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Dr. Andrew Rynne
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Dr. Andrew Rynne

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My friend had surgery for three brain aneurysms. She was

Answered by
Dr.
Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 2474 Questions

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Posted on Thu, 4 Apr 2019 in Lump
Question: My friend had surgery for three brain aneurysms. She was operated on four days ago by going through the groin to repair two of them. The next day they had to repair the third one by operating on the brain itself. She has not regained complete consciousness since then. It’s been 72 hours since she’s been awake. The doctor is saying she’s responding and that she is “doing well”. They put in a feeding tube yesterday. They were having trouble giving her pills because she was so deeply asleep. I’m very worried. She has a hard time with sedation. In the past when she’s had any procedure like a colonoscopy, it has taken her a long time to wake up. The doctor said the surgery was successful. He doesn’t seem overly concerned about how long it’s taking for her to regain consciousness. Is there reason to be worried?
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Answered by Dr. Dariush Saghafi 1 hour later
Brief Answer:
Time course to awaken from surgery

Detailed Answer:
Good evening and thank you for your question regarding your friend who recently was surgerized for 3 intracranial aneurysms. If I understand correctly 2 of the aneurysms were resolved by way of an intra-arterial catheter. You didn't specify the method used to take care of the aneurysms (coiling vs. flow diversion stent). I'm assuming her mental status was normal on the day interventional radiology saw her (2 repaired through the groin). Then, the next day she underwent a 2nd procedure which was an open neurosurgical procedure that involved repairing the 3rd aneurysm which could not be reached by catheter means.

Now, it's been 72 hrs. and she has not "regained complete consciousness." She has been so deeply depressed in her state of alertness that they have had to place a feeding tube. She DOES have a history of prolonged return to normal states of alertness following procedures where anesthesia is given or even light sedation from what I'm gathering.

I'm going to assume that if this were going exactly the same way as things had gone for her colonoscopy from which you say she had a tough time waking up then, you probably wouldn't be asking this question. Therefore, somehow this go around seems different to you, correct? I don't know if the DEPTH of her reduced state of alertness is more than you've ever seen for being 72 hrs. out, or the fact that she is requiring a feeding tube which maybe did not happen with the colonoscopy? Remember, she was operated on the brain and therefore, the type and potency of the anesthesia used in that procedure is going to likely be much MORE than anything she would get for a simple COLONOSCOPY. So if it took her A LONG time to wake up from that procedure, just imagine how much it might be when the brain is being fully sedated, partial skull being removed, and brain tissue needing to be moved and other manipulations made in order to take care of the aneurysm.

Therefore, I'm not surprised that it is taking a longer time to awaken. Having said that have you seen evidence of spontaneous movements of ALL of her limbs. If so, this is a very good sign. If she's at all opened her eyes and appeared as if she were looking about or tracking anybody or anything in the room....that too is a good time.

And so, while I can understand why it might take longer for her to wake up from this procedure with a history of being somewhat sensitive to anesthesia and procedural manipulation, I agree that 72 hrs. of not awakening and needing a feeding tube would concern me as well if I were in your place patiently waiting in the waiting room day after day to see if anybody will come out to tell you finally that she is now awake and talking, etc. THEREFORE, I think it would be perfectly reasonable to set up a meeting with the surgical team for an detailed update on what her level of consciousness actually is...there are assessment tools for that purpose and to let you know how she's progressed (according to the doctor in charge) back toward finally waking up. If you sense that there is hesitancy or reticence on his part to give you details then, either he doesn't really know why she's not waking up.....or there is something going on that he is thinking she may be able to overcome on her home with good attention, etc.

So, if I were the family member in this case I would ask that a NEUROLOGIST BE brought into the be consulted. And then, you speak with the neurologist to see if they plan to get an MRI or not or just CTA since the MRI may end up being a no-no in the face of 2 recent COILING procedure. The neurologist will be the one who should be able to tell you with a bit more certainty where your friend is along the spectrum of alertness and whether or not any complication may have occurred in the brain such as a stroke or small hemorrhage. Even if an MRI of the brain is not possible because of the recent coiling or even clipping procedure, a CT of the head is possible which can show the presence of a bleed.

If no blood is seen inside the head that appears to have been as a result of an aneurysmal rupture or other complication then, there may be more assurance to hang in there to see what happens as she continues to heal from the surgery. By the same token, no matter how "down" her level of consciousness seems to be to you....it is VERY HELPFUL for you or others from her family to go and visit and spend time with her to include things such as talking, reading to her, giving her tactile stimulation on the face, the head, the hands, arms, and the legs....just stroking, squeezing gently and so forth will add simulatory effects that can help the brain get more signals in for processing and this may also aid in jumpstarting things a bit more quickly.

The other thing I would ask about is to crosscheck the type of anesthetic or sedation she got in her last colonoscopy procedure and compare that to what she got this time around. I'll bet she did not get nearly the same POTENT or even type of agent then, as she got know but it's work looking into to see if they were the same or similar in some way. Also, I would ask the doctor if it is possible she may have some form of SENSITIVITY to muscle paralytics due to an ENZYME deficiency (usually lack of something we call pseudocholinesterase).

This type of enzyme deficiency is thought to exist in as much as 5-10% of the general population and never causes trouble UNTIL the patient is exposed to agents that contain succinylcholine or similar derivatives. Then, patients will appear to be difficult to wake up from surgery or response although in many cases they are more awake than they appear but because they are highly sensitive to the agents administered during anesthesia their MUSCLES ARE IMPAIRED/paralyzed. Now, the most severe complication that occurs with this type of issue is the patient's intolerance or inability to be weaned off the respiratory machine. In other words, patients usually can't be easily extubated with this type of problem. You didn't mention anything about them having difficulties with taking the breathing tube out so I'm assuming she's easily breathing on her own.

But no matter, even if she's breathing on her own....if her CT/MRI of the brain are normal and the neurologist decides that he really can't SEE anything suggestive of a stroke, bleed, or other pathological abnormality in the brain I would definitely look into this issue to see if it was checked an screened for PREOPERATIVELY. Usually that type of enzyme deficiency is LOOKED for by all anesthesiologists and many surgeons are highly sensitive to this as a post-op complication so they are always asking their anesthesiologists if there are any concerns to put the patient under and are equally concerned when patients don't seem to be coming out of it very easily.

Nevertheless, since we're here talking about it and you have a concern over the whole situation I would definitely inquire about this deficiency (even if your friend wakes up perfectly normally). I would look for if they ran the blood test that would suggest the presence of this deficiency. What they should be looking for is TOTAL CHOLINESTERASE activity. If this turns out to be positive then, further studies looking for inhibition potentials and even genetic studies could be carried out since we know what some of the genetic defects are that are responsible for this problem.

I would've also gotten a set of THYROID hormone studies (FT4 and TSH) prior to surgery....or at least in the past few months since HYPOTHYROIDISM can prevent from waking up after surgery.

I wish you and your friend all the best and a speedy recovery.

If I've provided useful or helpful information to your questions could you do me the utmost of favors in not forgetting to close the query along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I am definitely interested in getting updated information on how things are going in the next few weeks if you'd drop me a line at www.bit.ly/drdariushsaghafi

You can always reach me at that address for this or other questions. I wish you the best with everything and hope this information does help you.

This query required 60 minutes of professional time to research, assimilate, and respond in complete form.




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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