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LETTERS TO EDITOR
Year : 2018  |  Volume : 62  |  Issue : 3  |  Page : 238-239  

Acute exacerbation of Chiari malformation: A rare cause for non-awakening from anaesthesia


1 Department of Onco-Anaesthesia and Palliative Medicine, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication14-Mar-2018

Correspondence Address:
Dr. Kanil Ranjith Kumar
Department of Anaesthesiology, Pain Medicine And Critical Care, All India Institute of Medical Sciences, Room No. 5011, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_760_17

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How to cite this article:
Vig S, Kumar KR, Poudel D. Acute exacerbation of Chiari malformation: A rare cause for non-awakening from anaesthesia. Indian J Anaesth 2018;62:238-9

How to cite this URL:
Vig S, Kumar KR, Poudel D. Acute exacerbation of Chiari malformation: A rare cause for non-awakening from anaesthesia. Indian J Anaesth [serial online] 2018 [cited 2019 Dec 15];62:238-9. Available from: http://www.ijaweb.org/text.asp?2018/62/3/238/227355



Sir,

Arnold  Chiari malformation More Details (ACM) is described as underdevelopment of posterior fossa with varying degrees of cerebellar herniation.[1] It is commonly associated with hydrocephalus and meningomyelocele. We report non-awakening from anaesthesia in a patient with ACM with sacral meningomyelocele who underwent meningomyelocele correction.

A 2-year-old 12 kg male child, diagnosed with a case of sacral meningomyelocele with spina bifida was posted for surgical correction. Preoperatively, the child had weakness in lower limbs with no bladder and bowel control. Magnetic resonance imaging (MRI) showed spina bifida at S1 to S3 with meningomyelocele and low lying tethered cord. ACM with mild tonsillar herniation of 5 mm was present.

Anaesthesia was induced with fentanyl 25 mcg and propofol 30 mg. Atracurium 6 mg was used for orotracheal intubation. Intubation was uneventful, and the child was placed prone with head in neutral position. Anaesthesia was maintained with oxygen, air and sevoflurane with minimum alveolar concentration 1–1.1. The tethered cord was separated, large dural defect was repaired using dorsolumbar fascia, and a theco-peritoneal shunt was placed.

The total duration of surgery was 210 min. Blood loss was 30 ml, and the patient received 450 ml of crystalloids. There were no episodes of bradycardia or hypotension during surgery. At the end of surgery, neuromuscular blockade was reversed with neostigmine 600 mcg and glycopyrrolate 120 mcg. There were no signs of spontaneous respiratory effort. Only three doses of fentanyl (6 mcg each) were used for analgesia, and the nasopharyngeal temperature was 36.2°C.

Blood sugar, arterial blood gas (PH-7.38, PCO2-38, PO2-460, Na-135, K-4.2, Cl-108, HCO3-22, BE--2 Lactate-0.9, Glucose-110) and serum electrolytes were done to rule out other causes for delayed awakening, all were within normal range.

After excluding anaesthesia related causes for delayed recovery and being a case of ACM, we suspected an intracranial complication such as cerebellar herniation, pneumocephalus or subdural haemorrhage. Furthermore, pupils were unusually dilated and reacted sluggishly to light. Urgent computed tomography (CT) brain was done which showed crowding at the foramen magnum. CT brain excluded pneumocephalus and intracranial bleed but was inconclusive for cerebellar herniation. An emergency MRI confirmed exaggeration of Chiari malformation with tonsillar herniation up to 28 mm [Figure 1]. The child underwent emergency foramen magnum decompression with C1–C2 laminectomy, but there was no improvement in neurological status.
Figure 1: Magnetic resonance imaging showing tonsillar herniation with brain stem and spinal cord compression

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Acute exacerbation of Chiari malformation may present as foramen magnum syndrome. There are previous reports of acute tonsillar herniation after lumbar puncture and lumboperitoneal shunt placement.[2] Acute cerebellar herniation presenting as non-awakening from anaesthesia has not been reported. In our case, preexisting ACM and change in craniospinal cerebrospinal fluid (CSF) pressure gradient after opening the dura could have caused the initial displacement. The arrested CSF flow at foramen magnum with a shunt at spinal level could have further worsened the herniation.[3]

Anaesthesiologist may minimise intra-operative CSF leak by maintaining head low position at the time of dural opening and repair. Further we should keep a close watch on the amount of CSF leak apart from haemodynamic monitoring. From this case report, we hypothesise tonsillar herniation probably had set in due to CSF leak during repair of the large dural defect, which further got aggravated by placement of theco-peritoneal shunt. This unforeseen neurological complication may present as non-awakening from general anaesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Northrup H, Volcik KA. Spina bifida and other neural tube defects. Curr Probl Pediatr 2000;30:313-32.  Back to cited text no. 1
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2.
Sugrue PA, Hsieh PC, Getch CC, Batjer HH. Acute symptomatic cerebellar tonsillar herniation following intraoperative lumbar drainage. J Neurosurg 2009;110:800-3.  Back to cited text no. 2
    
3.
Dagnew E, van Loveren HR, Tew JM Jr. Acute foramen magnum syndrome caused by an acquired Chiari malformation after lumbar drainage of cerebrospinal fluid: Report of three cases. Neurosurgery 2002;51:823-8.  Back to cited text no. 3
    


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