Anesth Analg 2003;97:1854-1855
© 2003 International Anesthesia Research Society
LETTERS TO THE EDITOR
Mutism as a Complication of Total Intravenous Anesthesia by Propofol
Saffet Karaca, MD
Department of Anesthesiology, Medicine Faculty of Cerrahpasa, Istanbul University, Istanbul, Turkey
To the Editor:
Kati et al. (1) describe a 56-year-old woman who developed somnolence and mutism for 11 days postoperatively after total IV anesthesia with fentanyl, propofol, and vecuronium for a cemented hemiarthroplasty of the left hip. The authors concluded that this neurologic complication may be attributed to an unknown effect of propofol.
I think another possible explanation for the symptoms described in the case may have been a presentation of "cerebral microembolism after cemented hemiarthroplasty of the hip."
FAT embolism is known to occur after long-bone fracture and total hip arthroplasty (THA) (1,2). It is usually assumed that these emboli are trapped in the lung and do not reach the systemic circulation. On rare occasions, stroke may occur after THA, and this has been ascribed to paradoxical embolism via a patent foramen ovale (PFO) (3–6). Transpulmonary passage of small emboli, both fat and air, has recently been shown in experimental models (7). This introduced the possibility that the microemboli entering the lung during THA could traverse the lung and undergo embolization into the systemic circulation.
With use of transcranial Doppler sonography, embolic signals in the middle cerebral artery were detected during THA. The majority of signals occurred either during insertion of the cemented femoral component or immediately after relocation of the hip joint (8).
Brain computerized tomography images were not helpful for the diagnosis of small and multiple areas of acute or subacute brain infarction occasionally present with clinical features atypical for brain embolism. They can be detected by diffusion weighted brain imaging (DWI). DWI is a relatively recent imaging technique, which shows ischemic tissue damage within minutes after onset of the injury (9). However, it may also be useful in identifying subacute ischemic lesions in patients with minor stroke or transient ischemic attack who present several weeks after symptom onset (10,11).
References
- Kati I, Demirel CB, Anlar O, et al. An unusual complication of total intravenous anesthesia: mutism. Anesth.Analg 2003; 96: 168–70.[Abstract/Free Full Text]
- Patterson BM, Healey JH, Cornell CN, Sharrock NE. Cardiac arrest during hip arthroplasty with a cemented long-stem component. J Bone Joint Surg Am 1991; 73: 271–7.[Abstract/Free Full Text]
- Woo R, Minster GJ, Fitzgerald RH Jr, et al. Pulmonary fat embolism in revision hip arthroplasty. Clin Orthop 1995; 319: 41–53.[Medline]
- Christie J, Burnett R, Potts HR, Pell ACH. Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br 1994; 76: 409–12.[Medline]
- Ereth MH, Weber JG, Abel MD, et al. Cemented versus noncemented total hip arthroplasty: embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992; 67: 1066–74.[Web of Science][Medline]
- Pell ACH, Christie J, Keating JF, Sutherland GR. The detection of fat embolism by transesophageal echocardiography during reamed intramedullary nailing. J Bone Joint Surg Br 1993; 75: 921–5.[Medline]
- Weiss SJ, Cheung AT, Stecker MM, et al. Fatal paradoxical cerebral embolization during bilateral knee arthroplasty. Anesthesiology 1996; 84: 721–3.[Web of Science][Medline]
- Byrick RJ, Mullen JB, Mazer CD, Guest CB. Transpulmonary systemic fat embolism: studies in mongrel dogs after cemented arthroplasty. Am J Respir Crit Care Med 1994; 150: 1416–22.[Abstract]
- Edmonds CR, Barbut D, Hager D, Sharrock NE. Intraoperative cerebral arterial embolization during total hip arthroplasty. Anesthesiology 2000; 93: 315–8.[Web of Science][Medline]
- Aly A, Babikian VL, Barest G, et al. Brain microembolism. J Neuroimaging 2003; 13: 140–6.[Medline]
- Schulz UG, Briley D, Meagher T, et al. Abnormalities on diffusion weighted magnetic resonance imaging performed several weeks after a minor stroke or transient ischaemic attack. J Neurol Neurosurg Psychiatry 2003; 74: 734–8.[Abstract/Free Full Text]
Response
Ismail Kati, MD,
C. Bekir Demirel, MD,
Omer Anlar, MD,
Urfettin A. Hüseyinoglu, MD,
Emin Silay, MD, and
Kamuran Elcicek, MD
Yüzüncü Yil Üniversitesi, Tip Fakültesi Anesteziyoloji AD, Van, Turkey
In Response:
We appreciate the interesting comments from Dr. Karaca regarding our case report. However, the diffusion-weighted brain imaging technique is not available in our region.
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