Cerebral hemorrhage presenting as alteration of

266

Anesth Pain Med 2011 6 266～269 Case Report

Cerebral hemorrhage presenting as alteration of consciousness during the anesthesia recovery period -A case report-

Department of Anesthesiology and Pain Medicine Ansan Hospital of Korea University Ansan Korea

Doo Jae Min Woon Young Kim Sehwa Lee Yoon Sook Lee Jae Hwan Kim and Young Cheol Park

Received August 25 2010

Revised October 3 2010

Accepted February 11 2011

Corresponding author Woon Young Kim MD Department of

Anesthesiology and Pain Medicine Ansan Hospital of Korea University

516 Gojan-dong Ansan 425-707 Korea Tel 82-31-412-5291 Fax

82-31-412-5294 E-mail ckssiskoreaackr

Catastrophic neurological events can occur rarely in anesthetic

recovery period and they must be quickly diagnosed We report

here on a spontaneous intracerebral hemorrhage (SICH) that

developed during the anesthesia recovery period in a 52-year-old

man who had undergone uneventful orthopedic surgery He had

predisposing factors including 25 year history of heavy alcohol

consumption and smoking The risk of spontaneous intracerebral

hemorrhage following non-cardiovascular and non-neurovascular

surgery is exceedingly small during the anesthesia recovery period

especially for a patient with no history of hypertension and

coagulopathy We also describe the differential diagnosis of an

altered mental status that occurs during anesthetic recovery period

(Anesth Pain Med 2011 6 266sim269)

Key Words Anesthesia recovery period Cerebral hemorrhage

Consciousness Disorder Spontaneous rupture

Adverse events commonly occur in the postanesthesia care

unit and the complication rate may exceed 23 to 30 [12]

Pain (16) and nausea-vomiting (8) are the most common

complications and an altered mental status is seen in 3 to

9 of cases [23] Delayed emergence and emergence delirium

secondary to the anesthetic and analgesic medication that are

administered preoperatively are the principal causes of

postoperative changes of mental status but the differential

diagnosis is rather broad We report here on a case of altered

consciousness in a patient who was in the postanesthetic

recovery unit after undergoing orthopedic surgery The patient

was subsequently diagnosed with cerebral hemorrhage

CASE REPORT

A 52-year-old man weighing 55 kg and with an American

Society of Anesthesiologists (ASA) physical status of grade II

presented to the orthopedic surgery department for open reduc-

tion and internal fixation of his fractures in both forearms He

had no history of hypertension amyloid angiopathy cerebro-

vascular accident diabetes mellitus or a bleeding tendency But

he had a 25 year history of alcohol abuse (3 to 4 times

weekly) and smoking (1 pack daily) The results of the

preoperative liver function tests were mildly elevated The

alanine aminotransferase level was 67 (normal range 0minus45)

Otherwise the other preoperative lab values (complete blood

count urinary analysis electrolytes coagulation profile test

and electrocardiography [ECG]) were in the normal range

Monitors (ECG Blood Pressure [BP] cuff and Pulse Oximetry

[SpO2]) were applied for general anesthesia The BP was

checked in the leg because the patient had both distal radius

fractures of forearms and left ulnar fracture The preoperative

vital signs in the operating room were as follows heart rate

85 beats per minute BP 14673 mmHg and SpO2 98 After

the administration of propofol (120 mg) and rocuronium (40

mg) anesthesia was induced with additional desflurane (up to

5 vol) by a mask in a mixture of oxygen and nitrous oxide

(FiO2 05) Tracheal intubation was performed 2 minutes after

anesthesia was induced Anesthesia was maintained with

desflurane (vol 35minus65) O2 2 Lmin and N2O 2 Lmin

Normally the systolic BP (SBP) in the legs is usually 10 to

20 higher than in the brachial artery pressure [4] The BP

was maintained under 16080 in the leg during the operation

At the end of the operation the patient was fully awakened

and extubated The patient was then transferred to the PACU

Doo Jae Min et alCerebral hemorrhage during the anesthesia recovery period 267985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103

