RESUMO
We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l -carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration (AU)
Se presenta el caso de un paciente con un glioma insulofrontotemporal izquierdo, tratado con levetiracetam, valproato y clobazam. Se realizó una primera cirugía bajo anestesia general para la exéresis del lóbulo temporal tumoral, y 8 días después se sometió a una cirugía con el paciente despierto para mapeo del lenguaje, bajo sedación consciente con remifentanilo y anestesia local. A la llegada a quirófano, el paciente se encontraba cansado y con cierta bradipsiquia; tras parar la infusión de remifentanilo, y antes de abrir la duramadre, el paciente presentó una disminución del nivel de consciencia con privación respiratoria que requirió intubación endotraqueal y la finalización de la cirugía. En el periodo posoperatorio se apreció bradipsiquia moderada, cansancio y temblor de manos. Fueron detectados niveles altos de amonio en sangre, y la clínica mejoró tras la administración de L-carnitina y la suspensión del valproato. La encefalopatía por amonio, aunque con mínima sintomatología, debería ser considerada en pacientes tratados con valproato que van a ser sometidos a una cirugía bajo sedación, donde se requiere que el paciente colabore (AU)
Assuntos
Compostos de Amônio/efeitos adversos , Intoxicação do Sistema Nervoso por Metais Pesados/complicações , Mapeamento Encefálico/métodos , Craniotomia/métodos , Glioma/cirurgia , Falha de Tratamento , Vigília , Ácido Valproico/efeitos adversosRESUMO
We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration.
