2023 FSA Podium and Poster Abstracts

P038: NEUROLOGICAL SEQUELAE AFTER ELECTIVE THORACIC PSEUDOANEURYSM REPAIR
Mariah Gosling, MD; Alan Tran, MD; Arnaldo Vera-Arroyo, MD; University of Miami

Introduction: Although considered a high-risk procedure and a reported incidence of up to 10%[1], perioperative stroke in elective thoracic surgery is a fairly uncommon phenomenon. Likewise, the data on intraoperative seizures is limited likely due to the innate nature of the difficulty in detection. The reemergence of previous stroke-related deficits or transient worsening of poststroke neurologic deficits also known as poststroke recrudescence (PSR) has been associated with the use of sedative medications and anesthetic agents [4]. Hypotension, a common intraoperative finding is also an established trigger of PSR [4]. Recognizing perioperative stroke in the surgical ICU can be challenging due to delayed recognition from prolonged anesthetic effects. Post-operative neurological deficits are commonly attributed to stroke however seizure with postictal paralysis and ischemic stroke recrudescence should be considered. Nonetheless, it is important to recognize perioperative stroke and optimize management as this diagnosis carries an eight-fold higher mortality compared with those without perioperative stroke [2].

Case presentation: 62-year-old-male with HTN, migraines, DM, s/p CABG (x3 vessels) was found to have an incidental CT-A finding of 6 x 4.5 x 4.6 cm pseudoaneurysm at the ascending aorta. He underwent a scheduled, elective repair under deep hypothermic circulatory arrest with pericardial patch. The procedure was done on pump with a surgical approach that involved right sided cannulation. Post operatively, while intubated and sedated on propofol, the patient was able to follow commands. Within 6 hours post-operatively, the patient was found to have left-sided hemiplegia. Non-contrast head CT and CT-A of the head and neck did not demonstrate any acute intracranial findings. At this time the patient was not a candidate for thrombolytics as he was out of the time frame window and had a recent high-risk surgery. The head CT showed chronic regions of encephalomalacia in the right frontal, temporal and posterior parietal lobes. At this time the differential included stroke, recrudescence related to his right hemisphere encephalomalacia from surgery, infection, metabolic abnormalities and seizure with post ictal paralysis. Patient was not a candidate for MRI due to his cardiac mesh to further assess for ischemia, limiting the neurologic workup. Approximately 12 hours later, the patient was found to have an EEG confirmed generalized tonic-clonic seizure. The episode spontaneously terminated <1 min. Interval CT the following morning was unchanged. At this time the patient’s neurological symptoms resolved. These clinical findings could be explained by a subclinical or intraoperative seizure with postictal paralysis or a prior encephalomalacia with recrudescence of stroke symptoms due to the anesthetic agents administered or encountered hypotension during surgery.

Discussion: This case illustrates the importance of early identification of perioperative stroke during post-surgical monitoring including the consideration of multifactorial etiologies of neurological sequelae after surgery.

1. Selim M. Perioperative stroke. N Engl J Med. 2007;356:706–713


2. Bateman B et al. Perioperative acute ischemic stroke in noncardiac and nonvascular surgery. Anesthesiology. 2009;110:231–238.3


3. Ko, S. Perioperative stroke: pathophysiology and management. Korean journal of Anesthesiology. 2018 Feb; 71(1):-11.


4. Topcuoglu et al. Recrudesce of Deficits After Stroke Clinical and Imaging Phenotype, Triggers, and Risk factors. Jama Neurology. 2017;74(9):1048-1055