Abstract
We report a patient who developed sustained hypotension during craniotomy; further, owing to a mediastinal mass, critical tracheal stenosis and brain edema were observed after craniotomy, despite the absence of preoperative symptomatic superior vena cava (SVC) syndrome. A 62-year-old man underwent removal of a suspected metastatic brain tumor. The main brain tumor was speculated to be a metastatic tumor from lung cancer. A subsequent chest CT revealed a large solid tumor in the mediastinum. The maximum reduction in the cross-sectional area of the trachea was estimated to be 50 %. In addition, bilateral innominate veins were completely obstructed, and the superior vena cava was involved in the mass and was completely compressed. The patient did not show any cardiopulmonary symptoms or upper body edema. Intravenous lines were secured at the right extremity. General anesthesia was induced without any complications and was maintained with sevoflurane, remifentanil, and rocuronium. During the surgery, hemodynamic status fluctuated and was unstable. To maintain systolic blood pressure, continuous, massive infusion of noradrenaline was required. After the surgery, the patient was turned to the supine position. Massive facial edema was apparent. In addition, the bilateral upper extremities were significantly swollen. Despite the removal of the main lesion, brain edema was still observed on head CT. Chest CT revealed that the maximum reduction in the cross-sectional area of the trachea was estimated to be >90 %, which necessitated mechanical ventilation with tracheal intubation. On the day following craniotomy, tracheal stenting was performed uneventfully. The patient’s trachea was finally extubated, and his respiratory condition did not deteriorate. Although he did not develop SVC syndrome, the patient died from asphyxiation after coughing up blood at home 5 months after the procedure. It was suggested that fluid infusion from the upper extremities owing to the mediastinal tumor caused critical SVC syndrome.
Highlights
In case of impaired blood flow through the superior vena cava (SVC) to the right atrium due to external compression or intrinsic obstruction of the SVC, it is recommended that intravenous access should be secured in the lower rather than in the upper extremities for anesthesia management [1, 2]
We report a patient who developed sustained hypotension during craniotomy; further, owing to a mediastinal mass, critical tracheal stenosis
The bilateral innominate veins were completely obstructed before merging into SVC, and SVC was involved in the mass and was completely compressed
Summary
In case of impaired blood flow through the superior vena cava (SVC) to the right atrium due to external compression or intrinsic obstruction of the SVC, it is recommended that intravenous access should be secured in the lower rather than in the upper extremities for anesthesia management [1, 2]. We report a patient who developed sustained hypotension during craniotomy; further, owing to a mediastinal mass, critical tracheal stenosis. Case presentation A 62-year-old man was admitted to our hospital for the removal of a suspected metastatic brain tumor He had suffered from gait disturbance and visual field defects for 3 months. Craniotomy and removal of the brain tumor was performed in the left park-bench position. Head CT revealed remaining brain edema with mild midline shift despite removal of the main lesion (Fig. 2). After admission to ICU, the patient remained sedated under mechanical ventilation He was placed in the Fowler’s position to facilitate blood flow from the upper body. Following the successful tracheal stenting, the patient regained consciousness immediately after cessation of sedatives The patient did not develop SVC syndrome, he died from asphyxiation after coughing up blood at home 2 months after being discharged
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