A 69-year-old woman underwent thyroidectomy due to thyroid cancer. The surgery was uncomplicated. Three hours afterward, the patient developed slurred speech and right-sided weakness. Temperature is 36.3 C (97.3 F), blood pressure is 140/86 mm Hg, pulse is 90/min, and respirations are 18/min. On examination, the patient is alert and awake, but her speech is incomprehensible. Strength is 2/5 in both right upper and lower extremities. Sensations are decreased on the right side of the body. The dressing covering the operative site on the neck is dry. There is no stridor. The extremities are warm with normal capillary refill time. Neurologic examination prior to the surgery showed no abnormalities. Serum glucose and calcium concentration are normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 69-year-old woman underwent thyroidectomy due to thyroid cancer.  The surgery was uncomplicated.  Three hours afterward, the patient developed slurred speech and right-sided weakness.  Temperature is 36.3 C (97.3 F), blood pressure is 140/86 mm Hg, pulse is 90/min, and respirations are 18/min.  On examination, the patient is alert and awake, but her speech is incomprehensible.  Strength is 2/5 in both right upper and lower extremities.  Sensations are decreased on the right side of the body.  The dressing covering the operative site on the neck is dry. There is no stridor.  The extremities are warm with normal capillary refill time.  Neurologic examination prior to the surgery showed no abnormalities.  Serum glucose and calcium concentration are normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's new-onset dysarthria, right-sided weakness, and numbness are concerning for perioperative stroke. Most perioperative strokes are ischemic (vs hemorrhagic) and are caused by an embolism, thrombosis, or hypotensive episode (eg, watershed infarction). Patients with preoperative risk factors (eg, cardiovascular disease, carotid stenosis) have the greatest likelihood of stroke. Patients with symptoms of stroke, such as this one, should receive an emergency CT scan of the head without contrast to rule out hemorrhage. Once intracerebral hemorrhage is excluded, reperfusion therapy (eg, intravenous thrombolysis, mechanical thrombectomy) should be considered. Intravenous thrombolysis is sometimes contraindicated due to the risk of surgical site hemorrhage, but thrombectomy may still be possible, depending on the location of the stroke (eg, large-vessel occlusion). rule out hemorrhage Early recognition of postoperative ischemic stroke can be challenging due to the residual effects of general anesthesia but is essential because perioperative ischemic stroke has a high mortality rate (>40%) and reperfusion therapies are time dependent. Early treatment provides a better chance of neurologic recovery. (Choice A) Postoperative hypercapnia (diagnosed by arterial blood gas) can cause incomprehensible speech. However, hypercapnia of that severity would also lead to depressed mental status; this patient is awake and alert. In addition, focal neurologic deficits (eg, right-sided weakness) are unexpected. (Choice C) Postoperative hemorrhage, which can be visualized on a soft tissue CT scan of the neck, can compress the lymphatics, resulting in airway edema and leading to voice changes that can make speech incomprehensible. However, stridor would also likely be present. An anterior neck hematoma would not explain this patient's right-sided weakness. (Choice D) Subtotal thyroidectomy that releases free T4 from hyperactive thyroid tissue can cause intraoperative or postoperative thyroid storm. However, it typically manifests with hyperthermia, tachycardia, and hypertension (vs the normal vital signs in this patient). Tremor may be present, but focal neurologic deficits do not occur. (Choice E) Serum phosphorus levels can be elevated following thyroidectomy, when parathyroid function is also impaired (parathyroid hormone promotes excretion of phosphorus in the urine). However, elevated phosphorus levels typically cause muscle cramps, bone pain, and pruritus, which are not present in this patient. Educational objective: Perioperative patients with new neurologic deficits should receive a full stroke evaluation, including an emergency noncontrast CT scan of the head. Those with perioperative stroke may be eligible for time-dependent reperfusion therapies. References: Perioperative stroke: pathophysiology and management. (http://www.ncbi.nlm.nih.gov/pubmed/29441169)

A 69-Year-Old Woman Underwent Thyroidectomy Due to Thyroid Cancer