P-276SUBARACHNOIDAL-PLEURAL FISTULA WITH INTRACRANIAL HYPOTENSION SYNDROME: A RARE COMPLICATION OF EXTENDED LUNG RESECTIONS

Abstract

Objectives: Lung surgery with chest wall resection is an established procedure for the treatment of non-small cell lung cancer (NSCLC). In paravertebral localization of the tumour an opening of the dura can occur during resection. Subarachnoidal-pleural fistula (SAPF) with development of a subdural hygroma and an intracranial hypotension syndrome (IHS) is a very rare complication after extended lung resections. In literature there are only a few case reports about this complication. Case description: We report a 62-year-old male patient who underwent a lower lobectomy with chest wall resection due to NSCLC. During resection at the costovertebral joint the dura was opened and a few ml of cerebrospinal fluid (CSF) were lost. This injury was sealed with a fibrin patch (TachoSil®). On the 5th postoperative day the patient developed nausea, vomiting, confusion and headache. He also lost high amounts of pleural effusion. The cranial MRI showed a bilateral subdural hygroma with narrowing of the ventricles with a maximal width of 8 mm. Due to the clinical worsening up to somnolence the patient had to be mechanically ventilated. A high level of beta-trace protein was measured in the effusion. The myelography confirmed a persistent SAPF in the resection area. Due to the decreasing amount of effusion and improved neurology a surgical fistula closure was not necessary. The neurological symptoms disappeared under conservative treatment. Conclusion: SAPF with subdural hygroma and IHS occurs rarely after extended lung resections. It represents a significant perioperative complication, which entails respiratory and neurological impairment. It has to be considered if a persistently high pleural effusion or signs of cranial hypotension exist. It should not be underestimated, as it can result in tensionpneumocephalus, cerebellar insult, bleeding or meningitis. SAPF can be confirmed by laboratory tests and imaging. The type of treatment depends on clinical picture and amount of pleural effusion.