Correspondence
J Neurosurg Anesthesiol
Volume 27, Number 1, January 2015
FIGURE 1. Multiparameter monitor showing prolonged apnea and bradycardia during resection of hippocampus.
3. Ryvlin P, Nashef L, Lhatoo SD, et al. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. Lancet Neurol. 2013;12:966–977. 4. Pavlova M, Singh K, Abdennadher M, et al. Comparison of cardiorespiratory and EEG abnormalities with seizures in adults and children. Epilepsy Behav. 2013;29:537–541. 5. Sinha PK, Neema PK, Manikandan S, et al. Bradycardia and sinus arrest following saline irrigation of the brain during epilepsy surgery. J Neurosurg Anesthesiol. 2004;16: 160–163.
Central Cord Syndrome: A Rare Neurological Complication Following Hypotension During General Anesthesia in an Elderly Patient To JNA Readers: We present the case of a 90year-old woman with a body mass Departmental funding was received for this article. The author has no conflicts of interest to disclose.
76 | www.jnsa.com
index of 26.4 kg/m2, with motor impairment of upper extremities and sparing of lower extremities, characteristic of central cord syndrome following a 10-hour pancreaticoduodenectomy.1 The few reported cases have been attributed to hyperextension of the neck.2–4 Our study follows hypotension during surgery. The patient had no prior signs and symptoms of cervical spondylosis. She underwent anesthesia and intubation with minimum head extension. An internal jugular central line was inserted within 15 minutes, with the head rotated 30 degrees to the left without extension and table tilted 20 degrees head down. Otherwise, the patient remained supine, arms abducted at 85 mm Hg was maintained with a phenylephrine infusion; imaging studies revealed severe multilevel spondylotic changes with anterior and posterior cord compression at C3-C4, C4-C5, and C5-C6 levels (Fig. 1). Within 6 hours, motor function of the hands and forearms returned, followed by the shoulder girdle, and within 24 hours became normal. Neither dexamethasone nor methylprednisolone were administered. Chronically compressed cervical cord appears to be susceptible to injury r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 27, Number 1, January 2015
Correspondence
EEG as a Surrogate to Brain Imaging for Diagnosing Stroke in Morbidly Obese Patients
FIGURE 1. Magnetic resonance image of the cervical spinal cord showing severe multilevel spondylotic changes with anterior and posterior cord compression at C3C4, C4-C5, and C5-C6 levels.
from either dynamic compression from hyperextension or from relative hypotension. The potential importance of perfusion pressure was clearly demonstrated in a dog model of hemorrhagic hypotension in which animals with chronic but asymptomatic cervical cord compression showed signs of cord dysfunction with systemic arterial pressures of 20 to 25 mm Hg, which were greater when compared with dogs without cord compression.5 Our patient experienced minimal or no hyperextension of the neck. In the setting of severe multilevel cervical stenosis, we hypothesize that the sustained 15minute hypotension experienced by our patient was sufficient to result in temporary cord dysfunction manifested as central cord syndrome. Restoration of MAP to preoperative minimum values was associated with rapid and total recovery of cord function. This reversibility suggests perfusion, rather than head/neck hyperextension, was the most critical factor in our patient. In the elderly, r
2014 Lippincott Williams & Wilkins
wherein asymptomatic cervical spondylosis is common, MAP should be maintained at normal or above to prevent neurological sequelae. Kokila Thenuwara, MBBS, MD, MME Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA
REFERENCES 1. Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg. 1954;11:546–577. 2. Buchowski JM, Kebaish KM, Suk KS, et al. Central cord syndrome after total hip arthroplasty: a patient report. Spine (Phila Pa 1976). 2005;30:E103–E105. 3. Watanabe T, Takizawa D, Sato T, et al. A case of central cord syndrome following thyroidectomy. J Clin Anesth. 2010;22:307–309. 4. Yan K, Diggan MF. A case of central cord syndrome caused by intubation: a case report. J Spinal Cord Med. 1997;20: 230–232. 5. Hukuda S, Wilson CB. Experimental cervical myelopathy: effects of compression and ischemia on the canine cervical cord. J Neurosurg. 1972;37:631–652.
To JNA Readers: A 42-year-old morbidly obese male patient weighing 750 pounds presented with right-sided heart failure, pulmonary hypertension, and acute exacerbation of chronic renal failure. What followed was a long and complex admission. After 1 month, the patient was intubated for acute dyspnea, tachypnea, and investigations demonstrated biventricular failure and coliform (Escherichia coli) bacteremia. He remained comatose for the next 4 weeks at which time the neurocritical care service was consulted. On initial examination, all brainstem reflexes remained intact, but there was an absence of blink to visual threat on the right side and spontaneous movements were noted on the left side only. No right-sided movements could be elicited even with noxious stimulation. In the right lower extremity, there was a triple flexion response to plantar stimulation in addition to an extensor plantar response. Deep tendon reflexes were difficult to elicit due to a combination of body habitus and severe peripheral edema. The differential diagnosis included a left middle cerebral artery territory stroke or a hypoxic ischemic encephalopathy. An electroencephalogram was ordered because the patient’s body habitus precluded neuroimaging. Because of morbid obesity, the patient was unable to undergo either CT or MRI because his body weight and diameter exceeded those allowable. In this situation, we used electroencephalography (EEG) as a diagnostic tool. We performed 2-interval EEGs on this patient and both of them showed similar findings (Fig. 1). The EEG demonstrated an asymmetry between the hemispheres with sigThe authors have no funding or conflicts of interest to disclose.
www.jnsa.com |
77
J Neurosurg Anesthesiol
Volume 27, Number 1, January 2015
FIGURE 1. Multiparameter monitor showing prolonged apnea and bradycardia during resection of hippocampus.
