title: Delayed emergence from anesthesia associated with absent brainstem reflexes following suboccipital craniotomy.
abstract: One of the most feared complications after intracranial surgery is development of acute intracranial pathology, which may result in hypoperfusion and brain injury. Thus, early neurological assessment, performed in the operating room immediately after emergence from anesthesia, is a practice that may contribute to timely diagnosis of neurosurgical complications. Failure to awake after general anesthesia precludes conductance of neurological assessment. We report a patient who failed to emerge from anesthesia after suboccipital craniotomy and had absent brain-stem reflexes with fixed and dilated pupils consistent with severe brain injury. Approximately 60 minutes after termination of surgery, the patient suddenly woke up. After the fact, we discovered that the neurosurgeon performed a generous field block with bupivacaine along the neck incision line. We presume that our patient's failure to awaken was caused by paralysis of brain-stem caused by migration of bupivacaine from the site of the injection.
authors.affiliation: Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: James R
authors.initials: JR
authors.lastname: Munis
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Marcukaitis
authors.forename: Juraj
authors.initials: J
authors.lastname: Sprung
mesh_terms: D000328:Adult; D000762:Anesthesia Recovery Period; D000768:Anesthesia, General; D000779:Anesthetics, Local / Q000009:adverse effects*; D001139:Arnold-Chiari Malformation / Q000601:surgery*; D001933:Brain Stem / Q000187:drug effects*; D002045:Bupivacaine / Q000009:adverse effects*; D003399:Craniotomy / Q000009:adverse effects*; D006801:Humans; D007273:Injections, Intramuscular / Q000009:adverse effects; D008297:Male; D009334:Neck Muscles / Q000187:drug effects; D009460:Neurologic Examination / Q000187:drug effects; D009777:Occipital Bone / Q000601:surgery; D011183:Postoperative Complications / Q000139:chemically induced*; D012021:Reflex, Abnormal; D012025:Reflex, Pupillary / Q000187:drug effects; D012075:Remission, Spontaneous
chemical_list: D000779:Anesthetics, Local; D002045:Bupivacaine