Abstract Details

Title Massive Cerebral Edema and Super-Refractory Status Epilepticus: A Rare Postsurgical Complication of Cranioplasty

Topic Neuro Trauma and Critical Care

Presentation(s) P13 - Poster Session 13 (8:00 AM-9:00 AM)

Poster/Presentation
Number 1-003

Background

Cranioplasty is a surgery with high complication rate (infections, bone resorption, hematomas, etc.) but low mortality. There are case reports of massive cerebral edema and refractory seizures after uneventful cranioplasty. We report a case of unexpected, severe postoperative cerebral edema immediately following cranioplasty associated with super-refractory status epilepticus.

Objective N/A

Design/Methods

A 21-year-old man presented with severe headache, vomiting and abnormal behavior followed by seizures, requiring intubation. Computed tomography (CT) of head revealed left frontal intracerebral hemorrhage, an angiogram further revealed left arteriovenous malformation (AVM). He required emergent decompressive hemicraniectomy. AVM was not secured at that time. He was ultimately discharged to rehabilitation after a prolonged hospital stay and recovered some language and ability to walk several months later.

Patient was re-admitted 9 months post-bleed for elective AVM resection and cranioplasty, which were uneventful. Post-operatively, he had generalized tonic-clonic seizures requiring increasing sedation. Head CT and magnetic resonance imaging (MRI) of the brain demonstrated new diffuse bilateral cerebral edema. Continuous electroencephalography revealed nonconvulsive status epilepticus (NCSE). Seizure activity was refractory to multiple antiepileptic medications (AEMs) and treatment was escalated to a medically induced coma with pentobarbital along with induced hypothermia to achieve burst suppression and manage cerebral edema. Pentobarbital was weaned off by increasing antiepileptics but unfortunately, seizures continued despite 9 AEMs. Ultimately, vagus nerve stimulator (VNS) was placed, achieving some improvement in seizure frequency. Follow-up brain MRI showed no improvement in cerebral injuries.

Results N/A

Conclusions

Massive cerebral edema and super-refractory status epilepticus are uncommon complications after cranioplasty. Changes in atmospheric and intracranial pressure causing a marked disruption of cerebral blood flow are thought to lead to cerebral edema. This complication has shown to be fatal and unpredictable. Therefore, providers should be aware, as this must be discussed with patient and family prior to performing surgery.

Authors/Disclosures
Ramiro G. Castro Apolo, MD (Lehigh Valley Health Network) PRESENTER	Dr. Castro Apolo has nothing to disclose.
Erafat Rehim, MD (LVHN)	Dr. Rehim has nothing to disclose.
Jaspreet Johal, MD	Dr. Johal has nothing to disclose.
Christopher Melinosky, MD (Lehigh Valley Health Network)	Dr. Melinosky has nothing to disclose.
Preet M. Varade, MD (Lehigh Valley Hospital - Cedar Crest)	Dr. Varade has nothing to disclose.