Carbon dioxide: the cause of devastating stroke without hemodynamic compromise during laparoscopic nephrectomy with injury of the inferior vena cava: A case report

RATIONALE: Carbon dioxide pneumoperitoneum in laparoscopic surgery can bring about occult perioperative cerebral infarction, advancing our understanding of the causes of severe postoperative delayed recovery. PATIENT CONCERNS: Here, we report the case of a 35-year-old woman who underwent a right renal tumor resection in our institution, during which a raised pneumoperitoneum pressure (from 15 to 20 mm Hg) was adopted by the surgeon to prevent errhysis and to help stop the bleeding. Despite an accidental minor tearing of the inferior vena cava, vital signs remained stable throughout the procedure, and no obvious abnormality was observed in either end tidal carbon dioxide values or blood gas analysis. However, the patient unexpectedly suffered delayed recovery after the operation, presenting incomplete left hemiplegia and a positive Babinski sign. DIAGNOSES: Perioperative stroke was diagnosed by anesthesiologists, after excluding the effects of anesthesia. Cerebral hemorrhage was excluded, as no obvious abnormality was found in the density of brain parenchyma in the emergency computed tomography examination, and a digital subtraction angiography showed no abnormal thrombosis. Further magnetic resonance diagnosis led us to consider diffuse gas embolisms to be the cause of this acute stroke; a right echocardiography revealed that a patent foramen ovale (PFO) may account for the global cerebral gas embolisms. INTERVENTIONS: The patient received neuroprotective drugs (Vinpocetine, Edaravone, and Xingnaojing, which are commonly used as a standard of care in China), antiplatelets and other symptomatic treatments, plus dexamethasone to relieve edema. A contrast-enhanced echocardiography of the right heart was performed, the results of which were consistent with the sonography of a PFO. OUTCOMES: The patient was hospitalized for 14 days and eventually discharged after recovery. At the latest follow-up in August 2019, the patient recovered without residual neurological sequelae. LESSONS: Our results emphasize the need for vigilance regarding adverse cardiovascular and neurological events caused by carbon dioxide gas embolisms when encountering the inadvertent situation of vessels rupturing. Timely monitoring of paradoxical gas embolism by transoesophageal echocardiography is necessary and can avert the risk of severe complications. Urgent consideration should be given to stopping pneumoperitoneum and switching to laparotomy for hemostasis so that the patient can obtain the best benefit–risk ratio.