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LETTER TO EDITOR
Year : 2012  |  Volume : 6  |  Issue : 1  |  Page : 81-82

Persistent electrocardiogram changes during excision of craniopharyngioma


Department of Neuroanesthesiology Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Tumul Chowdhury
Department of Neuroanesthesiology, Neurosciences Center, 7th Floor, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.93069

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Date of Web Publication21-Feb-2012
 


How to cite this article:
Chowdhury T, Singh GP, Bharati SJ. Persistent electrocardiogram changes during excision of craniopharyngioma. Saudi J Anaesth 2012;6:81-2

How to cite this URL:
Chowdhury T, Singh GP, Bharati SJ. Persistent electrocardiogram changes during excision of craniopharyngioma. Saudi J Anaesth [serial online] 2012 [cited 2019 Dec 7];6:81-2. Available from: http://www.saudija.org/text.asp?2012/6/1/81/93069

Sir,

Neurosurgical patients show a variety of cardiac disturbances [1],[2] but majority of them are transient in nature. Here we have reported a case of cardiac ischemic after craniopharyngioma excision that persisted even in the postoperative period.

A 15-year-old male patient weighing 30 kg was admitted to the neurosurgery department with complaints of progressive, painless loss of vision in both eyes, and headache since the previous 5 years. After clinical and radiologic examination, the patient was diagnosed as a case of craniopharyngioma. The magnetic resonance imaging (MRI) revealed a large sellar suprasellar cystic mass compressing optic chiasma. There was edema surrounding the tumor and moderate hydrocephalus was present. The patient was scheduled for elective craniotomy and excision of tumor after undergoing routine laboratory investigations. All the preoperative investigations, including electrocardiogram (ECG) and X-ray chest were normal. On the day of surgery the patient was premedicated with 0.2 mg glycopyrrolate intramuscularly an hour before the surgery. In the operating room routine monitors, namely, ECG, pulse oximeter (SpO 2 ), noninvasive blood pressure (NIBP), and Bispectral index (BIS) were attached and the basal recording were noted. The ECG wave form appeared normal over the monitor. General anesthesia was induced with fentanyl 2 μg/kg, propofol 2 mg/kg, and tracheal intubation facilitated with rocuronium 1 mg/kg. Trachea was intubated using 6.0 mm cuffed portex endotracheal tube. Anesthesia was maintained with isoflurane in oxygen nitrous oxide mixture (40:60) and intermittent boluses of fentanyl and vecuronium as and when required. Intraoperative invasive monitoring, that is, central venous pressure and arterial blood pressure, was done using right internal jugular vein and left posterior tibial artery, respectively. Esophageal temperature (35.5°C-37°C) and depth of anesthesia (BIS 40-60) was maintained during anesthesia. During the intraoperative course while the tumor was being excised, ST segment depression was observed in lead II and V over the monitor, about 2 h after the start of surgery. ST analysis showed the values of ST depression gradually increased over time and became significant (more than 1 mm). About 40 min after the occurrence of ST depression, the T-wave inversion was also observed on the monitor. The patient was hemodynamically stable and the depth of anesthesia was well maintained at this time. The brain was well relaxed and the surgeon reported the condition of brain to be satisfactory. The intraoperative blood loss was reassessed. Intraoperative requirements and losses were adequately replaced and there was no deficit found. Arterial blood gases, serum electrolytes, and hemoglobin level were obtained all of which were normal. After ruling out all the possible causes for the newly developed ECG changes, handling of the hypothalamic region during the excision of the craniopharyngioma was thought to be the most probable reason. The patient was closely monitored throughout the intraoperative and postoperative course for any new event or ECG changes. Rest of the intraoperative course was uneventful and the patient was shifted to the neuro intensive care unit postoperatively for close monitoring and further management of the patient. The trachea was not extubated immediately after the surgery in order to prevent any further cardiac stress during extubation and was mechanically ventilated and sedated overnight. To rule out any cardiac event, the patient was investigated in the postoperative period. Twelve lead ECG showed ST depression with T-wave inversion in all the leads in the immediate postoperative period. However, these changes reverted back to normal over a period of about 6 h and the ECG repeated 8 h postoperatively showed no changes. Cardiac enzymes (Troponin T) were also normal. There was no episode of hemodynamic changes and all the vital parameters as well as postoperative laboratory investigations were within the normal range. On the morning following the day of surgery, the sedation was discontinued and the trachea was extubated once the patient was fully conscious, alert, and breathing adequately. The postoperative course was uneventful. The patient was shifted to the ward after assessing the discharge criterion and later discharged home with full neurologic score.

Craniopharyngioma, the most common suprasellar tumor of nonglial origin in children, involves excellent survival, but at the cost of postoperative morbidity. Intraoperative cardiac rhythm disturbances may occur due to anesthetics, light plane of anesthesia, fluid and electrolyte abnormalities, acid-base disturbances, hypoxemia, hypercarbia, hypothermia, and other neurosurgical causes, especially raised intracranial pressure. However, all these causes are ruled out in our patient. In addition, this patient showed a sudden appearance of T-wave inversion during surgical manipulation near hypothalamus. No case report so far has highlighted the persistent nature of these ST- and T-wave abnormalities, which were present in this patient up to 6 h postoperatively. Several mechanisms have been suggested to explain the cardiac and cerebral injury, including microvascular spasm and increased levels of circulating catecholamines. [3] In animal study, the arrhythmia-inducing area was found to lie dorsal and caudal to the optic chiasma and to extend caudally in the fornix. [4] It is likely that stimulation of anteriomedial hypothalamus produced similar ECG changes. We hypothesize that this surgical stimulus sometimes may produce such a strong stimulus, which may generate these types of ECG abnormalities that can persist for few hours even after surgery. The addition of sympathetic surge may also mimic cardiac ischemia-like changes. In conclusion, ST- and T-wave abnormalities may occur in craniopharyngioma excision and may persist after few hours in the postoperative period, but one should be vigilant enough to detect true myocardial ischemia with other laboratory methods too.

 
  References Top

1.Davis TP, Alexander J, Lesch M. Electrocardiographic changes associated with acute cerebrovascular disease: A clinical review. Prog Cardiovasc Dis 1993;36:245-60.  Back to cited text no. 1
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2.Kotake Y, Matsumoto M, Yorozu T, Takeda J. Recurrent ST-segment elevation on ECG and ventricular tachycardia during neurosurgical anesthesia. J Anesth 2009;23:115-8.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Catanzaro JN, Meraj PM, Zheng S, Bloom G, Roethel M, Makaryus AN. Electrocardiographic T-wave changes underlying acute cardiac and cerebral events. Am J Emerg Med 2008;26:716-20.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Tashiro N, Tanaka T, Fukumoto T, Hirata K, Nakao H. Emotional behavior and arrhythmias induced in cats by hypothalamic stimulation. Life Sci 1985;36:1087-94.  Back to cited text no. 4
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