The plaintiff age 45 was diagnosed with acoustic neuroma and underwent microsurgical right sub occipital craniectomy and tumor resection. Symptoms prior to surgery were hearing loss in the right ear , dizziness and headache. Prior history hypertension, anxiety. MRI and CT showed 2.7 C-P angle tumor. Surgery was elective.

Surgery was performed using facial nerve monitoring . Brain stem evoked potential monitoring was not done due to hearing loss on right. Operative report details uncomplicated surgical procedure . EBL 250. She was extubated in the OR and brought to NSICU for monitoring. She awoke, supposedly followed commands then became unresponsive to noxious stimuli within 50 minutes of arrival in the NSICU. Pupils were noted to be minimally reactive, there was positive scleral edema noted. She also experienced upper airway obstruction and desaturation and respiratory failure.

She was intubated, received IV Narcan without response and sent to CT scan. Stat CT scan showed right cerebellar venous infarct with intracerebellar hemorrhagic lesion with mass effect, Emergency surgery was performed. Swelling of cerebellum was noted and 4cm diameter of swelled cerebellum was removed. Intracerebellar hematoma was evacuated and additional hematomas were removed after exposure of undersurface. Ventricular drain was inserted. EBL 100. The next day she underwent additional surgery consisting of reopening of craniectomy and additional right cerebellar subtotal resection , decompression and removal of intracerebellar hematoma. EBL 500.

Additonal surgery was performed for right cerebellar wound infection and CSF leak. Post operatively PEG inserted, trach done, patient with hemiplegic, non ambulatory with dysphagia dysarthria, visual disturbance. She is non verbal but alert and aware.

Our questions include given the size of the tumor was stereotactic surgery an option?

Did surgeon injure vessel and was hematoma present prior to closure but unidentified?

EXPERT RESPONSES

In that case, we usually recommend stereotactic radiosurgery because of recent articles comparing outcomes indicate that in tumors smaller than 3.0 cm that clinical outcomes are better with radiosurgery compared to open surgery. Lesions over 3.0 cm appear to be better treated with open surgery as the potential benefits of radiosurgery go down as the size of the tumor goes up.Radiosurgery was not only an option….it appears to be the best option.

Surgical treatment of acoustics can lead to many complications. The development of an infarction and hemorrhage in the cerebellum is most often due to retraction injury to the cerebellum or to injury to a venous structure with associated venous stasis and hemorrhagic complications. This complication normally is treated with surgical evacuation of the hemorrhage and resection of infarcted cerebellum.

My initial take on the case is that the standard of care requires that alternative procedures such as radiosurgery should be considered and discussed in the informed consent process. The complications that she developed are rare. However, these complications are well described in the literature and are usually discussed at the time of the informed consent and a part of the consent form.We would have to look at the medical records to see if they responded to this complication in a timely and prudent manner.

The consequence of hemiplegia was most likely due to compression of the brainstem from the mass effect of the swollen cerebellum with the hemorrhage.

I believe that the injury to the venous system or retraction injury occurred during the surgery. However, these problems most likely lead to a progressive increase in mass effect over time. As the surgeon closes the coverings of the brain the cerebellum is usually pulsatile and below the surface of the dura. If the surgeon noted swelling in the cerebellum making it difficult for him to close the dura then it was most likely developing in front of him. Dr SB

Sounds like unfortunate, but well known complication of that surgery. DR SS

Likely an unfortunate complication. It does seem however like she had an unsual amount of post op surgery, but I would need to know how long traction was applied during the initial procedure, to what structures, brain condition as incision was closed, vessels encountered etc. Dr JM