Anesth Pain Med.  2016 Oct;11(4):362-365. 10.17085/apm.2016.11.4.362.

Hemisphere cerebral infarction after total laparoscopic hysterectomy in the Trendelenburg position: A case report

• Lee KH
• Jeon YG
• Cho DW
• Kim MH
• Lim HK

• KMID: 2358332
• DOI: http://doi.org/10.17085/apm.2016.11.4.362

Abstract

Perioperative stroke can lead to mortality or serious disability and usually occurs in patients undergoing cardiac, vascular, or neurologic surgery; it is rare in gynecological surgery. We report the case of a patient who suffered life-threatening cerebral infarction after elective laparoscopic hysterectomy. During the surgery, the patient was placed in the Trendelenburg position. On postoperative day one, the patient was diagnosed with right hemisphere cerebral infarction; brain computed tomographic angiography showed proximal right internal carotid artery occlusion. Decompressive craniectomy was performed to resolve brain swelling, but the patient died 10 days later.

Keyword

Cerebral infarction; Laparoscopic hysterectomy; Stroke; Trendelenburg position

MeSH Terms

Angiography
Brain
Brain Edema
Carotid Artery, Internal
Cerebral Infarction*
Decompressive Craniectomy
Female
Gynecologic Surgical Procedures
Head-Down Tilt*
Humans
Hysterectomy*
Mortality
Stroke

Figure

• 

  Fig. 1 Computed tomography angiography showing stenosis of the right proximal common carotid artery (arrow head) and total occlusion of the right internal carotid artery at the proximal common carotid artery bifurcation with poorly visualized right anterior and middle cerebral artery (arrow).

• 

  Fig. 2 The right internal carotid artery was not seen at the C2 cervical vertebra level (arrow).

• 

  Fig. 3 Pre and postcontrast CT showing right cerebral hemisphere infarction with midline shift.

Reference

1. Ng JL, Chan MT, Gelb AW. Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology. 2011; 115:879–90. DOI: 10.1097/ALN.0b013e31822e9499. PMID: 21862923.

2. Selim M. Perioperative stroke. N Engl J Med. 2007; 356:706–13. DOI: 10.1056/NEJMra062668. PMID: 17301301.

3. Lee JW, Kang H, Lim TH, Kim EG. A case of postpartum cerebral angiopathy with intracranial hemorrhage in Cesarean delivery. Anesth Pain Med. 2012; 7:359–62.

4. Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Georgia wR. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996; 53:309–15. DOI: 10.1001/archneur.1996.00550040037012. PMID: 8929152.

5. Likosky DS, Marrin CA, Caplan LR, Baribeau YR, Morton JR, Weintraub RM, et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke. 2003; 34:2830–4. DOI: 10.1161/01.STR.0000098650.12386.B3. PMID: 14605327.

6. Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernandese Fernandes J, et al. ESVS guidelines Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg. 2009; 37(4 Suppl):1–19. DOI: 10.1016/j.ejvs.2008.11.006. PMID: 19286127.

7. Hofmeijer J, Algra A, Kappelle LJ, van der Worp HB. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis. 2008; 25:176–84. DOI: 10.1159/000113736. PMID: 18212524.

8. von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, et al. Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology. 2001; 219:95–100. DOI: 10.1148/radiology.219.1.r01ap0695. PMID: 11274542.

9. Kasner SE, Demchuk AM, Berrouschot J, Schmutzhard E, Harms L, Verro P, et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke. 2001; 32:2117–23. DOI: 10.1161/hs0901.095719. PMID: 11546905.

10. El-Saed A, Kuller LH, Newman AB, Lopez O, Costantino J, McTigue K, et al. Geographic variations in stroke incidence and mortality among older populations in four US communities. Stroke. 2006; 37:1975–9. DOI: 10.1161/01.STR.0000231453.98473.67.

11. Hart R, Hindman B. Mechanisms of perioperative cerebral infarction. Stroke. 1982; 13:766–73. DOI: 10.1161/01.STR.13.6.766. PMID: 7147290.

12. Mavrocordatos P, Bissonnette B, Ravussin P. Effects of neck position and head elevation on intracranial pressure in anaesthetized neurosurgical patients: preliminary results. J Neurosurg Anesthesiol. 2000; 12:10–4. DOI: 10.1097/00008506-200001000-00003. PMID: 10636614.

13. Dunham CM, Sosnowski C, Porter JM, Siegal J, Kohli C. Correlation of noninvasive cerebral oximetry with cerebral perfusion in the severe head injured patient: a pilot study. J Trauma. 2002; 52:40–6. DOI: 10.1097/00005373-200201000-00009.

14. Park EY, Koo BN, Min KT, Nam SH. The effect of pneumoperitoneum in the steep Trendelenburg position on cerebral oxygenation. Acta Anaesthesiol Scand. 2009; 53:895–9. DOI: 10.1111/j.1399-6576.2009.01991.x. PMID: 19426238.

15. Hirvonen EA, Nuutinen LS, Kauko M. Hemodynamic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy. Acta Anaesthesiol Scand. 1995; 39:949–55. DOI: 10.1111/j.1399-6576.1995.tb04203.x. PMID: 8848897.