Intraoperative Harlequin Syndrome

Abstract

To the Editor: Recently, Mashour et al. (1) described a patient who developed an intraoperative Harlequin syndrome after an asymmetric epidural anesthetic. We (2) reported a similar case of a patient who developed postoperative ipsilateral Horner’s syndrome with contralateral facial flushing and sweating after high thoracic paravertebral analgesia. We believe that upward migration of local anesthetic in the paravertebral space was followed by an interruption of the sympathetic outflow at the level of preganglionic fibers originating from T1–3 spinal segments which impaired the oculomotor, vasomotor, and sudomotor response to the face on to the blocked side. Consequently, the contralateral side appeared excessively flushed and sweaty in special environmental circumstances such as exposure to heat. A similar Harlequin appearance after low thoracic epidural analgesia was described recently by Crawley (3) and thought to be related to the rostral unilateral migration of the local anesthetic to the upper spinal segments after Trendelenburg’s positioning during surgery. The explanation for perioperative Harlequin syndrome (with or without Horner’s syndrome) after regional anesthesia in the vicinity of sympathetic outflow track appears, therefore, logical. The mystery resides in the rarity of this condition. Crina L. Burlacu, MSc, FCARCSI Donal J. Buggy, MD, MSc, FRCPI, FCARCSI, FRCA Department of Anaesthesia, Intensive Care and Pain Medicine Mater Misericordiae University Hospital Ireland [email protected]