Publications

INTRODUCTION
Incidence of Perioperative stroke in cardiac, neurological and carotid
surgeries, is found to be as high as 2.5 – 5.2% (Wong GY, 2000),
however, other surgeries carry a minimal risk of perioperative stroke
which is 0.05%. Some prospective studies have shown the incidence to
be as high as 4.4% (Turnipseed WD, 1980). Mortality from
perioperative stroke in general surgery is found to be as high as 26%
(Parikh S, 1993). As there are no specic parameters or tests to predict
an acute ischemic stroke in patient with no related comorbidities
undergoing general surgery, it is a challenging task to avoid the
incidence of such complications.
CASE STUDY
A 62 year old 75 kg male presented with history of loose stools for a
period of 6 months. He was known hypertensive on regular
medications (Tablet Amlodipine 2.5mg OD). He was a smoker (15
pack years) and had history of alcohol abuse of 25 years for which he
was on alcohol de-addiction treatment (Tablet baclofen 30mg HS) for
the past two months. He was evaluated by gastroenterology team.
Colonoscopic ndings showed suspected carcinoma rectum with
multiple colonic polyps and Computed Tomography (CT) scan
showed carcinoma colon Grade 3B. Biopsy of the tissue/polyp
conrmed adenocarcinoma of colon. Patient was posted for
laparoscopic assisted total proctocolectomy by surgical oncology
team. Preoperative thromboprophylaxis was deferred as the risk of
bleeding outweighs thrombosis. ( Guidelines on Perioperative
Management of Anticoagulant and Antiplatelet Agents, 2018)
Preoperative anaesthetic evaluation was done where the patient was
found to have history of hypertension, alcohol abuse and smoking, as
mentioned above. Physical and systemic examination was
unremarkable and vital parameters were within normal limits. On
investigation, haemoglobin was 9.8mg/dl, which was optimized with
blood transfusion.
Patient's past surgical or anaesthetic history was insignicant.
Cardiologist and pulmonologist opinion was sought and patient was
cleared for surgery under moderate risk. Patient was reviewed by
Anaesthesiologist and was taken up for surgery (laparoscopic assisted/
open total Proctocolectomy + End Ileostomy) under moderate risk of
Anaesthetic complications (ASA Grade – 2). General anaesthesia with
epidural analgesia was planned for this surgery.
Epidural catheter was inserted at the level of L1 Vertebra, for
continuous infusion of analgesia. Patient was induced with Propofol,
Fentanyl and paralysis was achieved with non-depolarizing muscle
relaxant, atracurium. Anaesthesia was maintained with IPPV
(intermittent positive pressure ventilation), Isourane + Air / Oxygen
mixture + intermittent boluses of atracurium. Multimodal analgesia
was administered using Morphine and Paracetamol. Laparoscopic
assisted total proctocolectomy + End ileostomy was performed.
Intraoperative hemodynamics were stable with adequate urine output
maintained throughout. Patient was shifted to Surgical Intensive Care
Unit (SICU) for elective mechanical ventilation in view of prolonged
surgery (13 hours). Sedation was continued over-night for patient's
comfort and to facilitate synchronous ventilation.
On post-operative day 1, sedation was stopped, patient was weaned off
ventilator and extubated. Following extubation, right upper limb and
lower limb weakness were noted (new onset neurological decits) and
stroke was suspected. Magnetic Resonance Imaging screening of brain
was done which showed features suggestive of left Middle cerebral
artery territory infarction with marked left cerebral hemisphere
oedema, minimal midline shift and haemorrhagic transformation.
Diffusion restriction in right high posterior fronto-parietal lobe was
noted which was suggestive of acute infarcts (? Embolic). Diffuse
cerebral atrophy and chronic ischemic changes were also present.
Computed Tomography of brain with angiography of internal and
external carotid artery showed signs of Eccentric atheromatous
hypodense plague in left mid-distal Common Carotid Artery causing
moderate luminal stenosis with extension of plaque into left carotid
bulb and proximal External Carotid Artery. Eccentric calcied plague
was present in right carotid bulb causing mild luminal stenosis. Diffuse
atherosclerotic changes of bilateral Common Carotid Artery and Distal
Internal carotid artery (Left side >Right side) were noted along with
right fetal Posterior Cerebral Artery. Neurologist opinion was sought
and patient was started on antioedema measures and antiepileptics. On
post-operative day 2 patient sensorium deteriorated, and was
reintubated in view of low Glasgow Coma Scale (GCS) score. Repeat
CT scan of brain showed sub-acute infarct involving the left Middle
Cerebral Artery territory, right frontal lobe and genu of the corpus
callosum with mass effect and midline shift to right, effacement of the
adjacent sulcal spaces and left lateral ventricle with minimal left uncal
herniation. Neurosurgery opinion was sought who advised for
emergency decompression. Patient underwent Left fronto-temporo-
parietal decompressive hemicraniectomy with lax duroplasty using G-
patch and shifted to ICU for elective ventilation. He was gradually
weaned off from the ventilator and extubated. Patient was shifted out
of ICU on post-operative day 9 ( of post bowel resection). Patient was
discharged from the ward with advise of home physiotherapy and
regular follow-up