单侧运动症状偏头痛患者全麻后偏瘫外文文献

Case Report Hemiparesis after general anesthesia in a patient with migraine with unilateral motor symptoms Rachel A Hadler MD Joshua M Schiffman MD John G Augoustides MD Renyu Liu MD Linda Chen MD Department of Anesthesiology and Critical Care Hospital of the University of Pennsylvania University of Pennsylvania Health System 3400 Spruce St Philadelphia PA 19104 Received 10 April 2015 accepted 16 June 2015 Keywords Anesthesia general Disease management Headache Migraine disorders Perioperative period Abstract Design This is a case report Setting The setting is at a postoperative recovery area Patients A 52 year old woman with a history of migraine with unilateral motor symptoms developed hemiparesis after undergoing general anesthesia for total thyroidectomy Interventions No interventions were performed Measurements main results Head computed tomography and magnetic resonance imaging were normal Laboratorystudiesincludingbasicmetabolicpanelandcompletebloodcountwerealsowithinnormallimits Conclusions Generalanesthesiamaybeatriggerforhemiplegicmigrainesyndromes however itbehooves the practitioner to rule out acute neurologic and metabolic events before making this diagnosis 2016 Elsevier Inc All rights reserved 1 Introduction Atypical migraines can present unusual perioperative problems for the anesthesiologist Migraine with unilateral motor symptoms MUMS is a unique migraine disorder characterized by unilateral weakness disturbances temporally congruent to migraine headache symptoms Although similar tounilateralhemiplegicmigraine MUMSisadistinctdisorder In this article we discuss a case of unilateral weakness after general anesthesia in a patient with known MUMS and review perioperative management strategies for atypical migraines The Hospital of the University of Pennsylvania Institutional Review Board approval was granted to publish this case and patient consent was not obtained 2 Case report A 52 year old woman American Society of Anesthesiol ogists Physical Status classification II 175 cm and 96 kg underwent a total thyroidectomy with general anesthesia for a thyroidneoplasm Her history was notable for a distant history ofviralmeningitis amorerecentoneoftraumaticbraininjury and a recent diagnosis of MUMS as well as hypothyroidism fibromyalgia celiacdisease andmultipleectopicpregnancies General anesthesia was induced with intravenous lidocaine 100 mg fentanyl 200 g propofol 250 mg and vecuronium 7 mg An endotracheal tube 7 0 was placed uneventfully and anesthesia was subsequently maintained with desflurane end Disclosures none Corresponding author at Department of Anesthesiology and Critical Care 3400 Spruce St Philadelphia PA 19104 Tel 1 215 776 3717 E mail address Rachel hadler uphs upenn edu R A Hadler http dx doi org 10 1016 j jclinane 2015 06 011 0952 8180 2016 Elsevier Inc All rights reserved Journal of Clinical Anesthesia 2016 31 142 144 tidal 5 6 5 and later nitrous oxide 67 She received hydromorphone 2 mg intraoperatively At the conclusion of the procedure muscle relaxation was reversed with neostig mine 5 mg and glycopyrrolate 0 7 mg intravenous The patient woke up comfortably and was extubated without any complications She was brought to the Post Anesthesia Care Unit on 2 L O2nasal cannula Fifteen minutes after arrival in the Post Anesthesia Care Unit thepatientcomplainedofnewonsetnumbnessontheleft side of her face as well as onset of a migraine like headache Upon neurological examination the patient had weakness in her left extremities with near total paresis on her left lower extremity and 3 5 strength in her left upper extremity The patient had no right sided motor deficits Forty five minutes later the patient s weaknesshadnotresolved Throughoutthis period hermentalstatuswasintact Magneticresonance MR imaging and head computed tomography were ordered which were negative for any acute intracranial hemorrhage or ischemia Laboratories were within normal limits The patient was admitted overnight for surveillance and her neurologic deficits resolved over the following 24 hours without intervention The patient believed that her symptoms were consistent with previous MUMS exacerbations 3 Discussion Atypical migraine disorders may present with a variety of sensory and motor findings Migraine associated with unilateral motor weakness is a rare disorder characterized by unilateral give way weakness associated temporally with migraine symptoms Give way weakness is defined as a sudden loss of resistance during muscle strength testing of at least 2 sites on 1 site of the body 1 This pattern of weakness has been associated with pseudoneurologic syndromes and psychosomatic complaints must be consid ered in the differential diagnosis Patients are most commonly White females with a comorbid history of depression they commonly experience a rostrocaudal march of motor symptoms often accompanied by sensory disturbances