(695) Central Nervous System Vasculitis as a Cause for Delayed Emergence After General Anesthesia

Introduction: Delayed emergence (DE) after general endotracheal anesthesia (GETA) is common. DE may be due to residual anesthetics, surgical complications, neurologic insult, metabolic or chemical disturbances, and, rarely, vasculitis. Prompt assessment is critical when DE occurs, as timely intervention is paramount to mitigate adverse outcomes. This case details a complex presentation, and resolution, of DE as a result of intracerebral vasculitis.

Description: Surgical ICU (SICU) was consulted for DE. After an uncomplicated CSF shunt replacement, a 55-year-old female with a history of metastatic papillary thyroid carcinoma & pulmonary embolism with inferior vena cava filter placement was unresponsive. Preliminary CT head, CTA brain, MRI brain, and routine labs were unremarkable. Emergence and extubation were uncomplicated. During transport, decorticate posturing & decreased Glascow Coma Score (GCS) score was observed. After emergent intubation in SICU, she hemodynamically stable on post-operative day (POD) zero. On POD1, transesophageal echo (TEE) recommended by cardiology eliminated concerns for an unidentified left atrial thrombus related thromboembolic ischemia. A resident physician suggested a Rheumatology consult given the history of metastatic thyroid malignancy, premature aging, & noncontributory findings. Rheumatology ordered additional neuroimaging demonstrating diffuse leptomeningeal enhancement with diminution of cerebral arteries. Clinical correlation of intracerebral vasculitis was suggested by radiology. Plasma exchange therapy (PLEX) was initiated after minimal response to intravenous steroid treatment. Within one week, the patient was successfully extubated, conversing with family, participating in occupational, speech, and physical therapies.

Discussion: Clinical decompensation with DE requires rapid assessment and, at times, procedural intervention. Cerebral vasculitis, although uncommon, should be added to the DE differential when etiologies such as intracerebral hemorrhage, hypercapnia, hypothermia, narcotic overdosage perioperatively, thromboembolic stroke (including of cardiac origin in patients without prior TEE) are excluded. Multidisciplinary collaboration and clinical suspicion is key for management of critically ill patients after general anesthesia.