J Clin Neurol.  2018 Jul;14(3):393-400. 10.3988/jcn.2018.14.3.393.

Postoperative Transient Neurologic Dysfunction: A Proposal for Pathophysiology

• Phi JH
• Lee SJ
• Kang HS
• Kim JE
• Kim SK
• Cho WS
• Lee SY

• KMID: 2415058
• DOI: http://doi.org/10.3988/jcn.2018.14.3.393

Abstract

BACKGROUND AND PURPOSE
Sudden neurological deterioration which cannot be explained by structural change, ischemia or seizure is often observed among neurosurgical patients. We aimed to provide new insight into the pathophysiology of postoperative transient neurologic dysfunction.
METHODS
We describe prolonged but fully reversible focal neurologic dysfunction of unknown origin based on the initial evaluation in 8 patients who had received encephalo-duro-arterio-synangiosis for moyamoya disease. We performed brain imaging, including diffusion weighted imaging and perfusion magnetic resonance imaging or single photon emission computed tomography, and electroencephalography (EEG) during the episodes and after resolution of the symptoms.
RESULTS
The symptoms consisted of dysarthria, hemiparesis, or hemiparesthesia of limbs contralateral to the operated side. These symptoms developed between 12 hours and 8 days after surgery and lasted between 12 hours and 17 days. Structural imaging did not show any significant interval change compared with the immediate postoperative images. Perfusion imaging showed increased cerebral blood flow in the symptomatic hemisphere. EEG revealed low amplitude arrhythmic slowing in the corresponding hemisphere. Follow-up imaging and EEG after recovery did not show any abnormalities.
CONCLUSIONS
Transient neurologic dysfunction can occur during the postoperative period of brain surgery. Although this may last more than usual transient ischemic attack or seizure, it eventually resolves regardless of treatment. Based on our observation, we propose that this is the manifestation of the transient cortical depression triggered by mechanical stimulation, analogous to migraine aura associated with cortical spreading depression.

Keyword

transient neurologic dysfunction; cortical spreading depression; postoperative; migraine; moyamoya disease; encephalo-duro-arterio-synangiosis

MeSH Terms

Brain
Cerebrovascular Circulation
Cortical Spreading Depression
Depression
Diffusion
Dysarthria
Electroencephalography
Epilepsy
Extremities
Follow-Up Studies
Humans
Ischemia
Ischemic Attack, Transient
Magnetic Resonance Angiography
Migraine Disorders
Moyamoya Disease
Neuroimaging
Neurologic Manifestations*
Paresis
Perfusion Imaging
Postoperative Period
Seizures
Tomography, Emission-Computed, Single-Photon

Figure

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  Fig. 1 Perfusion MRI of patient 1 (Case 1) taken one week after the onset of intraventricular hemorrhage prior to surgery, on postoperative day 5 during the second episode of left arm weakness, and after recovery. A subtle increase in cerebral blood volume and CBF with shortening of TTP in the right frontal area was noticed during the second episode, compared with the images obtained at the preoperative period and after recovery from the episodes. CBF: cerebral blood flow, TTP: time to peak.

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  Fig. 2 Electroencephalography performed during the second episode of left arm weakness in patient 1 (Case 1). Continuous low amplitude arrhythmic mixed slowing was observed in the right hemisphere.

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  Fig. 3 Brain imaging and EEG tracings of patient 4 (Case 2). Left: single photon emission computed tomography performed during the preoperative and the postoperative period. There was an increase in perfusion in the right frontoparietal area during the episode compared with the preoperative period. Right: EEG performed during the episode shows continuous low amplitude arrhythmic mixed slowing was seen in the right hemisphere. EEG: electroencephalography.

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