Fig 1 CT scan of the head without contrast material and this was obtained during the recovery time It demonstrated the approximately 75 cm large acute ICH in the left frontotemporal lobe The ICH extended to both lateral ventricles and the 3rd and 4th ventricles through the external capsule

Fig 2 CT scans of the head obtained the next day postoperatively The density and size of the lobar ICH were reduced but localized swelling wasseen in the left frontotemporal lobe with residual IVH in both lateral ventricles

(Postanesthesia Care Unit) At the arrival to the PACU the

postoperative vital signs were as follows heart rate 85 beats

per minute BP 15080 mmHg and SpO2 98 He responded

appropriately to verbal stimuli Throughout the PACU stay the

blood pressure heart rates and oxygen saturation were moni-

tored at 5-minute intervals Two liters oxygen supplementation

was given during the PACU stay by a nasal prong Fifty μg

of fentanyl was intravenously injected for postoperative pain

control and a warm blanket was applied It was noted that the

patient complained of mild headache with an elevated BP

18095 at 50 minutes after the PACU admission Thus 10 mg

of labetalol hydrochloride was intravenously injected and then

the blood pressure fell to the normal range At 2 hours after

the PACU admission the patient showed a slow verbal

response and an altered consciousness Physical and neurologic

exams were immediately performed The patient did not exhibit

spontaneous eye opening but he opened his eyes in response

to a voice He showed a confused mentality minimal

withdrawal to painful stimuli and a positive Babinski sign on

both feet The Glasgow coma scale (GCS) score was 11 The

electrocardiographic findings serum electrolytes and glucose

level were normal Emergency computerized tomography (CT)

scanning without contrast was performed (Fig 1) On the

emergency CT a large acute intracranial hemorrhage (ICH)

