Background
Idiosyncratic reactions after general anesthesia are rare but real. If unknown beforehand, they can lead to overly aggressive workup and over-treatment, as well as prolong hospital stay significantly. We present a case of a patient with three different rare post-anesthetic conditions, which we were fortunately aware of and anticipated preoperatively.
Case Description
A 38 year old female with a history of paradoxical vocal cord dysfunction, hemiplegic migraine, and possible migraine-associated seizures presented for ERCP for papillary stenosis. She had a history of post-operative aggravation of paradoxical vocal cord dysfunction, which required use of her non-invasive positive pressure ventilator. She also described transient changes in mental status, paresis and other focal deficits on emergence from anesthesia in the past. Her physical exam in the preoperative area was unremarkable.
The procedure was performed under general anesthesia. Following extubation, the patient indicated difficulty breathing, so her home non-invasive ventilator was applied. She then had generalized seizure-like activity, which resolved with intravenous midazolam. She also had periods of non-responsiveness, right facial droop and paresis, but remained hemodynamically stable. She was admitted to the ICU overnight for monitoring and use of her non-invasive ventilator. Her neurological and respiratory symptoms improved by postoperative day 1, and she was discharged home.
She had a subsequent ERCP procedure under sedation. She was restarted on her non-invasive ventilator postoperatively and had an otherwise unremarkable recovery.
Discussion
Paradoxical vocal cord dysfunction involves adduction of the vocal cords during inspiration, leading to acute respiratory distress. It is traditionally associated with underlying psychiatric illness or anxiety, and triggers can include emotional distress. (1) This condition should be considered in the differential diagnosis for postoperative stridor. Management includes reassurance, non-invasive positive pressure ventilation and light sedation (2,3,4). Fortunately, our patient had established non-invasive ventilation settings for management of her symptoms.
Hemiplegic migraine is a rare subtype of migraine that typically presents with a motor aura of transient hemiparesis or hemiplegia along with migraine headache. It can mimic a cerebrovascular accident or transient ischemic attack if the aura develops acutely. (5) It can be managed with most typical abortive migraine treatments, and is best managed with guidance from the patient’s prior experiences. In this case, the patient had known aggravation of her symptoms in the postoperative period that reliably resolved with time. (6,7)
The association between migraine and seizures is unclear, but has been described. (8) The patient had prior episodes of seizure-like activity associated with migraines, and her seizure-like activity resolved with benzodiazepine therapy.
References
1. Denipah N, et al. Ann Emerg Med. 2017 Jan;69(1):18-23.
2. Gupta A, et al. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):287-8.
3. Larson B, et al. J Clin Anesth. 2004 May;16(3):230-4.
4. Roberts KW, et al. Anesthesiology. 1998 Aug;89(2):517-9.
5. Russell MB, et al. Lancet Neurol. 2011 May;10(5):457-70.
6. Greaney D, et al. Can J Anaesth. 2014 Mar;61(3):278-9.
7. Willson J, et al. Anaesthesia. 2007 Sep;62(9):956-8.
8. Mateo I, et al. Headace. 2004;44(3):265-270.
