Aortography is an important part of clinical evaluation in children with untypical or uncommon aortic coarctation image in echocardiography. In addition, in some cases, this procedure gives an opportunity to correct the abnormality by implantation of intravascular stent. A necessity of using general anaesthesia during aortography in children can lead to unusual complications. It is known and widely reported that general anaesthesia during surgery can cause a brachial plexus injury in approximately 0.2% of cases.Reference Cooper, Jenkins and Bready1 This complication is a result of muscle hypotonia after anaesthesia as well as of the patient’s malpositioning on the operating table. Such coincidence provokes the stretching and prolonged compression of nerves by the surrounding anatomical structures. A case of ischaemic injury of the brachial plexus related to an intervention as short as aortography has never been reported before. The shortness of procedure and bilateral presentation of this complication induced us to search for predisposing factors, which must have appeared in our case.
Case report
A 15-year-old girl was admitted to the hospital with aortic recoarctation. She had undergone a balloon angioplasty procedure 3 years earlier. The character of coarctation in two-dimensional and Doppler echocardiography determined the qualifications needed for aortography. After premedication, the patient was placed typically for aortography – in a supine position with arms raised over the head with shoulders flexed to 120 degrees and elbows flexed to 90 degrees (Fig 1). Subsequently, under general anaesthesia, the femoral artery was cannulated. The catheter was inserted into the aorta to visualise a region of stenosis and to measure systolic pressure gradient. The patient was qualified for intravascular stent implantation (type: Intrastent LD Double Strut 36 millimetres). Implantation was performed immediately and led to full stent expansion, which caused a drop in the systolic pressure gradient through the stenotic region. The length of aortography and implantation did not extend beyond 20 minutes and proceeded without complications. After the patient awoke from general anaesthesia, brachial plexus injury was noticed. Neurological consultation at that time revealed bilateral brachial plexus paresis in the upper part (roots C5 and C6 of the spinal nerves). Neurological examination showed muscle hypotonia, decreased muscle power, and sensory deficit – all more pronounced on the right side. The patient recovered fully after 6 months of typical treatment (injections of vitamin B6 and B12, non-steroidal anti-inflammatory drugs) and physical therapy rehabilitation.
Figure 1
Discussion
The brachial plexus, which supplies with motor and sense nerves most of the upper extremity and shoulder, is the most complex structure in the peripheral nervous system. A unique structure and superficial location between movable body parts – neck and arm – are the reasons for vulnerability to trauma. The most common type of injury occurs as an effect of ischaemic damage with subsequent disorders in circulation in vasa nervosum, nourishing the nerves of the plexus.Reference Desai, Uribe and Lachman2 General anaesthesia is usually considered as a predisposing factor provoking plexopathy.Reference Kumar Pillai, Ferral and Desai3 This causes muscle hypotonia leading to non-physiological shoulder positioning and to compression of the neighbouring skeletal structures on nerves. Similarly, an improper relationship between the patient’s arms and neck may cause stretching, compression of related arteries, and subsequently ischaemic brachial plexopathy.Reference Sawyer, Richmond and Hickey4 Another extremely important issue is the duration of procedure and immobilisation.Reference Shankar, vanSonnenberg and Silverman5 In previously reported cases of surgeries, which demanded raising the arms over the head, paresis appeared not sooner than after 2 hours of procedure.Reference Kumar Pillai, Ferral and Desai3, Reference Shankar, vanSonnenberg and Silverman5, Reference Brill and Walfisch6 In our case, plexopathia occurred after 20 minutes. Furthermore, it was bilateral, which suggests another factor that showed a significant predisposition to crucial ischaemia. On the basis of X-ray pictures, we excluded anatomical abnormalities and focused on a specific type of patient physique. The patient was 172 centimetres tall (93rd percentile) and weighed 52 kilograms (30th percentile). According to the World Health Organization-body mass index-for-age classification (tables of body mass index, gender- and age-specific, which are used to assess underweight, overweight, and risk of overweight in children and teenagers), our patient was on the 5th percentile. In our opinion, such a low weight in relation to height and asthenic physique increased the risk of brachial plexus injury caused by neighbouring skeletal structures. In these cases, it is impossible to reduce the pressure by adipose tissue or muscle tissue because of their impairment. This time it resulted in early ischaemia and a bilateral type of damage.
Nowadays, an increasing number of interventional procedures demand positioning a patient supine with arms overhead. This allows X-ray pictures to be made during the procedure at various angles, without changing the position, and helps to avoid beam-hardening artefacts from upper extremity bones. Paediatric interventional procedures are usually pursued under general anaesthesia, and therefore the awareness of risk of brachial plexus injury is necessary. Even a short time of immobilisation (20 minutes in our case) can become a reason for paresis, especially for patients prone to it. We claim that in case of extensive interventional procedures, children with asthenic physique and impaired adipose tissue should be given special attention. In improving the cure, either arm movements or temporary change of position can be helpful. Cooperation among the cardiologist, anaesthesiologist, and nursing staff is crucial to optimise patient care by avoiding brachial plexus injury. The cardiologist has the most significant role in the process as he decides the patient’s position, which is essential to carry out the procedure and is able to predict the length of immobilisation.
