Bilateral Thalamic and Right Mesencephalon Infarct Following General Anesthesia for Rectum Cancer With Laparoscopic Low Anterior Surgery: An Extreme Case of Perioperative Stroke

Abstract

Turkish Abstract

Introduction

Colorectal cancer (CRC) is a severe health problem worldwide, and it is currently the third most common cancer and the leading cause of cancer-related deaths in the United States¹. After the diagnosis of CRC, en-bloc surgery with adequate lymphadenectomy is a curative treatment in local or resectable CRC patients². Although surgery is the primary modality in selected cases, it can be associated with complications such as hemorrhage, anastomotic leak, surgical site infection, and perioperative stroke (POS). Bilateral thalamic and mesencephalon infarct (BTMI) due to POS is rare after colorectal surgery for rectal cancer in clinical practice³. Bilateral thalamic infarct is 0.6% of all cerebral infarctions³. These cases generally have impairment of consciousness, diplopia, sleepness, cognitive disturbances, and atypical observable symptoms⁴. After diagnosing BTMI in magnetic resonance imaging, medical treatments such as low-molecular-weight heparin, clopidogrel, and duloxetine are essential for clinical courses5. We aim to present the successful management of the BTMI duo to POS following laparoscopic low anterior surgery.

Case Report

A 55-year-old female patient was admitted with a complaint of rectal bleeding for rectum cancer. The patient had hypertension and no smoking, alcohol, coagulant disorder, or coronary artery thrombosis anamnesis in history. The laboratory's hemoglobin, iron, and carcinoembryonic antigen (CEA) were ten g/dl, level 26 µg/dl, and 56.5 µg/dl. Colonoscopy showed rectum cancer with partial obstruction. After anesthesia consultation, she underwent laparoscopic low anterior resection with a loop ileostomy. The laparoscopic surgery was uneventful, and there was no intraoperative complication during surgery and anesthesia. The patient was taken to an intensive care unit and monitored.
On the first postoperative day, a lack of cooperation delayed awakening after general anesthesia, mild disturbance of consciousness, hypersomnia, and vision defect occurred. Typical signs were vertebral carotid artery doppler ultrasonography and computed tomography (CT). MRI diffusion revealed the acute ischemic process in the right half of the fourth ventricle and the right posterior cerebral artery area circulation. Moreover, a contrast-enhanced MRI demonstrated the acute ischemia that shows diffusion restriction in bilateral thalamus and right mesencephalon levels. Neurology confirmed BTMI with nervous abducens and suggested low-molecular-weight heparin, modafinil of 100 mg, clopidogrel of 75 mg, and duloxetine of 30 mg. The patient recovered slightly after anticoagulant treatment and was discharged with a mild level of neurological sequelae postoperative fourteen days. She followed up on neurology and oncology polyclinics. After several months, the patient is in the postoperative 10th month, and there are no neurological sequelae.

Figure 1 Specimen of laparoscopic low anterior resection with tattoo

Figure 2 Bilateral thalamic and right mesencephalon infarct with magnetic resonance imaging

Discussion

CRC is a significant malignancy that can cause morbidity and mortality in the postoperative period or late diagnosis. An annual incidence of CRC is approximately 30-45/100000¹. Although surgery is the primary treatment approach, some crucial complications can occur, no matter how many precautions². Most critical difficulties lead to patients or operations, and an infarct following surgery, especially under general anesthesia, can cause several morbidity and mortality. Perioperative stroke (POS) is an emergency and life-threatening clinical entity that requires early diagnosis and treatment³. Bilateral thalamic infarction should be considered in the differential diagnosis of POS^3,4. Bilateral thalamic and right mesencephalon with nervous abducens injury infarct following general anesthesia is extraordinary for rectal cancer.
Some risk factors include hypercoagulopathy, cardiac emboli, oral contraceptives, pregnancy, dehydration, vasculitis, inflammatory bowel disease, malignancy, systemic infections, genetic mutations, and coagulation factor deficiency can cause cerebrovascular infarction or thrombosis^4,5. Furthermore, a cardiac embolism is a significant risk factor associated with bilateral thalamic infarcts^6,7. On the other hand, hypothermia, metabolic disturbances, relative or absolute overdosage of medications, and anesthetics agents can occur during perioperative strokes⁷. Therefore, it has suggested an interdisciplinary approach to prevent complications. Nonetheless, in the present case, there was no risk factor such as coagulation disorder, obesity, smoking, or drug use to cause BTMI.

Four perforated arteries nourish the thalamus. First, thalamogeniculate arteries arising from the P2 segment of the posterior cerebral artery (PCA) maintain the lateral part of the thalamus. Second, the polar artery originated from the posterior communicant artery (PcoA), which provides blood to the anterior part of the thalamus. Third, the thalamoperforate (paramedian) arteries emerge from the P1 segment of the PCA to irrigate the medial aspect of the thalamus. Finally, the posterior choroidal artery arising from the PCA provides blood supply to the pulvinar, posterior thalamus, and geniculate bodies8. As a result, different clinical symptoms and signs occur in ischemia/infarct or perfusion dysfunction⁹. Bilateral thalamic infarct develops in 75% of paramedian (paramedian artery) and 44% of inferolateral (thalamogeniculate artery) area^3,9. A classic triad of paramedian thalamic infarction consists of acute changes in consciousness, neuropsychological disorders, and vertical gaze disorders.

Moreover, lethargy, stupor, and hypersomnolence may be seen. Patients can be awakened, but they begin to fall asleep as soon as the stimulus ceases. Consciousness disorders are due to the involvement of the rostral mesencephalon and intralaminar nuclei. There may be vertical gaze disorders in which upward gaze paralysis is frequently seen. Neuropsychological anomalies, such as disorientation, apathy, apathy, anterograde amnesia, and recent memory defects and confabulations, can be observed in clinical practice. In infarcts involving the right medial thalamus, visual neglect, and constructional apraxia can be seen on the left. The findings are similar in bilateral thalamic infarcts, but they are more severe and permanent^3,9,10. In the present case report, her arterial pressure and other parameters were normal during surgery. However, a lack of cooperation, mild consciousness disturbance, and vision defect occurred on the first postoperative day.
Computed tomography and MRI are required to diagnose BTMI. In 1983, Guberman et al. diagnosed BTMI by CT and clinical examination¹¹. In addition, Lepore et al. showed the result of autopsy and MRI findings¹². However, a CT is not more sensitive to diagnosis in the acute process of BTI. So, primarily, MRI is suitable and effective in the first hours of clinical symptoms¹².

Management of BTMI has required early diagnosis and treatment. Postoperative perfusion thalamic and mesencephalon infarct have a good prognosis if early diagnosis and treatment begin. Anticoagulants Low-molecular weight-heparin and clopidogrel have been recommended in medical treatment¹². Furthermore, modafinil can be effective for sleepiness due to narcolepsy.

Acknowledgement

There is no financial and commercial support, translation, statistics, technical support for graphics, tables, and figures.

Informed Consent

References

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Information Presentation

38. ulusal gastroenteroloji haftası ve gastroenteroloji cerrahisi kongresinde, Antalya, 16-21 Kasım.