A 54-year-old ASA-1 male weighing 76 kg presented with a huge swelling in the occipital region of his scalp, growing rapidly in the last one and a half years (Fig. 1). He was operated upon twice, apparently for the same tumor, 7 years ago. Fine needle aspiration cytology of the progressively increasing occipital tumor revealed clusters of oval and spindle-shaped cells. A CT scan of the head revealed heterogeneously enhanced soft tissue density of the scalp lesion (10 × 6 × 10cm) in the right parieto-occipital region, with no obvious vascular invasions or intracranial extensions (Fig. 2). He was planned for wide excision of the tumor with a flap cover. In preoperative airway evaluation, the patient was found to be Mallampati grade 2 with limited neck extension movement. His hemoglobin was 12.9 gm/dl, and all other laboratory parameters were within normal limits. Informed written consent was obtained from him for the surgery and also for the reporting of the case in the medical literature. Standard monitors were attached to the operating room, and an 18G intravenous line was placed in the right forearm. He was induced with intravenous midazolam 2 mg, fentanyl 150 μg, propofol 120 mg, and succinylcholine 100 mg. Care of the huge occipital mass was taken, keeping it inside a ring made of cotton. After ensuring proper head, neck, and shoulder positioning, the trachea was intubated without much difficulty. The central venous line, arterial lines, and another 16G intravenous cannula in the left forearm were then secured, and the patient was positioned in the prone position for surgery. Intraoperatively, the tumor was found to invade the bone with infiltration into the dural venous sinuses, which was not seen at the time of the CT scan. As soon as the venous sinus was breached, blood started flowing profusely. Hemostasis was achieved by the use of bone wax. A large scalp flap was transposed into the defect, and secondary raw areas were covered with a split-thickness skin graft taken from the thigh. There was a loss of about 2 l of blood during surgery that lasted 4 h. About 4 l of crystalloids, 500 ml of hydroxyl ethyl starch, and three units of packed red cells (750 ml) were given intra-operatively during which the patient remained hemodynamically stable. The surgery was done in the prone position, and our problems started just when the patient was put back in the supine position after the completion of the dressing. We noted that the drain was filling up rapidly with fresh blood, and oozing was also noted on the dressings at the incision site. The rapid rate at which the drain filled up was alarming. A decision to immediately re-examine the wound was taken. Dressings and sutures were removed, and the surgical site was explored in the supine position itself. A liter equivalent of blood clots was discovered. On exploration, the dural sinus hemostasis was found disrupted, and this was again sealed with bone wax, and a pressure bandage was applied. The heart rate was 160 beats per minute, and the blood pressure had become unrecordable. Rapid intravenous fluids were given and an injection noradrenaline infusion was started to ensure perfusion; however, the patient started having bradycardia and developed asystole, probably due to a combination of hypotension, hypoperfusion, hypovolemia, and hypothermia. The patient received two cycles of cardiopulmonary resuscitation. Inj. adrenaline 1 mg was given before the return of spontaneous circulation could be noted. Three units of packed red cells, four units of fresh frozen plasma, and 1 l of crystalloid were transfused over an hour. There-exploration and hemostasis needed 1 h for completion. Blood gas analysis was done after CPR showed PH-7.15, PCO2-28, Po2-260, Hco3-14, Lactate-6, and Hb-7. The patient was shifted to the intensive care unit (ICU) on a mechanical ventilator with noradrenaline infusion running at 0.1μg/kg/min, which was gradually tapered and then stopped after 6 h. After 4 h of shifting into the ICU, the blood lactate value had come to 2.6, and the pH had stabilized to normal. His heart rate was still 150 beats per minute, and his arterial blood pressure was 90/60 mm Hg. In the ICU, he received 4 units of platelets and a balanced salt solution as intravenous fluid. Post-operative analgesia was maintained by intravenous fentanyl infusion at 40 μg/h and injection of paracetamol 1 gm every 8 h. He was on ventilator support for the next 16 h until his trachea was extubated. He was discharged from the intensive care unit on the third postoperative day.

Huge scalp swelling in the occipital region

CT scan of the head showing enhaced soft tissue density scalp lesion in the right parieto-occipital region