Emergency decompressive craniotomy with scalp block and closed-loop TCI sedation for acute ischemic stroke in a patient with incidental diagnosed large left ventricular mass, presenting with severe LV dysfunction.

Abstract

Dear Editor, An average built 35-year-old male presented to the emergency-department with a history of a sudden onset of left-sided weakness and bi-frontal headache, with a chronic history of ischemic cardiomyopathy, and acute myocardial infarction one year back, with current functional status New York Heart Association classification (NYHA) class III. Patient underwent thrombolytic therapy with 0.9 mg/kg alteplase (r-TPA) over 60 minutes after evaluating risk factors during the precious golden hour period. Over the next 12 hours, the GCS deteriorated. There was cerebral swelling with a midline shift of 8 to 12 mm, although the patient was not intubated or ventilated. In a repeat scan and the neurosurgeon planned to proceed with emergency decompressive craniotomy. Complete hemogram was normal, electrocardiogram revealed sinus tachycardia with left anterior hemiblock. Routine trans-thoracic echocardiogram suggested global left ventricular (LV) dysfunction with an ejection fraction of 20%, large left ventricular mass (query myxoma or thrombus attached to LV apex measuring 44 mm × 36 mm), and grade III mitral regurgitation with eccentric jet. [Figure 1] Computerized tomography showed Acute Ischemic Stroke (AIS) in the right middle cerebral artery territory. After explaining due appropriate risks and benefits of surgery to the patient relatives and interdisciplinary consensus, the team decided to proceed with craniotomy under Monitored Anesthesia Care using scalp block and manual closed-loop TCI Propofol sedation under spectral entropy monitoring.Figure 1: Echocardiography (ECHO) Revealing Large Left Ventricular Mass Attached LV Apex Measuring 44 Mm × 36 Mm (A) Parasternal Long Axis View, (B) Apical Four Chamber ViewBilateral scalp anesthesia was given using 24-gauge short bevel needle with 40 ml 0.2% Ropivacaine. After assessing for adequate block by pin prick method, entropy leads were attached and secured with 1-inch plaster tape. TCI sedation with Propofol was started with the initial effect site concentration of 1 microgram/ml, later escalated to 3 microgram/ml to maintain spectral entropy between 60-80 and hemodynamic parameters. Decompressive craniotomy was completed in 2 hours 10 minutes, with no complications; patient recovery was rapid and was obeying verbal comments when effect-site concentration reached 0.5 microgram/ml. After this emergency surgery, the patient was operated for his cardiac mass after 9 months and it was found to be thrombus on histopathological diagnosis. Thrombus, tumor, and vegetation are the most common causes of intracardiac mass and must be distinguished from normal variants such as papillary muscles, false tendons, sigmoid septum, and apical trabeculation.[1] Our patient was at high risk with associated large left ventricular mass, severe left ventricular dysfunction, and ischemic cardiomyopathy and grade III mitral regurgitation for emergency craniotomy. Anesthetic management in this clinical scenario could be associated with risk of complications ranging from peri-operative myocardial infarction, pulmonary edema, LV outlet obstruction and sudden cardiac arrest, new thrombo-embolic episodes, and hemorrhagic changes in infraction.[2] Scalp block with TCI Propofol sedation prevents hemodynamic perturbances associated with general anesthesia with intubation and cardio depressant effects of anesthetic agents. Manual closed loop TCI Propofol sedation with deep anesthesia control offers optimal titration with stable hemodynamic sedation and eliminates the need for unintended protection of the airway.[3] Considering the risk and benefit ratio, craniotomy with closed loop TCI Propofol sedation outweighed the risks of general anesthesia in our patient. Though awake craniotomy with TCI sedation is safe but has a few limitations like difficulty to alter ventilation in case of intraoperative cerebral edema and airway securement may be difficult in case requirement occur intraoperatively due to positioning of patient. In spite of appropriate anticoagulation, a thrombus traveling across the cardiac cycle has a high potential to embolize. It is imperative LV masses should be surgically removed as early as possible, owing to risk of recurrent thrombo-embolic phenomenon. We conclude that craniotomy under scalp block may be performed even in an emergency craniotomy in patients with high peri-operative risk. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.