- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA
- Ghaly Neurosurgical Associates, Aurora, IL 60504, USA
Ramsis F. Ghaly
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA
DOI:10.4103/2152-7806.65055© 2010 Ghaly RF. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Ghaly RF, Candido KD, Knezevic NN. Perioperative fatal embolic cerebrovascular accident after radical prostatectomy. Surg Neurol Int 1-Jul-2010;1:26
How to cite this URL: Ghaly RF, Candido KD, Knezevic NN. Perioperative fatal embolic cerebrovascular accident after radical prostatectomy. Surg Neurol Int 1-Jul-2010;1:26. Available from: http://sni.wpengine.com/surgicalint_articles/perioperative-fatal-embolic-cerebrovascular-accident-after-radical-prostatectomy/
Background:There is little written about the management of perioperative cerebrovascular accident (CVA). To the best of our knowledge, the present case report represents the first case in the literature of a well-documented intraoperative embolic CVA and perioperative mortality in a relatively healthy, young patient with no contributing comorbidity and no noteworthy intraoperative event.
Case Description:A 53-year-old man presented for radical prostatectomy under general anesthesia. The anesthetic course and procedure were uneventful. In the postanesthesia care unit (PACU), the patient was moving all extremities but was still sedated. One hour later, he developed left hemiplegia, facial dropping, slurred speech and his head was turned to the right. The next day his mental status deteriorated, and on an emergency basis he was intubated. A CT scan of the head showed a malignant hemispheric right cerebrovascular accident with leftward midline shift. Even aggressive treatment, including a right decompressive hemicraniectomy, could not lower the high intracranial pressure, and the patient expired on the third postoperative day.
Conclusion:Guidelines for identifying and treating perioperative hemispheric CVA are urgently needed, with modification of the antiquated and useless criterion of “patient seen neurologically normal at induction time” to more useful objective criteria including “intraoperative neurophysiological recording change, gross extremity movements, facial dropping, follows simple commands” while excluding a drug-induced, sedative-influenced globally-impaired cognitive state that may last for hours.
Keywords: Cerebrovascular accident, fatal, perioperative, radical prostatectomy
Cerebrovascular accidents (CVAs) are the second leading cause of death worldwide. It is estimated that more than 600,000 Americans are newly diagnosed yearly with stroke; one every 53 seconds, with one dying every 3.3 minutes.[
Prostate cancer is the most commonly diagnosed cancer in males.[
There is little written about the management of perioperative CVA. To the best of our knowledge, the present case report represents the first case in the literature of a well-documented intraoperative embolic CVA and perioperative mortality in a relatively healthy, young patient with no contributing comorbidity and no noteworthy intraoperative event.
A 53-year-old man, American Society of Anesthesiologists (ASA) physical status class II, presented for radical prostatectomy for prostatic adenocarcinoma without signs of metastasis. Past medical history included the following: diet-controlled diabetes, benign hypertension, well-controlled hypercholesterolemia, history of hepatitis and cholecystitis. Induction of anesthesia was achieved using fentanyl 2 mcg/kg, propofol 3 mg/kg and succinylcholine 2 mg/kg, followed by tracheal intubation. Anesthesia was maintained using sevoflurane 1 monitored anesthesia care (MAC) with controlled ventilation. Baseline blood pressure was 124/70 mm Hg, and systolic pressure was maintained at 100 mm Hg throughout the course of surgery. Radical retropubic prostatectomy and pelvic lymphadenectomy were performed. Frozen sections revealed no malignancy in the lymph nodes. Estimated blood loss was 500 mL and no transfusion was required. The patient was extubated in satisfactory condition while still in the operating room.
In the postoperative care unit (PACU), the patient could converse normally and was moving all extremities but was still mildly sedated. One hour later, he was found to have a left hemiplegia, facial dropping, slurred speech and his head was turned to the right. Pupils were equal and reactive. He was unable to stick his tongue out but was able to state that he was in a hospital. The patient had normal strength in the right arm and right leg. Neurology consultation recommended “no definitive therapy” because more than 8 hours had elapsed from the induction time, wherein the patient was found to be neurologically intact. Contributory factors for stroke were not present, which included obesity, smoking, family history of stroke, history of stroke or transient ischemic episodes (TIEs), intracranial cerebrovascular disease, noncontrolled hypertension, extracranial carotid stenosis, ulcerative atherosclerotic plaques, noncontrolled hyperlipidemia, peripheral vascular diseases, noncontrolled diabetes mellitus, sickle cell disease, cardiac causes (e.g., atrial fibrillation, myocardial infarction, atrial myoma, ventricular aneurysm, prosthetic heart valve, heart failure, coronary artery disease), hypercoagulable state (protein S and C deficiency, Factor V deficiency, antithrombin III, lupus anticoagulant, antiphospholipid antibody, anticardiolipin, homocysteinurea).[
Serial CT scans of the head were performed, which showed a right-sided cerebral infarction without mass effect [
At autopsy, the brain demonstrated non-hemorrhagic thromboembolic cerebrovascular disease and an acute infarct in the territory of the right middle cerebral artery (MCA) [
a) Autopsy brain section demonstrates extensive right temporal lobe softening caused by acute infarction; b) pathohistological slide (hematoxylin and eosin staining) showing necrosis, inflammation, neuronal loss due to severe ischemia; c) pathohistological slide (hematoxylin and eosin staining) showing blood vessel with fibrin thrombus
One of the serious risks of prostatectomy is deep venous thrombosis (DVT), with an incidence rate ranging from 1% to 4%, with pulmonary embolism noted in 0.5% of cases.[
The patient expired on postoperative day 3 despite hemispheric decompressive hemicraniectomy. Massive hemispheric cerebral infarct usually progresses to “malignant brain swelling” after a sudden interruption of the entire MCA territory, with a mortality rate of 80% in the first 3 to 5 days post ictus.[
The time for identifying a CVA is essential to begin effective anticoagulant therapy; for intravenous tissue plasminogen activator (tPA), this time limit is 3 hours; for other “stroke-rescue” procedures such as intra-arterial tPA and embolus retrieval mechanically, this time limit is 6 to 8 hours.[
An obvious limitation is to identify the last time that the patient was “neurologically normal.” If a CVA occurred while asleep or under anesthesia, then the clock starts when the patient went to sleep. For a perioperative CVA, this time is represented by the time of induction of anesthesia. Perioperative CVA therapy was withheld in this patient due to the assumption that the patient presented as neurologically “normal” at induction time, and 8 hours had already elapsed at extubation, despite the fact that in the PACU, on admission the patient was moving all extremities. The current recommendation for stroke-rescue procedures to be done beyond the 8-hour window is considered as investigatory only.[
General anesthesia is typically recommended for radical prostatectomy; however, regional block may have the advantage of promoting blood flow to the extremities, preventing venous stasis by enhancing blood rheology, which will not affect mental status during neurological examination. Nonetheless, the inability to assess lower extremity motor function following the regional block may be troubling; and if spinal subarachnoid blockade is performed, this may expedite the process of brain herniation in susceptible patients.
Guidelines for identifying and treating perioperative hemispheric CVA are urgently needed, with modification of the antiquated and useless criterion of “patient seen neurologically normal at induction time,” to more useful objective criteria including “intraoperative neurophysiological recording change, gross extremity movements, facial dropping, follows simple commands” while excluding a drug-induced, sedative-influenced globally-impaired cognitive state that may last for hours.
We would like to thank Drs. Jamie A. Jackobsohn and Sangeeta Mehend, Department of Pathology, Advocate Illinois Masonic Medical Center, Chicago, IL, for autopsy pictures.
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