A Case of Delayed Spontaneous Aneurismal Rupture after Ear Surgery Under General Anesthesia
A 54-year-old woman visited our department due to bilateral hearing impairment and intermittent otorrhea without dizziness of protracted duration. She did not have tinnitus or otalgia, but complained of recent symptom aggravation. Furthermore, she had no known history of medical or surgical problems, except that she was a chronic hepatitis B carrier.\nDuring physical and radiological examinations, a yellowish purulent discharge was noted in the right ear canal and attic destruction was identified. The left ear drum was thinned inferiorly and in a retracted state (), and the Weber test showed left deviation. Pure tone audiometry showed air conduction threshold of 72 dB HL and bone conduction threshold of 28 dB HL for the right ear and air conduction threshold of 50 dB HL and bone conduction threshold of 20 dB HL for the left. Auditory brainstem response testing showed peak waves at 70 dBnHL on the right and at 50 dBnHL on the left. A temporal bone computed tomographic (CT) scan showed sclerosis of mastoid bone and soft tissue densities in the middle ear, attic area, and mastoid cavity on the right side (), but ossicles and other inner ear structures, and the external auditory canal were relatively healthy. Other routine laboratory tests were within normal ranges. However, no evaluation of cerebrovascular structures was performed.\nTwo days after admission, right side canal wall up mastoidectomy with type I tympanoplasty was performed under general anesthesia. The dura and sigmoid sinus were not exposed during surgery. At about 2 hours after surgery, the patient complained of a headache and a rigid sensation in upper and lower extremities. At this time, her blood pressure was elevated at 170/100. Mentally, she was mildly drowsy and oxygen saturation had fallen to 80%. Accordingly, she was placed on mask ventilation, and our department of internal medicine was consulted regarding management. Endo-tracheal intubation was decided upon but not instituted because her condition recovered to near normal within an hour. Department of neurosurgery was then asked to undertake a proper evaluation. However, brain CT returned non-specific findings. Subsequently, the patient was followed a normal recovery course and pattern. Nevertheless, we recommended further evaluation, particularly brain magnetic resonance image, but the patient and her family rejected the idea. Accordingly, regular discharge was ordered 1 week after surgery.\nTwo weeks after discharge, the patient visited our emergency room with a severe headache and a mental status of stupor. Emergent brain CT and angiography was performed and a subarachnoid hemorrhage (SAH) from a ruptured anterior intercommunicating artery was visualized (). Emergent trephination was performed, and subsequently, she was admitted to our neurologic intensive care unit. Nevertheless, intracranial bleeding persisted at follow-up brain CT 2 days later (). The patient expired 1 week after this second admission without recovering consciousness.