was shown in the left basal ganglia both lateral ventricles and

the 3rd and 4th ventricles Emergency decompressive craniec-

tomy and hematoma removal were performed After surgery he

was sent to the intensive care unit (ICU) and the follow-up

CT (Fig 2) was taken two days later He stayed in the ICU

for 24 days and gradually regained consciousness and he was

268 Anesth Pain Med Vol 6 No 3 2011985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103

then transferred to a rehabilitation facility

DISCUSSION

The differential diagnosis of altered mental status

during anesthetic recovery period

Delayed emergence from general anesthesia due to the

residual effects of oral intravenous and inhalational sedative

analgesic and anesthetic medications is a most common cause

of an altered mental status for patients in the PACU This

situation may be complicated by preexisting mental dysfunc-

tion postoperative hypothermia or unrecognized preoperative

ingestion of alcohol opioids benzodiazepines and other presc-

ription and illicit drugs that potentiate the effects of anesthe-

sia-related medications

Emergence delirium is a behavioral manifestation of recovery

from general anesthesia and this ranges from mild confusion

and lethargy to extreme excitement and combativeness

Emergence delirium is the second most common cause of an

altered mental status in patients in the PACU Return of the

cognitive function after general anesthesia may be slower in

the elderly population in the immediate postoperative period

whereas agitation and combativeness are more frequently

observed in children and young adults [5] Emergence delirium

may also be produced by the perioperative administration of

ketamine or atropine and by postoperative withdrawal from

alcohol or illicit drugs Moreover it may be amplified by

anxiety and by discomfort such as surgical pain nausea

pruritis and gastric or urinary bladder distention

An abnormal mental status after surgery may be an

indication of hypoxemia andor hypercarbia due to the residual

effects of anesthetic agents incomplete reversal of neuromu-

scular blockade airway obstruction pneumothorax or pulmo-

nary aspiration [67] Rarely metabolic derangements such as

hypoglycemia hyperglycemia hypothermia hypercalcemia or

hypermagnesemia may contribute to an abnormal mental status

in patients in the PACU Finally once the reversible causes of

acutely altered sensorium are excluded neurologic events such

as seizure activity and embolic or hemorrhage stroke must be

considered

Therapeutic and diagnostic approach to altered

mental status

A spontaneous intracerebral hemorrhage (SICH) is defined as

a blood clot that arises in the brain parenchyma in the

absence of trauma SICH accounts for 10 to 15 of all

strokes and it is associated with a higher mortality rate than

either ischemic stroke or subarachnoid hemorrhage Arterial

hypertension represents the most common cause of nontrau-

matic ICH in patients between 40 and 70 years of age and

accounts for over 50 of cases [89] Thus it constitutes by

far the most important modifiable risk factor for spontaneous

ICH [1011] Further independent risk factors include moderate

and heavy alcohol abuse old age diabetes mellitus coagulo-

pathy and anticoagulant treatment [12] Excessive use of

alcohol increases the risk of ICH by impairing coagulation and

directly affecting the integrity of cerebral vessels [13]

Cigarette smoking seems to increase the risk for subarachnoid

hemorrhage (SAH) but is less strongly associated with SICH

[11] Diabetes mellitus is more commonly associated with

SICH than with SAH [14]

The classic presentation of SICH is a sudden onset of focal

neurological deficit that progresses over hours with accom-

panying headache nausea vomiting an altered consciousness

and an elevated BP However because inhalational anesthetics

may produce a number of various changes in the mental status

after surgery such as headache emergence excitement and

delirium during the recovery period it is hard to distinguish

between the early signs of SICH and the residual effect of

inhalational anesthetics [15] Emergency Computerized tomo-

graphy (CT) scanning is the initial diagnostic procedure of

choice for acute stroke MRI and cerebral angiography are

being increasingly used in the diagnosis of SICH Yet they are

expensive diagnostic tools to routinely use whenever a patient

complains of headache So conducting neurologic and physical

exams are generally preferred as the first step before

performing CT or magnetic resonance imaging (MRI)

Although delayed emergence from general anesthesia and

emergence delirium are the most common causes of the mental

status changes found in the PACU setting the immediate

evaluation must also include considering the potentially

catastrophic conditions such as hypoxemia incomplete reversal

of neuromuscular blockade and embolic or hemorrhage stroke

SICH is rare during the PACU stay but it must always be

considered in the differential diagnosis of mental status

changes CT scanning is the initial diagnostic procedure of

choice However we recommend to conduct neurologic and

physical exams as the first step before performing CT or

magnetic resonance imaging (MRI)


