Lung cancer patient suffered aortogenic stroke after sleeve pneumonectomy


A 70-year-old man came to the hospital because he had been coughing up blood for about 6 months. He said he smoked a pack a day for 50 years. The initial clinical evaluation revealed that he suffered from hypertension. He had not received any antiplatelet or anticoagulant treatment.

The chest x-ray showed the presence of a mass in the right pulmonary hilum, and CT scans and PET-CT of her chest revealed a tumor in the pulmonary hilum with stenosis of the right upper lobe bronchus, with a standardized capture value. of 8.5. Calcification of half of the ascending aorta was also noted.

After a subsequent bronchoscopy, the medical team noted a large area of ​​redness and irregularity in the bronchial epithelium between the trachea and the lower lobe bronchus, as well as a narrowing of the right upper lobe bronchus. Clinicians took a transbronchial biopsy of the lesion and pathological evaluation identified squamous cell carcinoma.

Results of additional biopsies of the lower trachea, a ring above the tracheobronchial angle and that of the B6 / B7-10 spur, also supported a diagnosis of squamous cell carcinoma. However, ultrasound-guided transbronchial needle aspiration did not identify any malignant cells in the subcarinal lymph nodes.

Clinicians assessed the patient’s lung function – the forced expiratory volume in 1 second was 2850 ml (116.1% of predicted) and the lungs diffusing capacity for carbon monoxide was 15.80 ml / minute / mm Hg (90.1% of predicted value) – and determined that the patient would not be able to tolerate the surgical removal of the right lung.

Magnetic resonance imaging (MRI) of the patient’s brain showed no signs of metastasis or infarction. The stage was determined to be T4N0M0, and the patient was scheduled for right sleeve pneumonectomy.

Surgeons performed the surgery using a midline sternotomy (MS), moving the aorta upward several times to access the tracheobronchial bifurcation.

The surgical process has been described in case report as follows: “Mediastinal lymph node dissection was performed, and the left main bronchus and trachea were sectioned and anastomosed using 4-0 polydioxanone ventilated through the operating field. A running suture in the membranous part was performed with ventilation of the diseased lung to better expose the operating field. The cartilage portion was anastomosed with interrupted sutures after the double lumen endotracheal tube was routed into the left main bronchus. After the anastomosis, the right main pulmonary artery and the right upper and lower veins were stapled, the right lung was extirpated, and a pneumonectomy of the right sleeve was performed. “

After the surgery, the patient was extubated and transferred to intensive care before he fully regained consciousness. At this point, clinicians observed that the patient had mild paralysis affecting both arms.

The day after surgery, the patient underwent an MRI of his head, which identified many high-intensity areas in the brain, most of them located in the cerebellum. However, a subsequent magnetic resonance angiogram of the head showed that the cerebral or vertebrobasilar arteries had not changed.

Echocardiography and computed tomography with injection of contrast medium also showed no signs of cardiac thrombus, malformation or valve disease. Clinicians concluded that the patient had suffered a multiple embolic stroke – possibly due to the need to move the ascending aorta several times during surgery to access the surgical site for the tracheobronchial anastomosis.

The patient began treatment with heparin and the neuroprotective agent edaravone. From 14 days after surgery, treatment with warfarin was initiated, at a dose adjusted to an international normalized ratio of prothrombin time of 1.5 to 2.5.

He received continuous anticoagulant therapy and rehabilitation for 2 weeks, and was discharged 30 days after surgery without further complications. Case authors reported that at 5 years after surgery, the patient was doing well and remained cancer-free.

Discussion

Clinicians presenting this case of a lung cancer patient who developed a cerebral infarction following carinal resection with MS said they believed it was the first report of Multiple embolic stroke of the aorta, possibly associated with surgery after sleeve pneumonectomy.

The development of stroke immediately after surgery raises the possibility that it is due to repeated mobilization of the ascending aorta, which is necessary to allow surgical access to the operative field, the authors explain.

They noted that sleeve pneumonectomy is used for extensive tumor resection involving the tracheobronchial angle, carina, or lower trachea. Right sleeve pneumonectomy is usually performed using a right posterolateral thoracotomy in the fifth intercostal space; on the other hand, MS allows ventilation of the diseased lung.

The advantages of the MS approach include less incisional pain and less postoperative ventilatory restriction, the authors observed, warning that the decision to use a posterolateral thoracotomy or an MS approach requires careful consideration of the pros and cons.

Analysis of 801 surgeries recorded in a patient registry to determine if MS is an equivalent incision to thoracotomy in the treatment of primary lung carcinoma, found non-significant differences in favor of thoracotomy for operative mortality, postoperative complications, and similar rates of long-term survival. However, the mean postoperative length of stay for MS lobectomy was 7.5 days versus 8.5 days for thoracotomy (P= 0.06).

“The midline sternotomy offers more complete staging, shorter postoperative hospital stay and better patient acceptance with an equivalent operation and compared to thoracotomy. Concerns about increased wound infections in MS patients appear unfounded. “, concluded the authors of the analysis.

The authors of the case said that although most surgeons prefer the posterolateral thoracotomy, the MS approach has several advantages, including less postoperative incisional pain and, in some patients, ventilation of the diseased lung, which “may reduce the difficulty in performing the anastomosis under intubation of the left main bronchus. “

Nonetheless, the team warned, MS requires repeated mobilization of the ascending aorta to allow surgical access for the airway anastomosis. This can cause aortic plaque to flow through the arteries in the brain, causing multiple embolic strokes – primarily a cerebellar infarction, which can be attributed to embolism associated with surgery.

Case authors cited a study suggesting a 1.29-1.7% prevalence pulmonary embolization and superior vena cava thrombosis, a postoperative complication of carinal resection. Their own patient’s case is particularly rare, as there have been no reports of postoperative embolic stroke associated with the MS approach, the case authors said.

The patient presented the three MRI findings characteristic of an aortogenic embolic stroke: ≥ 3 lesions, lesions with a maximum diameter of

The patient’s preoperative CT scan showed semicircular calcification of the ascending aorta. “It is suggested that atherosclerotic plaques ≥ 4 mm thick, ulcerated aortic plaques, and motile aortic plaques on transesophageal echocardiography (TEE) are risk factors for ischemic stroke,” wrote the case authors.

They cited a to study showing that in patients with stroke, and in particular cryptogenic stroke, the 2-year incidence of recurrent stroke or death gradually increased with the size of the arch plaque, by 10.1% in patients with patients without plaque 16.5% in patients with small plaque and 26.7% in those with large plaque.

The case authors stated that given the risk of embolic stroke by mobilization of the aorta, the use of ETO in aortic calcification may help inform the choice of approach for pneumonectomy. in sleeve. Their patient “did not develop sequelae associated with multiple embolic stroke and has been doing well for 5 years after surgery,” the team wrote. “However, it is important to consider the presence of aortic calcification when choosing the appropriate approach for sleeve pneumonectomy.”

Conclusion

The authors concluded that, since aortogenic embolic stroke can occur after sleeve pneumonectomy with MS, the possibility of aortogenic embolic stroke caused by repeated mobilization of the aorta should be considered when calcification of the The ascending aorta is seen on the preoperative CT scan.

Last updated on November 16, 2021

  • Kate Kneisel is a freelance medical journalist based in Belleville, Ontario.

Disclosures

The authors of the case report said they had no competing interests.


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