The patient is a 12 yo boy with sudden onset of shaking and staring for several seconds followed by unresponsiveness.  The patient's father reported that his son had been vomiting 2 weeks and had had headaches for 2 days.  

On arrival in the emergency room the patient was sleepy but arousable.

A CT was done which showed a large partially solid, partially cystic, partially calcified lesion in the third ventricle. He was found on ophthalmologic exam to have papilledema. His neurologic examination worsened over the next few hours. An emergency ventriculostomy was performed with an initial ICP of 40 mmHg. The patient was started on dexamethasone and an MR was ordered.  MR showed both a suprasellar mass with both cystic and solid components. Plan was to resect a presumed CRANIOPHARYNGIOMA through an interhemispheric approach. A femoral intravenous infusion catheter was placed to administer large volumes of blood if necessary during surgery. There were no intraoperative problems. Post operatively the patient developed diabetes insipidus and was given subcutaneous arginine vasopressin twice.  A post op CT scan showed pneumocephalus and no hematoma.  On post-op day number one he developed left lower extremity swelling and was thought to have a deep venous thrombosus.  Hypercoagulation workup found no reason for coagulation. Clotting was thought to be due to the femoral infusion line. The femoral intravenous infusion catheter was removed.  Repeat ultrasound showed extension of clot into the external iliac vein. Post op day 5 the patient was placed on enoxaparin. Post op day 14 he  suddenly developed labored breathing, tachycardia, and tachypnea.  A CT of chest showed a pulmonary saddle embolism in both pulmonary arteries.  The patient received oxygen to dilate his pulmonary vasculature.  Enosaparin was continued.  5 days later repeat CT showed resolution of clot. The patient was discharged on levothyroxine, cortisone, and DDAVP. 



DVT 25000 -- 1/10 that rate in children. Femoral line especially high risk.  Low molecular weight heparins more frequently used in children.

Reluctance to anticoagulate.

American College Chest Physicians: use spontaneous compression devices.  Use  of anticoagulation 12 hours after brain tumor surgery.

IVC filters an alternative.  Have been shown safe in children.  

Study on anticoag and ventric found safe to anticoagulate.

Post operative pharmacologic anticoagulation safe in both children and adults after both minor and major neurosurgeical procedures.

(Yvette Marquez)