REFERENCES

1 Hines R Brash PG Waltrous G OConnor T Complications

occuring in the postanesthesia care unit a survey Anesth Analg

1992 74 503-9

2 Zeler J Wells DG Anesthetic-related recovery room compli-

cations Anaesth Intensive Care 1987 15 168-74

3 Van der Walt JH Webb RK Osborne GA Morgan C Mackay

P The Australian Incident Monitoring Study Recovery room

incidents in the first 2000 incident reports Anaesth Intensive Care

1993 21 650-2

4 Bickley LS Szilagyi PG Bates B Bates guide to physical

examination and history taking 10th ed Philadelphia Wolters

KluwerLippincott Williams amp Wilkins 2009

5 Mecca RS Postoperative recovery In Clinical Anesthesia 3rd ed

Edited by Barash PG Gullen BF Stoeling RK Philadelphia Pa

Lippincott-Raven 1997 pp 1279-303

6 Mathew JP Rosenbaum SH OConnor T Barash PG Emergency

tracheal intubation in the postanesthesia care unit physicain error

or patient disease Anesth Analg 1990 71 691-7

7 Daley MD Norman PH Colmenares ME Sandler AN Hypoxa-

emia in adults in the post-anesthesia care unit Can J Anaesth

1991 38 740-6

8 Gomori JM Grossman RI Hackney DB Goldberg HI Zimmer-

man RA Bilaniuk LT Variable appearances of subacute intra-

cranial hematomas on high-field spin-echo MR AJR Am J Roent-

genol 1988 150 171-8

9 Viswanathan A Chabriat H Cerebral microhemorrhage Stroke

2006 37 550-5

10 Fewel ME Thompson BG Jr Hoff JT Spontaneous intracerebral

hemorrhagea review Neurosurg Focus 2003 15 1-16

11 Thrift AG McNeil JJ Forbes A Donnan GA Risk factors for

cerebral hemorrhage in the era of well-controlled hypertension

Melbourne Risk Factor Study (MERFS) Group Stroke 1996 27

2020-5

12 Ariesen MJ Claus SP Rinkel GJ Algra A Risk factors for

intracerebral 6 hemorrhage in the general population a systematic

review Stroke 2003 34 2060-5

13 Cowan DH Effect of alcoholism on hemostasis Semin Hematol

1980 17 137-47

14 Juvela S Prevalence of risk factors in spontaneous intracerebral

hemorrhage and aneurysmal subarachnoid hemorrhage Arch

Neurol 1996 53 734-40

15 Boucher BA Witt WO Foster TS The postoperative adverse

effects of inhalational anesthetics Heart Lung 1986 15 63-9


Fig 1 CT scan of the head without contrast material and this was obtained during the recovery time It demonstrated the approximately 75 cm large acute ICH in the left frontotemporal lobe The ICH extended to both lateral ventricles and the 3rd and 4th ventricles through the external capsule

Fig 2 CT scans of the head obtained the next day postoperatively The density and size of the lobar ICH were reduced but localized swelling wasseen in the left frontotemporal lobe with residual IVH in both lateral ventricles

(Postanesthesia Care Unit) At the arrival to the PACU the

postoperative vital signs were as follows heart rate 85 beats

per minute BP 15080 mmHg and SpO2 98 He responded

appropriately to verbal stimuli Throughout the PACU stay the

blood pressure heart rates and oxygen saturation were moni-

tored at 5-minute intervals Two liters oxygen supplementation

was given during the PACU stay by a nasal prong Fifty μg

of fentanyl was intravenously injected for postoperative pain

control and a warm blanket was applied It was noted that the

patient complained of mild headache with an elevated BP

18095 at 50 minutes after the PACU admission Thus 10 mg

of labetalol hydrochloride was intravenously injected and then

the blood pressure fell to the normal range At 2 hours after

the PACU admission the patient showed a slow verbal

response and an altered consciousness Physical and neurologic

exams were immediately performed The patient did not exhibit

spontaneous eye opening but he opened his eyes in response

to a voice He showed a confused mentality minimal

withdrawal to painful stimuli and a positive Babinski sign on

both feet The Glasgow coma scale (GCS) score was 11 The

electrocardiographic findings serum electrolytes and glucose

level were normal Emergency computerized tomography (CT)

scanning without contrast was performed (Fig 1) On the

emergency CT a large acute intracranial hemorrhage (ICH)

was shown in the left basal ganglia both lateral ventricles and

the 3rd and 4th ventricles Emergency decompressive craniec-

tomy and hematoma removal were performed After surgery he

was sent to the intensive care unit (ICU) and the follow-up

CT (Fig 2) was taken two days later He stayed in the ICU

for 24 days and gradually regained consciousness and he was



DISCUSSION




































considered


mental status
















































REFERENCES



1992 74 503-9






1993 21 650-2












1991 38 740-6




genol 1988 150 171-8


2006 37 550-5






2020-5





1980 17 137-47



Neurol 1996 53 734-40





DISCUSSION




































considered


mental status
















































REFERENCES



1992 74 503-9






1993 21 650-2












1991 38 740-6




genol 1988 150 171-8


2006 37 550-5






2020-5





1980 17 137-47



Neurol 1996 53 734-40




REFERENCES



1992 74 503-9






1993 21 650-2












1991 38 740-6




genol 1988 150 171-8


2006 37 550-5






2020-5





1980 17 137-47



Neurol 1996 53 734-40



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Cerebral hemorrhage presenting as alteration of