3. Ryvlin P, Nashef L, Lhatoo SD, et al. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. Lancet Neurol. 2013;12:966–977. 4. Pavlova M, Singh K, Abdennadher M, et al. Comparison of cardiorespiratory and EEG abnormalities with seizures in adults and children. Epilepsy Behav. 2013;29:537–541. 5. Sinha PK, Neema PK, Manikandan S, et al. Bradycardia and sinus arrest following saline irrigation of the brain during epilepsy surgery. J Neurosurg Anesthesiol. 2004;16: 160–163.
Central Cord Syndrome: A Rare Neurological Complication Following Hypotension During General Anesthesia in an Elderly Patient To JNA Readers: We present the case of a 90year-old woman with a body mass Departmental funding was received for this article. The author has no conflicts of interest to disclose.
76 | www.jnsa.com
index of 26.4 kg/m2, with motor impairment of upper extremities and sparing of lower extremities, characteristic of central cord syndrome following a 10-hour pancreaticoduodenectomy.1 The few reported cases have been attributed to hyperextension of the neck.2–4 Our study follows hypotension during surgery. The patient had no prior signs and symptoms of cervical spondylosis. She underwent anesthesia and intubation with minimum head extension. An internal jugular central line was inserted within 15 minutes, with the head rotated 30 degrees to the left without extension and table tilted 20 degrees head down. Otherwise, the patient remained supine, arms abducted at 85 mm Hg was maintained with a phenylephrine infusion; imaging studies revealed severe multilevel spondylotic changes with anterior and posterior cord compression at C3-C4, C4-C5, and C5-C6 levels (Fig. 1). Within 6 hours, motor function of the hands and forearms returned, followed by the shoulder girdle, and within 24 hours became normal. Neither dexamethasone nor methylprednisolone were administered. Chronically compressed cervical cord appears to be susceptible to injury r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 27, Number 1, January 2015
Correspondence
EEG as a Surrogate to Brain Imaging for Diagnosing Stroke in Morbidly Obese Patients
FIGURE 1. Magnetic resonance image of the cervical spinal cord showing severe multilevel spondylotic changes with anterior and posterior cord compression at C3C4, C4-C5, and C5-C6 levels.
from either dynamic compression from hyperextension or from relative hypotension. The potential importance of perfusion pressure was clearly demonstrated in a dog model of hemorrhagic hypotension in which animals with chronic but asymptomatic cervical cord compression showed signs of cord dysfunction with systemic arterial pressures of 20 to 25 mm Hg, which were greater when compared with dogs without cord compression.5 Our patient experienced minimal or no hyperextension of the neck. In the setting of severe multilevel cervical stenosis, we hypothesize that the sustained 15minute hypotension experienced by our patient was sufficient to result in temporary cord dysfunction manifested as central cord syndrome. Restoration of MAP to preoperative minimum values was associated with rapid and total recovery of cord function. This reversibility suggests perfusion, rather than head/neck hyperextension, was the most critical factor in our patient. In the elderly, r
2014 Lippincott Williams & Wilkins
wherein asymptomatic cervical spondylosis is common, MAP should be maintained at normal or above to prevent neurological sequelae. Kokila Thenuwara, MBBS, MD, MME Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA
REFERENCES 1. Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg. 1954;11:546–577. 2. Buchowski JM, Kebaish KM, Suk KS, et al. Central cord syndrome after total hip arthroplasty: a patient report. Spine (Phila Pa 1976). 2005;30:E103–E105. 3. Watanabe T, Takizawa D, Sato T, et al. A case of central cord syndrome following thyroidectomy. J Clin Anesth. 2010;22:307–309. 4. Yan K, Diggan MF. A case of central cord syndrome caused by intubation: a case report. J Spinal Cord Med. 1997;20: 230–232. 5. Hukuda S, Wilson CB. Experimental cervical myelopathy: effects of compression and ischemia on the canine cervical cord. J Neurosurg. 1972;37:631–652.
To JNA Readers: A 42-year-old morbidly obese male patient weighing 750 pounds presented with right-sided heart failure, pulmonary hypertension, and acute exacerbation of chronic renal failure. What followed was a long and complex admission. After 1 month, the patient was intubated for acute dyspnea, tachypnea, and investigations demonstrated biventricular failure and coliform (Escherichia coli) bacteremia. He remained comatose for the next 4 weeks at which time the neurocritical care service was consulted. On initial examination, all brainstem reflexes remained intact, but there was an absence of blink to visual threat on the right side and spontaneous movements were noted on the left side only. No right-sided movements could be elicited even with noxious stimulation. In the right lower extremity, there was a triple flexion response to plantar stimulation in addition to an extensor plantar response. Deep tendon reflexes were difficult to elicit due to a combination of body habitus and severe peripheral edema. The differential diagnosis included a left middle cerebral artery territory stroke or a hypoxic ischemic encephalopathy. An electroencephalogram was ordered because the patient’s body habitus precluded neuroimaging. Because of morbid obesity, the patient was unable to undergo either CT or MRI because his body weight and diameter exceeded those allowable. In this situation, we used electroencephalography (EEG) as a diagnostic tool. We performed 2-interval EEGs on this patient and both of them showed similar findings (Fig. 1). The EEG demonstrated an asymmetry between the hemispheres with sigThe authors have no funding or conflicts of interest to disclose.
www.jnsa.com |
77
![[Pneumocephalus as a rare complication of general anesthesia].](/assets/img/hold.png)
