Asleep–Awake–Asleep Technique with Endotracheal General Anesthesia in a Patient of Hemiballismus for Pallidotomy: A Unique Challenge

Background: Hemiballismus is a relatively rare movement disorder. It is usually caused by a lesion that involves the contralateral subthalamic nucleus (STN). Stereotactic pallidotomy is the procedure of choice in the treatment of medically intractable hemiballismus.

Case Description: A 24-year-old female with history of left thalamic and midbrain cavernoma having right sided hemiballistic movements with right sided weakness, underwent craniotomy and excision of cavernoma under general anesthesia in February 2019. Patient got symptomatic relief from hemiballismus for 2 months, again developed hemiballismus of increased severity in spite of pharmacological treatment. Hence, it was decided to go for surgical treatment in form of left pallidotomy. After all preoperative workup, patient was given general anesthesia with standard doses of inducing agent propofol and muscle relaxant atracurium and maintained on sevoflurane. Patient was then taken to MRI and CT scan for mapping of globus pallidus. Patient was shifted to operating room and left sided burr hole was completed under anesthesia. Stereotactically, left-sided pallidus was identified. Wakeup test was done and patient was asked to follow the commands for checking effects of left pallidotomy. After confirming benefits with help of neurologist, permanent pallidotomy was done. Effects of pallidotomy rechecked and patient was taken under general anesthesia again, shifted to MRI for confirmation of lesion of pallidotomy. Patient was then reversed and extubated in operating room.

Conclusion: Pallidotomy presents unique challenge to attending anesthesiologist. Anesthesia was given by asleep–awake–asleep technique. Dexmedetomidine and narcotic based anesthesia was the technique of choice.

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Artikel online veröffentlicht:
25. März 2020