Perioperative stroke after esophageal surgery

A 65-year-old man received general anesthesia for extended esophagectomy with 3-field lymph node dissection. Although he was without many risk factors for stroke except smoking, chest computed tomography performed preoperatively showed a small calcification at the origin of the left subclavian artery on the aortic arch. The anesthetic course was uneventful. On the first postoperative day, when the patient awoke from sedation, he presented with left conjugate deviation of the eyes and right hemiparesis. Immediate computed tomography scanning revealed cerebral infarction in the area of the left middle cerebral artery associated with hyper density indicating a thrombus. Both transthoracic echocardiography and carotid ultrasonography were performed to determine the cause of stroke. As a result, severe atheromatous stenosis of the left internal carotid artery was noticed, while there was neither thrombus nor shunt in the heart. Intraoperative cerebral emboli during surgical manipulation of the carotid artery were strongly suspected as a possible cause of the stroke. Preoperative carotid screening by ultrasonography may be advocated to identify such a patient as the present case with occult carotid atherosclerosis at risk for a subsequent stroke.