A 15 year old girl presented to the ER with coma following several tonic–clonic convulsions.\nThe patient was previously healthy with no personal or familial medical history. During her visit to a dentist for endodontic treatment, the dentist injected 1.5 ml of 2 % lidocaine (the total dose was 30 mg) and epinephrine 1:100,000 for local anesthesia. The solution was injected on the left side by an expert hand without prior aspiration.\nThe injection lasted about 2 min. By the end of the injection, the girl collapsed and several intermittent tonic–clonic convulsions ensued. These lasted about 30 min and were followed by deep coma.\nGlasgow coma scale (GCS) was three, brainstem reflexes were intact, and no fever was noticed. Vital signs were within normal limits.\nHer left cheek and gingiva were edematous and a giant gingival hematoma was noticed.\nOptic disc examination showed no edema.\nElectrocardiogram (ECG) was normal except for sinus tachycardia (120 beat per minute).\nElectroencephalography (EEG) showed diffuse slow activity, predominately theta rhythms, with no signs of continuous status epilepticus.\nBrain computed tomography (CT) revealed reduced white–gray matter differentiation with effacement of cerebral sulci which was compatible with cerebral edema.\nBrain magnetic resonance imaging with venogram (Fig. ) and angiogram (Fig. ) MRI + MRV + MRA showed cerebral edema, bilateral and almost symmetric hyperintense T2 lesions with restricted diffusion in both frontal and occipital lobes (Fig. ), and no underlying cerebral venous thrombosis CVT.\nLumbar puncture was performed and revealed the following results: 10 lymphocytes, elevated protein (50 mg/dl), no RBCs, and negative gram stain. Whereas blood glucose was 50 mg/dl, CSF glucose was 70.\nOrdinary labs including Calcium, Albumin, MG, Na, K, creatinine, urea, LFTs, CBC, Plt, PT, PTT, and INR were all normal and troponin was negative.\nThe patient was admitted to the ICU and intubated.\nPhenytoin at dose 15 mg/kg was loaded with close cardiac monitoring, and a maintenance dose of 100 mg twice daily was initiated in the second day.\nA bolus (1 g/kg) of Mannitol was given intravenously, followed by a maintenance dose of 0.5 g/kg/8 h. GCS, consequently, improved to nine in 2 days.\nThe patient recovered completely and was discharged after a week of admission.
Patient 1 was a 52-year-old male with a medical history of multiple sclerosis, who underwent arthroscopic rotator cuff repair due to a spontaneous complete rupture of the left supraspinatus tendon. The positioning of the patient applied during surgery was the beach chair position. Preoperative blood pressure (BP) was 135/80 mm Hg; heart rate (HR) 66 beats per minute (bpm); oxygen saturation (SpO2) values between 98% and 100%. For premedication, the patient received orally administered midazolam. Single-injection ISB was performed prior to induction of anesthesia and intubation. Total intravenous anesthesia (TIVA) was maintained with propofol and sufentanil. For left ISB, the patient initially received single-dose injections of 1% lidocaine (20 mL) and 0.75% ropivacaine (20 mL) followed by a second single-dose injection of 0.75% ropivacaine (10 mL) three hours after initial local anesthetic injections and 15 min prior to termination of TIVA, and extubation. Safety checks prior to injection did not show any aspiration of blood or cerebrospinal fluid. Adverse cardiac or neurologic symptoms were not recorded. Advancement and placement of the catheter was performed in PNS technique using a stimulating catheter. An effective ISB was confirmed by physical examination prior to surgery. BP was measured every 5 min with a noninvasive cuff. The patient underwent an uneventful operative rotator cuff repair under the ISB and intravenous anesthesia. Intraoperatively, recorded systolic blood pressure (SBP) levels of 100–110 mmHg were interrupted by SBP levels of ≥90 and <100 mmHg for a maximum of 90 min due to the application of controlled hypotension. Administration of antihypertensive and/or vasoconstrictor drugs was not recorded. SpO2 (98% to 100%), and end-tidal CO2 (ETCO2) values (30% to 34%) were normal throughout the case. The duration of surgery was 170 min. After termination of TIVA, and extubation in the operating room (OR), the patient remained in a severely impaired conscious state. In the postanesthesia care unit the patient showed a sustained severe impairment of consciousness, and neurological examination by a neurologist additionally revealed aphasia, multi-modal neglect to the right, left-sided gaze preference, dysphagia, severe right-sided central facial palsy, severe right-sided hemiparesis graded as 2/5 according to the Medical Research Council (MRC) scale for muscle strength, right-sided positive pyramidal tract signs, and right-sided hemihypesthesia. These symptoms were further accompanied by complex behavioural manifestations (anxiety, vocalization, aggression) and facial motor movements suggesting complex focal seizures. Due to vomiting with pulmonary aspiration, the patient underwent an emergency intubation. Brain imaging four hours post-surgery did not detect any cerebral lesions.