Delayed emergence from anesthesia resulting from posterior cerebral artery infarction after Guglielmi detachable coil embolization

Abstract

In the treatment of unruptured intracranial aneurysms, Guglielmi detachable coil (GDC) embolization is a good alternative to surgical clipping which requires invasive surgery [1]. The authors experienced a delayed emergence from anesthesia in a post anesthesia care unit (PACU) after GDC embolization of an unruptured intracranial aneurysm under general anesthesia. We report a case of a thromboembolism at the Lt. posterior cerebral artery detected on an angiogram that was immediately performed after a neurologic deficit was detected in the patient. A 70-year-old male (169 cm, 74 kg) was admitted for the treatment of a 6 mm unruptured basilar top aneurysm that had been incidentally found during a work up for lung cancer. He was on hypertension and diabetes mellitus medications and had taken aspirin with clopidogrel for 5 days prior to the procedure. Routine laboratory tests were unremarkable and he did not have any neurologic deficit on admission. Bispectral index monitoring was added to the routine monitoring and general anesthesia was induced with intravenous propofol 120 mg, alfentanil 400 μg and rocuronium 50 mg. After tracheal intubation, deep anesthesia was maintained with 6% desflurane in 50% oxygen with nitrous oxide to secure immobil ity during the procedure. Phenylephrine was continuously infused to compensate for the hypotension. There was no remark able event during the procedure. Glycopyrrolate 0.4 mg and neostigmine 1.5 mg were administered after the completion of the procedure. The patient was extubated after confirmation that the bispectral index had reached 80 and self respiration had sufficiently recovered. The patient opened his eyes when his name was called. The proce dure took 45 minutes and the total anesthesia time was 70 minutes. The total dosage of rocuronium was 60 mg. In the PACU, oxygen supplementation of 5 L/min with a facial mask was sufficient to maintain the SpO 2 at 100%, but the patient could not obey commands and looked uncomfortable while breathing. The blood pressure and heart rate were stable and the tympanic membrane temperature was 35.8 o C. To rule out the possibility of incomplete recovery from the neuromuscular blocking agent, additional glycopyrrolate 0.2 mg and neostigmine 1.0 mg were injected intravenously. Muscle relaxation was monitored with an electrical stimulator by applying the