Perioperative fatal embolic cerebrovascular accident after radical prostatectomy

Abstract

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.

Figure 1

Axial CT scan of the brain without contrast 2 hours after completion of prostatectomy demonstrates early lucency of evolving infarction in the right MCA territory

Figure 2

Axial CT scan of the brain without contrast 20 hours after completing prostatectomy demonstrates right MCA territory infarction with 3-mm midline shift

Figure 3

Axial CT scan showing total right hemispheric infarction, herniation of the brain through the defect, massive bihemispheric swelling, loss of white-gray matter differentiation

Figure 4

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