Proceeding with a general anaesthetic in a patient with ongoing symptoms of a hemiplegic migraine
Topics:
Published Date: 26th October 2020
Publication Authors: Singh P, Goel R
This is the first case in the literature to report a case of hemiplegic migraine aura resolving post‐general anaesthesia. A patient known to have frequent hemiplegic migraines had left‐sided facial droop in the pre‐operative period for elective day‐case surgery. She awoke in recovery with no facial droop.
Description
A 59‐year‐old woman presented for elective day‐case surgery, examination under anaesthetic with seton removal and video‐assisted anal fistula treatment. Previous surgeries were all unremarkable. Whilst being consented for her procedure, she told the surgical team she was about to have a migraine and in front of the surgeons developed a dense left‐sided facial droop. She said that this was very typical of her usual symptoms; however, it was very concerning for all staff involved. After discussion with the patient and the surgical team a decision to continue with surgery was deemed appropriate. She woke in recovery with no hemiplegia and her usual migraine headache and was discharged later the same day.
Discussion
There are multiple case reports in the literature discussing hemiplegic migraine after general anaesthesia with other associated symptoms [1]; however, there are no articles to our knowledge that discuss proceeding with a general anaesthetic with active symptoms in a patient known to have hemiplegic migraines. Hemiplegic migraines are migraines with a motor aura causing weakness. These types of migraines can occur as a sporadic or familial disorder. From available genetic studies, it is thought that mutations in genes involved in ion transport are responsible. Aura is caused by reversible cerebral cortical dysfunction, which is considered to be due to brief neuronal excitation with prolonged inhibition of neuronal activity [2]. We want to highlight the difficulties of making the decision as to whether or not to proceed with this case. Initial impression at the time was to wait until the symptoms had resolved; however, after discussion with the patient and the surgical team, a decision to continue to theatre was made. She was known to have frequent episodes, almost daily, and it was unclear how long the hemiplegia would last before it subsided, which risked cancelling her procedure. There was also the risk of her having another migraine on a future date if she was cancelled and brought back.
Goel, R; Singh, P. (2019). Proceeding with a general anaesthetic in a patient with ongoing symptoms of a hemiplegic migraine. Anaesthesia. 74 (S4), 84