Intracranial bleeding following induction of anesthesia in a patient undergoing elective surgery for refractory epilepsy
The patient was a 47-year-old male with hypertension who was diagnosed with multi drug-resistant Left (L) temporal lobe seizures secondary to (L) mesial temporal sclerosis. His seizure had started at the age of 35 years. The seizure semiology was that of a complex partial seizure with secondary generalization. Electroencephalography (EEG) revealed the seizures to be originating from the (L) temporal lobe. A Video EEG further confirmed the (L) temporal seizure focus and was concordant with the previous EEG and imaging features. He was investigated with a magnetic resonance image of the brain, which revealed evidence of mesial temporal sclerosis of the (L) temporal lobe. Patient was then submitted for neuropsychological evaluation and found to be suitable for epilepsy surgery. He was admitted for an elective anterior temporal lobectomy with amygdalo-hippocampectomy. The preoperative imaging done did not reveal evidence of any other underlying abnormality in the brain besides the mesial temporal sclerosis.\nPatient was admitted electively for his surgery. During the preoperative evaluation he was found to be well with a controlled blood pressure of 130/80 on a single oral antihypertensive medication. Just prior to induction, his blood pressure was noted to be 150/100. Patient was subsequently induced using intravenous propofol, fentanyl, and rocuronium. Intubation was then done using an appropriately sized tube. No difficulty was encountered during this procedure. Patient was then maintained on total intravenous anesthesia (TIVA). Blood pressure monitoring revealed that the initial postinduction blood pressure was 180/100, which subsequently was controlled and maintained so throughout the surgery at a range of systolic 170-120 and diastolic 90-60. Patient was subsequently handed over to the neurosurgical team.\nFollowing craniotomy, it was noted that the dura and underlying brain was very tense. Upon durotomy, the brain bulged out and there was evidence of subarachnoid hemorrhage seen over the cortical surface. A transcortical approach was attempted via the medial temporal gyrus. During corticectomy, an intraparenchymal clot was encountered. The clot was evacuated and subsequently a left selective amygdalo-hippocampectomy was performed [Figure -].\nIn the immediate postoperative patient was kept ventilated and sedated. A computed tomographic (CT) scan of his brain revealed the presence of a small residual temporoparietal intraparenchymal clot as well as bleeding with the subarachnoid space especially in the region of the left sylvian fissure []. CT Angiography as well as digital subtraction angiography was done and revealed no evidence of any underlying vascular lesion that might be the source of intraparenchymal bleeding that was noted intraoperatively. This patient's postoperative course was complicated with hydrocephalus with ventriculitis as well as nosocomial pneumonia. Despite aggressive therapy he succumbed to widespread infection about one month postoperatively.