and preceded by unilateral headache The MUMS population is characterized by a higher incidence of allodynia and cluster headache like reactivity of the eyes and nose as well as mood disorders and fibromyalgia Diagnostic criteria for MUMS and the more common unilateralhemiplegicmigrainedisordersoverlapsuchthatsome sufferers may fit the criteria for either diagnosis No prior postoperativecasesofhemiplegiainMUMSpatientshavebeen reported however several case reports of postoperative weakness in hemiplegic migraine sufferers may shed some light on perioperative management for these patients Hemi plegic migraines may be familial or sporadic 3 autosomal dominant familial subtypes have been characterized and may shed some light on the etiology of hemiplegic migraine All 3 subtypes involve alterations in cortical ion channels that are suspected to increase cortical susceptibility to waves of depolarization resultingintransientdepressionofbrainactivity with a significant adverse impact on ion homeostasis and a resultant release in excitatory amino acids This excitation is suspectedtoplayaroleinmigraineorigin Identicalionchannel mutations have been identified in sufferers of nonfamilial hemiplegic migraine as well however the 3 identified mutations seen incertain calciumchannels sodium potassium adenosine triphosphatases and sodium channels do not account for all instances of hemiplegic migraine 2 Other studies of migraine sufferers in general and individuals with familialhemiplegicmigraineinparticularsuggestthatfailureof autoregulation of cerebral vasculature may also play a role in migraine causation In population studies common triggers includestress insomnia certainodors andstarvation 3 Some have suggested that anesthesia be added to this list 4 Itmaybeextrapolatedthattheperioperativeperiod withits concomitant stresses periods of prolonged fasting unusual odors and exposuretoanesthesia wouldbea high risk period for the migraine patient Case reports suggest that hemiplegic migraine has been induced with a wide variety of anesthetic techniques ranging from fentanyl sedation to peripheral nerve blocks to general anesthesia Opioids have been implicated as possible players 5 at this stage there is little evidence to elucidate whether other commonly used anesthetic agents might be contributors to migraine symptoms as well In patients who present with hemiplegia in the postoper ative period migraine related symptoms must essentially be a diagnosis of exclusion It is critically important to rule out ischemic and embolic cerebrovascular events through imag ing Other considerations in the differential diagnosis may include anoxic brain injury paradoxical embolism orcerebral artery dissection 6 A close review of the anesthesia record can rule out periods of extreme hypotension or hypertension dysrhythmia and hypoxia Computed tomography scans MR imaging and computedtomography MR angiography may all be of utility to rule out vascular injury or occlusion an echocardiogram to rule out patent foramen ovale or intracar diac thrombus A neurology consult may be obtained and if there is significant concern for a thromboembolic event a workup for coagulopathies may be considered 5 If the workup is otherwise negative and the patient has a history of migraines with motor deficits with similar presentation and resolution then it may be safe to conclude that the postoperative hemiparesis is a migraine presentation Evidence for continuing preoperative migraine prophy laxis such as calcium channel blockers is equivocal 7 blockers are frequently avoided in these patients as case reports suggest that they have exacerbated symptoms in patients with other atypical migraine variants 8 Intranasal ketamine was used with some success in 1 study based on the hypothesis that it could function to antagonize the depolariz ing waves caused by cortical ion channel dysfunction 9 there are currently no reports in which ketamine is used as an anesthetic in patients with hemiplegic migraine disorders although its use as an opioid sparing agent in this population may be worth considering 143Hemiparesis after general anesthesia in a patient 4 Conclusion The perioperative period offers a myriad of triggers for the migraine patients The role of their anesthesiologist then is to mitigate these factors as much as possible while managing any migrainesymptomsthatdoemerge Inconsideringthemigraine patient with postoperative unilateral weakness or hemiplegia the practitioner must definitively rule out ischemic thrombo embolic and hemorrhagic intracranial events before consider ing other possibilities Psychogenic and factitious etiologies must be considered however hemiplegic migraines should stay high on any differential for a migraine sufferer with postoperative headache and unilateral weakness References 1 Young WB Gangal KS Aponte RJ Kaiser RS Migraine with unilateral motor symptoms a case contr