Elsevier

World Neurosurgery

Volume 111, March 2018, Pages 22-25
World Neurosurgery

Case Report
Postoperative Stridor and Acute Respiratory Failure After Parkinson Disease Deep Brain Stimulator Placement: Case Report and Review of Literature

https://doi.org/10.1016/j.wneu.2017.11.176Get rights and content

Background

Parkinson disease (PD), a neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra of the midbrain, is commonly thought of as a motion disorder, but it can have significant effect on the respiratory system. Respiratory failure is the most common cause of death in these patients, but it can also affect laryngeal function causing dysphonia, dysphagia, and dysarthric speech. Acute upper airway obstruction is a rare finding in PD, especially in the perioperative settings. In this article we report a PD patient who developed upper respiratory obstruction postoperatively. We also review the literature and highlight the importance of preoperative evaluation to identify patients who may be at risk of this complication.

Case Description

We describe a PD patient presenting for brain stimulation electrode implantation under general anesthesia, who postoperatively developed stridor and near complete upper airway obstruction despite maintenance of oral anti-Parkinson medication regimen intraoperatively. The patient was reintubated in post-anesthesia-care unit, and tracheostomy was performed after 1 week due to persistent vocal cord dysfunction.

Conclusions

Baseline vocal cord impairment in PD patients can be acutely aggravated perioperatively. Symptoms such as dysphagia and dysarthria, which can indicate susceptibility to postoperative upper airway obstruction, may not be well recognized by the patient and family. Surgical candidates should be carefully interviewed preoperatively, and watchful monitoring of respiratory function intraoperatively and postoperatively is of paramount importance. Neurosurgical and neuroanesthesia team should be aware of, and prepared to manage, this potentially life-threatening airway obstruction in PD patients.

Introduction

Any potential risk of significant airway compromise in the perioperative period warrants thorough investigation, optimization, and a management plan that may involve multidisciplinary efforts.

Parkinson disease (PD) is the second most common movement disorder. The cause of PD is unknown, but it involves dopaminergic neuron destruction in the substantia nigra, locus ceruleus, and other brain centers.1 Dysphagia and dysarthria occur frequently as results of motor control impairment of the larynx and other components of the upper airway. Approximately 90% of persons with PD will develop dysarthria during the course of the disease; however, patients themselves may be unaware of any speech problems.2

Perioperative stresses related to surgery and anesthesia represent a significant hazard for PD patients, including deterioration in respiratory function. It has been reported that these patients are susceptible to pulmonary aspiration, laryngospasm, and altered function of the ventilatory muscles, resulting in an obstructive breathing pattern,3 but near to complete upper airway obstruction is rarely seen. We report a case where a PD patient was reintubated postoperatively (postop) in the post anesthesia care unit (PACU) and subsequently undergoing a tracheostomy due to such complications after deep brain stimulator (DBS) placement.

Section snippets

Case Description

A 71-year-old Arabic-speaking female with a 13-year history of PD treated with carbidopa-levodopa, amantadine, and entacapone presented as a candidate for DBS treatment due to uncontrolled dyskinesias. During preoperative discussion, the patient adamantly refused awake craniotomy due to her concerns of language barrier and cultural differences. Therefore the consensus was to place bilateral DBS under magnetic resonance imaging guidance in an intraoperative magnetic resonance imaging suite.

Discussion

PD is a progressive, neurodegenerative disorder caused by loss of dopamine-producing neurons in the brain. Respiratory abnormalities have been well described since the initial description of PD in 1817.4 Respiratory complication, especially aspiration pneumonia, is the most common cause of death in PD patients.5, 6

It is well known that PD can affect the larynx, leading to dysphonia and dysphagia. Surprisingly, however, symptomatic upper airway obstruction is not common in PD. Little is known

Conclusion

As the elderly population grows, inevitably we will encounter increasing numbers of PD surgical patients. Parkinson disease–related stridor and acute upper airway obstruction are rare but potentially can be lethal if not recognized early and managed appropriately. The purpose of our case report is to raise awareness of such significant complications. We therefore recommend the following steps when caring for surgical patients with long-standing PD: 1) careful preoperative evaluation of PD

Acknowledgment

We would like to thank Theresa M. Kline, MLIS for helping with the literature search.

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Conflict of interest statement: The authors do not have any conflicts of interest and the manuscript is not supported by any federal or industrial grants. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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