Neurologic complications of anesthesia: A practical approach

Postoperative Neurological Deficits Following Regional Anesthesia: A Rare Case of Transient Aphasia and Hemiparesis

Neurological impairments after anesthesia are fairly common and can oftentimes be serious. A thorough patient evaluation is imperative to discriminate between impairments related to the anesthesia itself and more serious, unrelated complications. Transient motor deficits, aphasia, and postoperative delirium have been reported after general anesthesia and can be related to perioperative stress, exacerbation of previous undiagnosed neurological disorders, and the under-reported psycho-emotional effects of undergoing anesthesia. We present the case of a 57-year-old female who developed expressive aphasia and right-sided weakness following elective ankle arthrodesis performed under monitored anesthesia care (MAC) with regional anesthesia. Medical history was significant for type 2 diabetes mellitus (T2DM), hypertension (HTN), chronic kidney disease (CKD), and Charcot joint. Her presentation sparked initial concern for a cerebrovascular event; however, imaging ruled out stroke and large vessel occlusion. Her neurological deficits were attributed to a rare and under-reported anesthesia-related complication: the psycho-emotional effects of regional anesthesia. The patient demonstrated a gradual recovery of speech and motor function without additional interventions and required inpatient rehabilitation to regain functional independence. This case highlights the importance of prompt evaluation of postoperative neurological symptoms, particularly in patients with significant comorbidities, and underscores the need for increased awareness of rare complications associated with anesthesia.

Anesthetic Considerations in Athletes: A Review

Athletes present a unique challenge for anesthesiologists because of their specific physiology and the demands of their sport. Anesthesia for athletes requires careful consideration of factors such as muscle mass, hydration status, and the potential for drug interactions with performance-enhancing substances. Additionally, the use of specific anesthetic agents, such as inhalational and intravenous anesthetics, requires adjustments to the dosing regimen to ensure adequate anesthesia. Sports anesthesia is a subspecialty that encompasses not only expert knowledge regarding regional and general anesthesia and pain management but also the pathophysiology unique to athletes and psychological concerns associated with professional sports and complete knowledge about World Anti-Doping Agency guidelines as well as substance abuse. Moreover, the pressure of being scrutinized by a broad circle of concerned persons, including family members, team members, coaches, club owners, media, and fans, makes this an area of excellence and expertise. This review highlights how an athlete's physiological changes can alter anesthetic drug effects. Considering the importance of vigilant preoperative assessment, selecting the proper anesthesia plan, and perioperative strategies for better recovery and performance outcomes.

Movement Disorders Associated With Radiotherapy and Surgical Procedures

Occasionally, movement disorders can occur following interventional procedures including but not limited to radiotherapy, dental procedures, and cardiac, cerebral and spinal surgeries. The majority of these disorders tend to be unexpected sequelae with variable phenomenology and latency, and they can often be far more disabling than the primary disease for which the procedure was performed. Owing to poor knowledge and awareness of the problem, delays in diagnosing the condition are common, as are misdiagnoses as functional movement disorders. This narrative review discusses the phenomenology, pathophysiology, and potential treatments of various movement disorders caused by interventional procedures such as radiotherapy and neurological and non-neurological surgeries and procedures.

Neurologic Complications of Surgery and Anesthesia

Surgery and anesthesia carry risks of ischemic, hemorrhagic, hypoxic, and metabolic complications, all of which can result in neurologic symptoms and deficits. Patients with underlying cardiovascular and cerebrovascular risk factors are particularly vulnerable. In this article the authors review the neurologic complications of surgery and anesthesia, with a focus on the role of the neurologic consultant in preoperative evaluation and risk stratification and diagnosis and management of postoperative complications.

Hepatic Encephalopathy: From Metabolic to Neurodegenerative

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome of both acute and chronic liver disease. As a metabolic disorder, HE is considered to be reversible and therefore is expected to resolve following the replacement of the diseased liver with a healthy liver. However, persisting neurological complications are observed in up to 47% of transplanted patients. Several retrospective studies have shown that patients with a history of HE, particularly overt-HE, had persistent neurological complications even after liver transplantation (LT). These enduring neurological conditions significantly affect patient's quality of life and continue to add to the economic burden of chronic liver disease on health care systems. This review discusses the journey of the brain through the progression of liver disease, entering the invasive surgical procedure of LT and the conditions associated with the post-transplant period. In particular, it will discuss the vulnerability of the HE brain to peri-operative factors and post-LT conditions which may explain non-resolved neurological impairment following LT. In addition, the review will provide evidence; (i) supporting overt-HE impacts on neurological complications post-LT; (ii) that overt-HE leads to permanent neuronal injury and (iii) the pathophysiological role of ammonia toxicity on astrocyte and neuronal injury/damage. Together, these findings will provide new insights on the underlying mechanisms leading to neurological complications post-LT.

Early clinical surrogates for outcome prediction after stroke thrombectomy in daily clinical practice

BACKGROUND AND PURPOSE

To investigate early clinical surrogates for long-term independency of patients treated with thrombectomy for large vessel occlusion stroke in daily clinical routine.

METHODS

All patients with anterior circulation stroke enrolled in the German Stroke Registry-Endovascular Treatment from 07/2015 to 04/2018 were analysed. National Institute of Health Stroke Scale (NIHSS) on admission, NIHSS percentage change, NIHSS delta and NIHSS at 24 hours as well as existing binary definitions of early neurological improvement (ENI; improvement of 8 (major ENI)/10 (dramatic ENI) NIHSS points or reaching 0/1 were compared for predicting functional outcome at 90 days using the modified Rankin Scale (mRS). Excellent and favourable outcome were defined as 0-1 and 0-2, respectively.

RESULTS

Among 2262 endovasculary treated patients with acute ischaemic anterior circulation stroke, NIHSS at 24 hours had the highest discriminative ability to predict excellent (receiver operator characteristics (ROC)_{NIHSS 24 hours} area under the curve (AUC) 0.86 (0.84-0.88)) and favourable long-term functional outcome (ROC_{NIHSS 24 hours} AUC 0.86 (0.85-0.88)) in comparison to NIHSS percentage change (ROC_{% change} AUC mRS ≤1: 0.81 (0.78-0.83) mRS ≤2: 0.81 (0.79-0.83)), NIHSS delta change (ROC_{Δ change} AUC mRS ≤1: 0.74 (0.72-0.77), mRS ≤2: 0.77 (0.74-0.79)) and NIHSS admission (ROC_Adm AUC mRS ≤1: 0.70 (0.68-0.73), mRS ≤2: 0.67 (0.68-0.71)). Advanced age was the only independent predictor (adjusted OR 1.05, 95% CI 1.03 to 1.07, p<0.001) for turning the outcome prognosis from favourable (mRS ≤2) to poor (mRS ≥4) at 90 days.

CONCLUSION

The NIHSS at 24 hours postintervention with a threshold of ≤8 points serves best as a surrogate for long-term functional outcome after thrombectomy for anterior circulation stroke in daily clinical practice. Only advanced age significantly decreases its predictive value.