Brainstem infarction and locked in syndrome: A less recognized complication of atlantoaxial injury

Background: Clinical reports and studies concerning the development of brainstem lesions and locked in syndrome after cervical injury are rare. Anesthesiological management can be important to prevent nerve tissue injury during endotracheal intubation and the process of positioning as well as electrophysiological testing and diagnostic imaging help to verify postoperative brainstem infarction. Case Report: The case report describes the history of an 88 y/o female patient with fracture of the dens, that was caused by a syncopal fall. In addition she had a history of atrial fibrillation, which may have evoked the syncope. The patient showed unexpected neurologic complications after atlantoaxial screw fixation. For surgical procedure fiberoptic intubation and awake positioning of the patient were successful managed and no neurological deficit was found prior induction of general anesthesia. Surgical intervention and sequence of general anesthesia was than performed uncomplicated. Nevertheless patient developed clinical signs of a locked in syndrome postoperatively. Neurophysiological testing of brainstem auditory evoked potentials, somatosensory evoked potentials, motor evoked potentials and blink reflex helped to verify the diagnosis. Diagnostic imaging showed brainstem infarction as source of the clinical and neurophysiological findings. Unfortunately the patient deceased as result of neurological dysfunction and cardiovascular instability. Conclusions: The presented case highlights the importance of a sufficient perioperative anesthesia regime in addition to surgical strategy and the rational use of diagnostic imaging and neurophysiological methodologies to classify clinical symptoms irrespective of the poor outcome in a particular patient.