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Bilateral thalamic infarct after general anaesthesia for laparotomy: an unusual case of perioperative cryptogenic stroke

Sir, Perioperative stroke (POS) is a rare but devastating complication of surgery. The incidence of POS depends on several patientand procedure-related factors (1). We present a case of a healthy young woman diagnosed as having cryptogenic POS following general anaesthesia for resection of a pancreatic tumour. A 19-year-old, ASA physical status class 1 woman with no known allergies was admitted to our centre for surgical resection of a pancreatic pseudopapillary tumour. Uneventful exploratory surgery for the same reason had been performed at a different centre 2 weeks before her current admission. Anaesthesia induction and maintenance were uneventful and were accomplished with thiopental, fentanyl, isoflurane, and vecuronium. An 18-G epidural catheter was also introduced at the level of L3–L4 for intraand post-operative analgesia. During the anaesthesia course, all monitored parameters were within acceptable limits (ECG: normal sinus rhythm and heart rate 80– 110 beats/min; intra-arterial mean blood pressure: 455 mmHg; central venous pressure: 3–8 mmHg; oesophageal temperature: 435.5 1C; end-tidal CO2: 33–38 mmHg; oxygen saturation: 497%; pH: 7.38–7.46; and serum lactate: o2 mmol/l). The only significant intra-operative event was 1800 ml blood loss owing to the vascular nature of the tumour and an accidental tear in the portal vein. During the 275-min procedure, 2000 ml colloids, 5000 ml crystalloids, and 1500 ml packed red blood cells were administered. At the end of the procedure, the patient remained intubated and was transferred to the intensive care unit (ICU) because of the large amount of blood loss and transfusion. In the ICU, she had adequate spontaneous breathing but was difficult to arouse and did not respond to painful and verbal stimuli for 3 and 6 h, respectively, after the operation. Twelve hours after the ICU admission, she was extubated and at this time she was drowsy; although she was able to understand simple commands, she was unable to speak and had a left facial droop. A cranial computed tomography revealed a bilateral thalamic infarct, which was confirmed by diffusion magnetic resonance imaging (Fig. 1). Enoxaparin (40 mg b.i.d.) was begun for anticoagulation. Transthoracic and transoesophageal echocardiographic evaluations failed to identify a potential cardiac source of emboli. Genetic, collagen vascular disease, and coagulation profile studies failed to demonstrate any abnormalities that may have predisposed the patient to a hypercoagulable state. A slow but progressive improvement in the patient’s neurological condition was noted, and she was transferred to a general ward 9 days later and discharged home 2 days after that. Two months after the operation, the patient was symptom-free except for minimal memory problems. Cryptogenic stroke is frequently caused by a paradoxical embolism through a patent foramen ovale (PFO). We were unable to show an interatrial communication in this patient. However, it is not possible to definitively exclude the possibility of such a communication because a probe patent PFO may allow right-to-left shunting and therefore be visible only under specific circumstances such as mechanical ventilation and increased intra-abdominal pressure (2). We propose that cryptogenic POS should be considered as a possible cause of delayed awakening after general anaesthesia, even in patients with very low patientand procedure-related POS risk.