66-year-old female underwent a left suboccipital craniotomy for resection of a tentorial meningioma. The postoperative course has been difficult, marked by deterioration associated with posterior temporal and cerebellar edema and hemorrhage. First she seems to be in good general conditions showing only a slight strength deficiency in the left upper limb, but about a month after the surgery she started showing asthenia and melena, and esophageal gastroduodenoscopy revealed a sclerosis of active arterial bleeding from duodenal ulcer. Afterwards she started to experience nausea and vomiting symptoms.
1) Are the post-surgery symptoms exhibited by the patient, and which continue to date, compatible with a normal post-surgery course or should they be attributed to a complication occurring during surgery?
2) Can you suggest any further therapies to improve the symptoms?
3) What is the expected prognosis?
Sex:F, Age:66 years old
Removal of uterine fibroma in 1991
Septoplasty in 1977 and 1992
On Nov 2007, craniotomy with removal of subtentorial meningioma:normal intrasurgical course with roughly 300 ml of blood loss.At the end of the surgery, the patient shows anisocoric pupils, right>left 3:2, with weak reactions.E1, Vt, M1.Performed a post-surgery cerebral CAT-scan. The patient is then moved to post-surgical neurosurgery intensive care for monitoring.
During the stay in intensive care:
presence of closed lumbar subarachnoid drainage.
On Nov, the sedation is interrupted followed by a progressive waking of the patient (GCS at E4VtM6). Extubation follows.
On Dec, the patient’s neurological conditions deteriorate requiring re-intubation; another urgent cerebral CAT scan is performed which shows a dishomogeneous hematic collection in the surgical site, with a compression of the trunk and of the IV ventricle as well as a dilation of the supratentorial ventricles. The patient is moved into OR for an EVD placement at +10 cmH2O. The patient is taken back to the neurosurgery intensive care unit where she is sedated again, GCS at E1VtM3, pupils are slightly anisocoric right>left.
After two days, the sedation is permanently interrupted. On Dec, the EVD is closed upon neurosurgeon instructions. On the next day, the patient is discharged from the intensive care unit and transferred to a neurosurgery unit. The patient is alert and cooperative. Slightly anisocoric (right>left), photoreactive pupils. The patient carries out simple instructions using all 4 limbs but showing a strength deficiency in the left upper limb, Vertical and horizontal nystagmus, left dysmetria, swallowing and cough reflexes appear normal.
Respiratory report from Intensive Care:
maintained the oro-tracheal (O.T.) probe until Nov; on Dec, following neurological deterioration, the probe is repositioned (nasotracheal intubation). Final extubation after 4 days.
Hemodynamic report from Intensive Care:The patient has remained stable.
Follow-up exams during Intensive Care stay:
Cerebral CAT scan (Dec):EVD positioned in the right ventricle with internal air and abundant subthecal front air.
Cerebral CAT scan (Dec):the intracranial air has been partially reabsorbed, appearance of hematic collection in the occipital cornu of the lateral right ventricle.
Cerebral CAT scan on Dec.:unvaried results compared to the previous exam;
Chest X-Rays on Dec: no pathological signs.
When the patient is taken back to neurosurgery from intensive care, she seems to be in good general conditions showing only a slight strength deficiency in the left upper limb, which improves later.The CAT and MRI follow-up scans of the surgical site are satisfactory.The next post-surgical course remains normal until mid December, when the patient starts showing asthenia and melena.Since the hemochromocytometric exams show a progressive and rapid anemization, and after surgical evaluation and blood transfusions, an esophageal gastroduodenoscopy (EGDS) reveals a sclerosis of active arterial bleeding from duodenal ulcer, possibly secondary to drugs and surgical stress.In the following days, the patient remains in good general conditions with a progressive increase of the hemochrome.
On Dec 2007, the patient is discharged from the neurosurgery unit of Padua with the following instructions:
- therapyà NPT 4 (oliclinomel N-4) 2000 ml + polyvitamins, Pantorc 40 mg x 3, Benexol B12 1 vial, Ferlixit 1 vial, Lederfolin 1 vial, Zofran as needed, Lixidol as needed.
- resume physiotherapy and mobilization after an EGDS follow-up exam.
After the discharge from the neurosurgery unit of Padua and the transfer to the neurology unit of Portogruaro, the patient starts some physical exercise and manages, for the first time, to get up from bed by herself and sit for a few minutes.
On Dec when administered the contrast medium during the MRI follow-up exam, the patient exhibits a sense of nausea.Since then and through the next few days, the patient continues to experience nausea and vomiting.
After 3 days, during a discharge of a few days from the neurology unit, and appropriate transport, the patient’s nausea and vomiting symptoms intensify.After two days of not being able to eat normally, on Jan, the patient is admitted again.Occult blood is found in the feces.
From that moment on, the patient continues to experience strong nausea and persistent vomiting.
After an improvement lasting a few days, on Jan, another CAT scan is performed with a subsequent increase in nausea and vomiting.
CAT scan shows the following:exam performed without contrast medium.When compared with the exam taken on Nov2007, a hypodense area due to previous craniotomy is detected at the left cerebellar level, in the subtentorial region.In the left occipital region, a breach is found in the area where the craniotomy had occurred.No other abnormalities of bilateral brain parenchymal density.Non-dilated ventricular system in axis.
Since mid-February, vomiting and sense of nausea have decreased and the patient is managing to make some movements, such as turning on her right side or sitting for a few minutes.
The postoperative course has been difficult, marked by deterioration associated with posterior temporal and cerebellar edema and hemorrhage. This may have been secondary to a venous infarct, based on the CT scan of December. Also, likely secondary to the cerebellar edema and compression of the 4th ventricle, hydrocephalus developed, necessitating ventricular drainage.
The patient is now awake, but impaired. Most of the time is spent in bed, though she is able to sit a chair for short periods of time.
In answer to the questions:
1. Recovery from major surgery such as this can be difficult, and the surgery, itself, while certainly indicated, has significant risks. Her neurological compromise is not necessarily normal, but is a risk of an operation in this area.
2. I do not recommend any other specific therapies, other than supportive. It is important to continue to obtain CT scans, particularly if she does not improve, to make sure that hydrocephalus does not redevelop.
3. It is difficult to be very specific about prognosis. Her most recent MRI does not show brainstem injury, so this is favorable. It may be difficult for her to regain normal motor functioning. I would not be surprised, as long as she remains healthy otherwise, if she has significant cognitive improvements over the next several months. Fortunately, this is a benign tumor (assuming the pathology is meningioma), so concern about recurrence in the near future is low.