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LETTERS TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 50-52
 

Spontaneous intracerebral hemorrhage in a hypertensive patient after mandibular nerve block in pain clinic


1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Command Hospital (SC), Pune, Maharashtra, India

Date of Web Publication6-May-2019

Correspondence Address:
Dr. Shalendra Singh
Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_1_19

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How to cite this article:
Singh S, Dwivedi D, Hooda B, Davis J. Spontaneous intracerebral hemorrhage in a hypertensive patient after mandibular nerve block in pain clinic. Indian Anaesth Forum 2019;20:50-2

How to cite this URL:
Singh S, Dwivedi D, Hooda B, Davis J. Spontaneous intracerebral hemorrhage in a hypertensive patient after mandibular nerve block in pain clinic. Indian Anaesth Forum [serial online] 2019 [cited 2019 Aug 26];20:50-2. Available from: http://www.theiaforum.org/text.asp?2019/20/1/50/257674




Sir,

Peripheral trigeminal nerve block (TNB) with alcohol for trigeminal neuralgia (TN) is widely used as a percutaneous procedure for medically intractable TN. Mandibular nerve block (MNB) has been widely used in clinical practice as one of the most efficient blocks in V3 territory pain. Various local as well as systemic complications after the administration of alcohol injection, for example, dysesthesia, difficulty swallowing, ulceration of cheek, osteomyelitis, trismus, transient cranial nerve palsies, external rectus palsy, and diplopia, have been described in literature.[1] We present the case of a spontaneous intracerebral hemorrhage in an elderly hypertensive patient after alcohol injection in pain clinic.

A 63-year-old (80 kg, 170 cm) male patient arrived at the pain clinic with a history of TN refractory to optimal medical therapy for the last 1 year. He had a history of hypertension and was on irregular treatment with basal blood pressure of 156/92 mmHg. He also had a past history of ischemic stroke with no neurological deficit and was on aspirin 150 mg once daily for the last 1 year. In the pain clinic, standard monitoring was done. Left MNB was given with 1 ml of 2% lignocaine with 0.5 ml of pure alcohol (dehydrated alcohol injection) under fluoroscopic guidance. Ten minutes after the block, the patient complained of slurring of speech with weakness in the right side of the body. On examination, his heart rate was 68/min, blood pressure was 216/116 mmHg, and oxygen saturation was 99%, with anisocoria. The patient was given intravenous (IV) labetalol 10 mg before shifting the patient to computed tomography (CT) scan. CT scan revealed left-sided basal ganglia and thalamic bleed (30 mL) with intraventricular extension and midline shift of 4 mm toward the right side [Figure 1]. Within few minutes of CT scan, the patient's Glasgow Coma Scale (GCS) dropped to E2V2M2 with irregular respiration, and emergency intubation was done. The patient's blood pressure was managed with labetalol 60 mg. To control raised intracranial pressure, 350 ml of 20% mannitol was infused. The patient was shifted again for CT scan due to sudden deterioration in GCS. CT scan revealed increased size of bleed with intraventricular extension. An emergency craniotomy under anesthesia was planned. He remained hemodynamically stable throughout the surgery. At the end of the surgery due to low GCS, the patient was not extubated and was shifted to the intensive care unit (ICU) for further management. The patient was kept in the ICU for few days before being shifted to the ward.
Figure 1: Computed tomography scan of the patient revealed left-sided basal ganglia and thalamic bleed with intraventricular extension with midline shift of 4 mm toward the right side

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Spontaneous hemorrhage accounts for 20%–30% of all strokes and results in 30%–50% mortality over 30 days of presentation.[2] A history of hypertension is found in nearly 80% of cases.[2],[3] Peripheral TNB with alcohol has long duration of pain-free period that depends on the nerve blocked. Mean pain-free duration in the recent study was substantially longer with alcohol injection in TN than those previously reported results.[4] In a recent large study of 710 cases, 61 complications (8.6%) were reported with no mortality.[4] The common complication was sensory discomfort which got resolved in few months. However, in patients with comorbidities, especially hypertension and on anticoagulant medications, TNB should be done with careful monitoring. Pain during procedure, especially after alcohol injection, may result in sudden malignant hypertension leading to various neurological complications. Dexmedetomidine and lignocaine IV can be used to blunt hypertensive response and intracranial pressure.[5] Preprocedural assessment of patients, adequate analgesia, and peri-procedural monitoring will prevent these complications as well as lead to their early identification, if any. It is highly recommended to closely monitor hemodynamic changes in such subset of patients in pain clinic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McLeod NM, Patton DW. Peripheral alcohol injections in the management of trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:12-7.  Back to cited text no. 1
    
2.
de Oliveira Manoel AL, Goffi A, Zampieri FG, Turkel-Parrella D, Duggal A, Marotta TR, et al. The critical care management of spontaneous intracranial hemorrhage: A contemporary review. Crit Care 2016;20:272.  Back to cited text no. 2
    
3.
Singh S, Sethi N. Neuroanesthesia and pregnancy: Uncharted waters. Med J Armed Forces India [Preprint]. 2018. Available from: https://www.sciencedirect.com/science/article/pii/S0377123718301473. [Last Posted on 2018 Dec 18]. doi: https://doi.org/10.1016/j.mjafi.2018.10.001.  Back to cited text no. 3
    
4.
Han KR, Chae YJ, Lee JD, Kim C. Trigeminal nerve block with alcohol for medically intractable classic trigeminal neuralgia: Long-term clinical effectiveness on pain. Int J Med Sci 2017;14:29-36.  Back to cited text no. 4
    
5.
Singh S, Chouhan RS, Bindra A, Radhakrishna N. Comparison of effect of dexmedetomidine and lidocaine on intracranial and systemic hemodynamic response to chest physiotherapy and tracheal suctioning in patients with severe traumatic brain injury. J Anesth 2018;32:518-23.  Back to cited text no. 5
    


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