Case report

A 68 years hypertensive male was posted for TURP surgery. Blood Chemistry was within normal limits.ECG was suggestive of left ventricular hypertrophy (LVH) and 2D ECHO showed concentric LVH with diastolic dysfunction. Chest X-ray was consistent with mild cardiomegaly.USG abdomen showed mildly enlarged liver with medical renal disease, bilateral cortical scarring with small shrunken left kidney. The patient was on antihypertensive medications and his blood pressure was within acceptable limits. Blood pressure at the time of induction was 140/90 mm Hg. All standard monitors (cardioscope, pulse oximeter, sphygmomanometer) were attached. Subarachnoid block was given with 3.4 ml of 0.5%bupivacaine in sitting position with 25 Gauge spinal needle and T₁₀ level was achieved. Glycine1.5% was used as irrigating fluid. All vital parameters were monitored and were within acceptable limits. After 45 min of surgical resection the patient became drowsy and unresponsive to oral commands. His respiration became irregular and there was a rise in blood pressure to 170/90 mm Hg and heart rate of 120/min. TURP syndrome was suspected and the patient was intubated. Surgery was abandon and blood samples for serum electrolytes ammonia and osmolality were sent to laboratory. The patient was shifted to ICU.

Course in intensive care unit

To our surprise all the investigations including Sr.electrolytes, ammonia and osmolality were within normal limits.12 lead ECG was within normal limits and CPK-MB was marginally raised and Troponin-t was negative.

Patient came out of muscle relaxants in ICU and was maintaining saturation on T-piece but Patient was drowsy and not responding to oral commands . Rest all vital parameters were within normal limits.

Supportive treatment consisting of appropriate antibiotics, DVT prophylaxis,antihypertensives,analgesics sedatives water bed, chest physiotherapy were provided.

Figure 1

Table showing course of the patient in I C U

Figure 2

Discussion

Cerebrovascular accidents in patients with meningioma who are hypertensive can occur during stressful conditions like surgery and anesthesia . So the occurrence of such an event during TURP where altered sensorium can be attributed to electrolyte abnormalities require a high degree of suspicion.

A standard search of literature could not reveal occurrence of cerebrovascular accident in TURP which was associated with a post clinoid meningioma.

Subarachnoid block(SAB) is a widely accepted anesthetic choice for TURP surgeries because it has advantages like early recognition of TURP syndrome, bladder perforation and decreased blood loss intraoperatively. Except for hypertension and LVH on ECHO our patient did not have any positive finding. Use of a subarachnoid block in such a case is justified. If the diagnosis of postclinoid meningioma was already done we would have not given SAB to the patient. Although central neuroaxial blockade is considered relatively safe procedure certain complications like seizures, transient neurological deficit and radiculopathy and myelopathy [₁₇₂₃] can occur. Diagnosis of a brain tumour after spinal anaesthesia is rare[₇]Few case reports mention pituitary tumors due to apoplexy or necrosis[₄₁₂] and pineal tumor[₆]. A case report of incidental finding of meningioma after spinal anaesthsia has been reported[₁₄].Case reports of intracranial meningioma presenting after general anaesthesia are also reported.These patients were either asymptomatic or so subtly symptomatic that no suspicion of intracranial tumor had been entertained preoperatively .Each patient presented with failure to wake up after routine general anesthesia for a nonneurosurgical procedure[₈₁₆].

TURP syndrome itself can lead to confusional state,unresponsiveness[₁₁] and it is difficult to pin point the exact cause of this neurological states in patients presenting with CVA intraoperatively.Sometimes Sr sodium level may not be the only cause of CNS signs in TURP[₁₃]. A case of intraoperative CVA during laminectomy is reported in which decreased cerebral perfusion resulted due to raised jugular venous pressure as a result of prone position [₉].Hypotension may be one of the reasons for intraoperative strokes in patients who are given bolus doses of local anaesthetic epidurally during surgery or as a part of post operative pain relief [₅].Rarely cerebral air embolism can occur due to right to left shunt if prostatic venous sinuses are open and are above the level of heart.

If cerebral embolisation is suspected then early diagnosis is both essential and feasible as the mortality associated with infarction of more than 50% of the middle cerebral artery territory is 85%[₁₅]. C.T. scanning within 5 hrs of symptoms can demonstrate changes in 70-80% patients presenting with acute hemispheric strokes[₁₅].Use of newer modalities of investigations like bispectral index may prove to be the earliest indicator of acute perioperative stroke[₁₀].Recent modalities like transcranial Doppler may diagnose CVA early and help in deciding the treatment modalities[₁].

To conclude, better results in the management of patients with intraoperative stroke requires high degree of suspicion early recognition and prompt treatment. Even careful physical examinations and investigations preoperatively does not necessary mean uneventful intraoperative course. Early neurological evaluation and CT Scan is adviced in such cases.Use of newer monitoring equipments like bispectral index and transcranial Doppler may prove beneficial in early detection of intraoperative stroke.

Acknowledgement