PRNewswire
Ahmedabad (Gujarat) [India], June 26: A 35-year-old woman, mother of one, had persistent lower back pain for a very long time. However, in the second pregnancy the pain became relatively severe where even doctors were unable to administer spinal anaesthesia. She delivered a healthy child under general anaesthesia. Just a month after this, her pain became intolerable, so she consulted Dr. Dipak Patel, Sr. Neurosurgeon at Zydus Hospital, Ahmedabad. MRI of her spine indicated a tumor at Lumbar 2, but she did not have any other neurological deficits i.e. no weakness or numbness. However, she and her family were counselled about the probable complications like the tumor could be malignant in nature, developing weakness in lower limbs or incomplete tumor removal if it were close to the spinal nerve roots. Yet leaving it untreated carried a graver danger as she could develop paralysis of lower limbs or lose control of urine and stool. They went ahead for surgery.
The tumor was removed by Dr. Dipak and team (Dr. Anand Shah, Dr. Ravi Chauhan, Dr. Vandan Raiyani), and the surgery went smoothly. The tumor measured just 2x1.5 cm, appeared benign, and was removed entirely using intraoperative neuromonitoring (IONM) and surgical microscope.
Within 4 hours of being shifted to the ICU, she developed epileptic convulsions and was losing consciousness and started to become drowsy. She even complained of blurry vision, which happens when the visual cortex doesn't receive enough blood. Seizures originate in the brain rather than the spine, so a repeat CT was done to investigate the underlying cause of this rare development. Reports showed bleeding inside the skull and a pocket of trapped air, along with elevated blood pressure levels.
However, she stabilised soon only to massively deteriorate the next day. She was slipping in and out of consciousness, so they repeated her MRI and CT scans. The team was baffled when the scans showed new hemorrhages in her brain. These findings were extremely rare and her condition deteriorated further. Her BP had risen sharply and over the next two days the bleeding spread and pressure inside her skull increased. Without any reasoning behind the erratic results, the team had to convince her family for surgery as it had then become a matter of survival. The treating team consulted specialists from radiology, and neurology (Dr. Dinesh Saini) to understand the cause of this anomaly. Meanwhile, she had to be placed on ventilator support to manage the swelling. She was then taken back into surgery, where the clots were removed and a part of the skull bone was deliberately left off to relieve pressure. Decompressive craniectomy gives the swollen brain room to expand, and post-surgery, she remained on ventilator support and she recovered gradually.
The team suspected the original growth was a paraganglioma, a neuroendocrine tumor. These are extremely rare, highly vascular, and largely benign, account for a small fraction of all spinal tumors.
Dr. Dinesh Saini, Neurologist, diagnosed PRES or posterior reversible encephalopathy syndrome. PRES is a neurovascular disorder marked by the acute onset of seizures, altered consciousness, headache, and reversible vision loss, typically in the setting of rapidly rising blood pressure. Sudden surges in pressure overwhelm the brain's ability to regulate its own blood flow, breaking down the blood-brain barrier and causing fluid to leak into tissue which fit her hypertensive spike and visual symptoms precisely.
"In nearly four decades of practice, this is among the rarest phenomena I have encountered in a patient," said Dr. Dipak Patel. "We frequently operate on complex brain tumor and spinal tumor cases, even malignant ones however, in her case, the precise cause for her complication remains unknown. In the coming months she is scheduled to undergo a cranioplasty, in which a 3D-printed titanium plate, made to fit her skull, will replace the bone flap that was removed. The original bone was not reused as it had lost its blood supply and could cause infections. The lightweight, perforated implant will allow any fluids to drain safely" he further added.
The case underscores how rare neurological complications can arise even after successful surgery. Early recognition and expert intervention proved critical in achieving recovery.
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