Anesth Analg 2006;103:1625-1626
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000246281.32826.e1
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
Acute Cerebellar Stroke After Inadvertent Cannulation and Pulmonary Artery Catheter Placement in the Right Vertebral Artery
Mary E. Arthur, MD,
Manuel R. Castresana, MD,
Jack W. Paschal, MD, and
Vijay S. Patel, MD
Department of Anesthesiology and Perioperative Medicine; Division of Cardiothoracic and Critical Care Anesthesia; marthur{at}mail.mcg.edu (Arthur, Castresana, Paschal)
Department of Cardiothoracic Surgery; Medical College of Georgia; Augusta, Georgia (Patel)
To the Editor:
Although external anatomic landmarks have traditionally been used to identify the location of the internal jugular vein, factors such as hyperextension of the neck and extreme head rotation may lead to a miscalculation (1,2). If the needle is directed too laterally or inserted too deeply, puncture of the vertebral artery may occur (3,4), which may result in stroke.
A 68-year-old man with significant three-vessel coronary artery disease presented for coronary artery bypass grafting. We identified anatomic landmarks and used a 1  in. 22-gauge needle to locate the internal jugular vein. We placed an 18-gauge catheter in the path of the finder needle until the blood was aspirated. We noted nonpulsatile blood return and inserted a 9F introducer sheath, using the Seldinger technique. Upon attempting to float the pulmonary artery catheter, we noted an arterial wave form tracing. Checking our position with a handheld ultrasound device (SonoSite, Bothell, WA) revealed that the sheath was located in a pulsatile vessel other than the carotid artery. Surgical exploration of the neck identified a large hematoma surrounding an uninjured carotid and the sheath lodged in the right vertebral artery (5). The sheath was removed and then the vessel was repaired. Cardiac surgery was postponed to forestall a hemorrhagic conversion of the infarct (6,7).
Brain computed tomography (CT) scan 10 h after surgical exploration showed focal hypodensity within the right cerebellum in the right posterior internal cerebellar artery (PICA) (Fig. 1). An angiogram of the neck showed a right vertebral artery visualizable only at the C2–3 level ascending toward the transverse foramina to join the left vertebral artery; magnetic resonance imaging (MRI) of the brain showed an acute infarct involving the right cerebellum and straddling the right horizontal fissure in a watershed distribution between the PICA and the superior cerebellar artery (SCA) (Fig. 2). The patient did not have any clinical sequel. Follow-up serial CT scans and MRI of the brain showed decreased edema and no hemorrhagic conversion. The patient did well and 4 wk later underwent uneventful coronary revascularization.
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Figure 1. CT of the brain without contrast showing a focal hypodensity within the right cerebellum posteriorly consistent with the right PICA distribution.
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Figure 2. MRI of the brain with diffusion-weighted images showing an acute infarct involving the right cerebellum that appears to straddle the right horizontal fissure of the cerebellum almost in a watershed distribution between the PICA and SCA.
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This rare, but potentially serious, complication might have been prevented, had we used ultrasound guidance in cannulating the internal jugular vein (8,9). If the vertebral artery is cannulated, surgical exploration with repair of the vessel should be performed, followed by neurological and radiological studies to detect a possible infarction.
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