Neurocritical Care

, Volume 5, Issue 3, pp 206–209 | Cite as

Delayed emergence from anesthesia associated with absent brainstem reflexes following suboccipital craniotomy

  • James R. Munis
  • Anthony W. Marcukaitis
  • Juraj Sprung
Practical Pearl

Abstract

One of the most feared complications after intracranial surgery is development of acute intracranial pathology, which may result in hypoperfusion and brain injury. Thus, early neurological assessment, performed in the operating room immediately after emergence from anesthesia, is a practice that may contribute to timely diagnosis of neurosurgical complications. Failure to awake after general anesthesia precludes conductance of neurological assessment. We report a patient who failed to emerge from anesthesia after suboccipital craniotomy and had absent brain-stem reflexes with fixed and dilated pupils consistent with severe brain injury. Approximately 60 minutes after termination of surgery, the patient suddenly woke up. After the fact, we discovered that the neurosurgeon performed a generous field block with bupivacaine along the neck incision line.

We presume that our patient's failure to awaken was caused by paralysis of brain-stem caused by migration of bupivacaine from the site of the injection.

Key Words

Anesthetics local bupivacaine administration/adverse effects brain-stem reflexes chemically induced paralysis bupivacaine 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Wijdicks EF. The diagnosis of brain death. N Engl J Med 2001;344:1215–1221.PubMedCrossRefGoogle Scholar
  2. 2.
    Douglas JH III, Ross JD, Bruce DL. Delayed awakening due to lidocaine overdose. J Clin Anesth 1990;2:126–128.PubMedCrossRefGoogle Scholar
  3. 3.
    Haugen FP. The failure to regain consciousness after general anesthesia. Anesthesiology 1961;22:657–666.PubMedCrossRefGoogle Scholar
  4. 4.
    Ott VV, Pollack MM, Riddick L, Reisch RE, Epstein BS. Delayed awakening from anesthesia and child abuse. Anesthesiology 1983;58:178–180.PubMedCrossRefGoogle Scholar
  5. 5.
    Morss HL, Baillie TW. A case of postoperative respiratory insufficiency and prolonged unconsciousness. Br J Anaesth 1958; 30:19–21.PubMedCrossRefGoogle Scholar
  6. 6.
    Morgenthaler K, Larsen B, Grundmann U, Silomon M. [Intracranial haemorrhage. A reason for delayed awakening after general anaesthesia]. Anaesthesist 2005;54:450–454.PubMedCrossRefGoogle Scholar
  7. 7.
    Fuzaylov G, Kim AH, Rosow CE. Delayed awakening from general anesthesia in a hypovolemic infant. Paediatr Anaesth 2005;15:435–436.PubMedCrossRefGoogle Scholar
  8. 8.
    Kreidstein A, Boorin MR, Crespi P, Lebowitz P, Barst S. Delayed awakening from general anaesthesia in a patient with Hunter syndrome. Can J Anaesth 1994;41:423–426.PubMedGoogle Scholar
  9. 9.
    Bruder N, Ravussin P. Recovery from anesthesia and postoperative extubation of neurosurgical patients: a review. J Neurosurg Anesthesiol 1999;11:282–293.PubMedCrossRefGoogle Scholar
  10. 10.
    Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med 1994;331:1756–1760.PubMedCrossRefGoogle Scholar
  11. 11.
    Grattan-Smith PJ, Butt W. Suppression of brainstem reflexes in barbiturate coma. Arch Dis Child 1993;69:151–152.PubMedGoogle Scholar
  12. 12.
    Yang KL, Dantzker DR. Reversible brain death. A manifestation of amitriptyline overdose. Chest 1991;99:1037–1038.PubMedGoogle Scholar
  13. 13.
    Sprung J, Jones FD, Rosen JS, Thomas P, Bourke DL. Asymptomatic carotid stenosis and stroke during neck surgery. Otolaryngol Head Neck Surg 1996;115:568–572.PubMedCrossRefGoogle Scholar
  14. 14.
    Schubert A, Mascha EJ, Bloomfield EL, DeBoer GE, Gupta MK, Ebrahim ZY. Effect of cranial surgery and brain tumor size on emergence from anesthesia. Anesthesiology 1996;85:513–521.PubMedCrossRefGoogle Scholar
  15. 15.
    Albrecht RF Jr, Wagner SR, Leicht CH, Lanier WL. Factitious disorder as a cause of failure to awaken after general anesthesia. Anesthesiology 1995;83:201–204.PubMedCrossRefGoogle Scholar
  16. 16.
    Cherng CH, Wong CS, Ho ST. Acute aphesia following tourniquet release in intravenous regional anesthesia with 0.75% lidocaine. Reg Anesth Pain Med 2000;25:211–212.PubMedGoogle Scholar
  17. 17.
    Nicoll JM, Acharya PA, Ahlen K, Baguneid S, Edge KR. Central nervous system complications after 6000 retrobulbar blocks. Anesth Analg 1987;66:1298–1302.PubMedCrossRefGoogle Scholar
  18. 18.
    Scott DL, Ghia JN, Teeple E. Aphasia and hemiparesis following stellate ganglion block. Anesth Analg 1983;62:1038–1040.PubMedCrossRefGoogle Scholar
  19. 19.
    Haile DT, Frie ED, Hall BA, Sprung J. Transient postoperative aphonia following instillation of bupivacaine into the shoulder joint. Can J Anaesth 2006;53:212–213.PubMedCrossRefGoogle Scholar
  20. 20.
    Schneider H, Paul A. [Transient total motor aphasia. A complication of an axillary brachial plexus block]. Anaesthesist 1992; 41:423–425.PubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2006

Authors and Affiliations

  • James R. Munis
    • 1
  • Anthony W. Marcukaitis
    • 1
  • Juraj Sprung
    • 1
  1. 1.Department of AnesthesiologyMayo Clinic College of MedicineRochester

Personalised recommendations