summary We have reviewed the cases of 57 patients with medial sphenoid meningioma who were operated on in our department during the period 1976 to 1988. The patients were grouped according to location, and their pertinent clinical features are presented. Given the frequency of invasion of the cavernous sinus by such tumours, the following question must be considered in each individual case: the potential benefit of the most radical surgery possible, to minimize the recurrence rate, must be weighed against the cost to the patient in diminished quality of life of iatrogenic neurological impairment. We currently advocate the following strategy: radical removal of tumour tissue lying within the cavernous sinus is unwarranted for the first operation if it would entail iatrogenic neurological damage. Only if subsequent follow-up reveals either fast growth of this tissue, or neurological signs and symptoms attributable to it, do we then attempt uncompromising radicality at a second operation.     

Intracranial subdural hematoma after unintended durotomy during spine surgery

PURPOSE: To report a case of intracranial subdural hematoma occurring after a spinal dural tear that was made unintentionally during the course of a posterior laminectomy and spinal fusion at the L(5)-S(1) level. The possible physiopathological mechanisms are discussed. Clinical features: On the fourth postoperative day, a 59-yr-old woman displayed persistent headache following unintended durotomy during spine implant revision. Perioperative blood loss was 2840 mL and intravascular replacement was about 3000 mL. She was hydrated with iv fluids and treated with non-steroidal anti-inflammatory drugs. The symptoms improved but persisted. With the aggravation of the headache complicated with unconsciousness and the appearance of focal neurological signs on the eighth day, a computed tomography was obtained and revealed a right subdural hematoma. Following surgical drainage, the patient made an uneventful recovery. CONCLUSION: This case reminds us that subdural hematoma formation can complicate durotomy during spine surgery. Neurological deterioration in the postoperative period should prompt clinicians to rule out the diagnosis and intervene rapidly as appropriate.     

Resolution of spinal epidural haematoma without surgery in a haemophilic infant

Summary. Non-traumatic spinal epidural haematoma is a rare complication of haemophilia. We report a seven-month-old boy who presented with symptomatic spinal epidural haematoma. He was found to have a hemophilia B trait, and after factor IX replacement, his neurological signs were stabilized and follow-up MRI demonstrated rapid resolution of the haematoma. This illustrative case suggests that surgical intervention can be deferred as the first step in treating spinal epidural haematoma in a haemophilic infant.     

Intracranial and spinal meningiomas in patients with breast carcinoma: case reports

Breast carcinoma has a high predisposition to metastasize to the brain parenchyma or spinal epidural space with development of progressive neurological symptoms and signs and frequently death of the patient. We report 8 patients with known breast cancer who developed neurological symptoms attributable to an intracranial meningioma and 1 patient who developed spinal cord dysfunction resulting from a thoracic meningioma. The removal of the meningiomas resulted in return of normal neurological function in all patients. At follow-up, all our patients are alive without evidence of meningioma or breast carcinoma recurrence, except 1 patient who died of a metastatic malignant melanoma. This clinical association requires repeated emphasis because of the potential benefit in management of patients with suspected metastatic disease. We have reviewed and summarized the reported literature and added our 8 cases. The mean age of presentation before the second tumor was 6 years. Breast carcinoma was diagnosed first in 85% of cases. The clinical symptoms of the meningiomas were focal neurological signs in 50% of the patients, raised intracranial pressure in 40%, and a seizure in 10%.     

Use of Bovine Pericardium and Sutureless Biological Glue in Left Ventricular Rupture After Mitral Valve Replacement,Five Years of Follow-up

Rupture of the left ventricular wall after mitral valve replacement is an infrequent but lethal complication. Reporting correction technique of ventricular rupture with bovine pericardium patch secured with glue and without suturing: a 51 years-old female patient, with double rheumatic mitral lesion, severe stenosis and discrete insufficiency, who had a mitral valve replacement. During surgery, the patient presented a ventricular rupture of the posterior wall (atrioventricular disruption), which was successfully repaired using bovine pericardium with sutureless biological glue over the epicardium of the damaged area. Sixty months after surgery the patient has no symptoms.     

TEE probe via endoscopy mask: the right thing at the wrong time?

New neurological deficit after spinal surgery is a rare complication that requires a quick diagnostic and therapeutic approach to reduce the risk of permanent neurological disabilities. We report a patient who presented with transient neurologic deficit after surgery for lumbar disk herniation resulting from bupivacaine diffusion to either the epidural or the subarachnoid space occurring after the anesthetic infiltration of the surgical wound. Early magnetic resonance imaging excluded more serious causes of such neurological deterioration after lumbar laminectomy. This complication should be considered by the anesthesiologist in the differential diagnosis of neurological deficits after operations on the lumbar spine. IMPLICATIONS: We report a patient who presented in the recovery room with a transient neurologic deficit likely resulting from surgical injection of local anesthetic after lumbar laminectomy. This uncommon complication should be considered in the differential diagnosis of postoperative neurological deficits. Early magnetic resonance imaging excluded more serious causes of this complication.     

Primary posttransplant lymphoproliferative disorder of the gallbladder in a lung transplant patient presenting with acute cholecystitis

BACKGROUND: Acute cholecystitis in an immunocompromised host is potentially devastating. Posttransplant lymphoproliferative disorder (PTLD) is a well described complication of immunosuppressive therapy used after solid organ transplantation; however, isolated involvement of the gallbladder has not been described. METHODS: Case report format is used. RESULTS: We report a case of PTLD isolated to the gallbladder, as well as histological evidence of acute cholecystitis, in a patient who presented with signs and symptoms of acute cholecystitis 1 year after single lung transplant. CONCLUSIONS: PTLD can occur in the setting of acute cholecystitis and may be missed if careful pathological examination is not undertaken.     

Brainstem anesthesia presenting as contralateral third nerve palsy following peribulbar anesthesia for cataract surgery

Brainstem anesthesia is a serious complication that has been reported to occur more commonly with retrobulbar anesthesia compared to peribulbar anesthesia. We herein report a case of contralateral third nerve palsy following administration of peribulbar anesthesia for cataract surgery. Two hours after the surgery, the patient recovered completely without any residual neurological deficit. The importance of immediate recognition of clinical signs and symptoms of central spread of the local anesthetic and the mechanical factors of the block that could have contributed to this complication are discussed in this report.