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Ann Thorac Surg 1995;60:683-685
© 1995 The Society of Thoracic Surgeons

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Case Report

Subarachnoid–Pleural Fistula After Resection of a Pancoast Tumor With Hyponatremia

Departments of Surgery and Radiology, University of Maryland, Baltimore, Maryland

Accepted for publication December 13, 1994.

	Abstract

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Resection of superior sulcus neoplasms is associated with a number of complications resulting from the extensive nature of the resection and the necessity to sacrifice certain adjacent structures. One of the complications of resection is the development of subarachnoid–pleural fistula, with the subsequent appearance of air in the cerebrospinal fluid circulation. We report a case in which a subarachnoid–pleural fistula led to persistent pneumocephaly in a patient who exhibited postoperative hyponatremia, confusion, and gait disturbance.

	Introduction

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Since the mid-1950s, the two cornerstones for treatment of superior pulmonary sulcus neoplasms have been irradiation and en-bloc resection. This combined approach has been refined to achieve up to 41% 5-year survival of patients without nodal involvement [1]. Superior sulcus tumor resection can lead to complications, including the rare case of subarachnoid–pleural fistula [2]. We describe here a case of postoperative pneumocephaly and hyponatremia.

A 68-year-old man with a 60 pack-year history of cigarette smoking, presented for elective resection of a left-sided Pancoast tumor. He experienced approximately 6 months of vague left shoulder pain radiating down the medial aspect of his upper arm. A chest roentgenogram revealed an ill-defined left apical mass, and subsequent computed tomography confirmed the presence of a large superior pulmonary sulcus mass invading the ribs posteriorly.

His preoperative work-up included a computed tomographic scan of the head, which was negative for brain metastases. Computed tomography–guided fine-needle aspiration identified a poorly differentiated large cell carcinoma, suggestive of squamous cell differentiation. The preoperative serum sodium level was normal.

The patient underwent preoperative therapy with 60 Gy of small- and large-field irradiation with concurrent weekly carboplatin chemotherapy according to an in-house trimodality protocol. Upon completion of this course he underwent elective surgical resection.

General endotracheal anesthesia was employed with one-lung ventilation, and an indwelling epidural catheter was placed for postoperative analgesia. A left upper lobectomy (with sparing of lingular segments) and en-bloc posterior chest wall resection was performed. He tolerated the operation well and was extubated in the operating room.

His initial postoperative course was uneventful. The immediate postoperative chest tube output was high, with a combined anterior and posterior chest tube output of 820 mL on postoperative day 1. By postoperative day 2, air leaks in both chest tubes had sealed, although their combined output was 1,080 mL.

The patient became confused and agitated over the next 2 days. On postoperative day 4 he pulled out his posterior chest tube and epidural catheter. The chest tube output for the 24 hours preceding had been 1,175 mL. A computed tomographic scan of the patient's brain failed to demonstrate any acute pathology that could account for his mental status.

The confusion had resolved by postoperative day 5; however, he continued to complain of dizziness and headache. He displayed moderate unsteadiness of gait. Laboratory evaluation showed a serum sodium level of 126 mEq/L. He was restricted to 1,000 mL/day of fluids and given intravenous furosemide. Chest tube output fell to 290 mL on postoperative day 7, and the remaining chest tube was removed. Despite treatment, the serum sodium level continued to decline, reaching 121 mEq/L on postoperative day 8.

Urine electrolyte analysis showed an osmolality of 427 mOsm/L and a urine sodium level of 34 mEq/L (concurrent serum analysis showed an osmolality of 256 mOsm/kg and a serum sodium level of 122 mEq/L), suggestive of the syndrome of inappropriate antidiuretic hormone secretion. A magnetic resonance image of the brain was obtained. This examination failed to demonstrate any neoplastic mass, but revealed a significant amount of air in the lateral ventricles (Fig 1).

View larger version (152K): [in this window] [in a new window]   Fig 1. . Magnetic resonance image made on postoperative day 10 demonstrating pneumocephaly in the lateral ventricles.

	Comment

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Various complications have been described with thoracotomy and pulmonary resection. The resection of a superior sulcus lesion is associated with unique sequelae due to the structures invaded by neoplasms in this anatomic location and the extensive nature of the resection. Invasion by tumor of the dorsal sympathetic chain, stellate ganglion, brachial plexus nerve roots, and subclavian artery will leave patients with deficits consistent with the structures sacrificed at resection. Likewise, complications common to routine thoracotomy, such as debilitating pain, costochondritis and thoracic dehiscence, may also occur [3].

Neurologic sequelae after resection of superior sulcus tumors can include injury to intercostal nerves manifesting as numbness of the involved dermatome, or as meningitis from occult cerebrospinal fluid leak. With first rib resection, the long thoracic and thoracodorsal nerves may be damaged, resulting in complications such as winged scapula. Transverse myelitis and paraplegia have also been documented [4].

Subarachnoid–pleural fistula is known to occur after penetrating wounds to the thorax and with fractures of the thoracic spine [5]. Iatrogenic subarachnoid–pleural fistula can occur with posterior chest wall resections involving removal of ribs and the transverse processes of the vertebrae with which they articulate. Cerebrospinal fluid leaks into the pleural space are common in this setting, and introduction of pleural fluid, air, or bacteria into the cerebrospinal fluid circulation can occur [6].

This patient underwent resection of a superior sulcus tumor with subsequent development of a suspected subarachnoid–pleural fistula with significant neurologic complaints, and hyponatremia with an unclear cause. Evidence supporting the presence of a subarachnoid–pleural fistula includes an abnormally high chest tube output of serous fluid and the finding of air in the lateral ventricles of the brain as documented by magnetic resonance imaging.

Hyponatremia is associated with a variety of intracranial diseases including tumors, meningitis, hormone-secreting pituitary adenomas, and subarachnoid hemorrhage. Two different pathophysiologic mechanisms cause hyponatremia in these settings: the syndrome of inappropriate antidiuretic hormone secretion and a less well defined entity known as cerebral salt wasting [7]. Many pulmonary neoplasms can lead to antidiuretic hormone-mediated hyponatremia [8]. Resection of such neoplasms should lead to resolution of this syndrome.

Although the presence of air within the cerebrospinal fluid circulation is seldom physiologic, the pathologic effects of its presence are largely unstudied. This case suggests a link between intraventricular air and the syndrome of inappropriate antidiuretic hormone secretion. Demonstration of intraventricular air by magnetic resonance imaging on postoperative day 8 suggests that an ongoing process such as postoperative subarachnoid–pleural fistula caused pneumocephaly in our patient, rather than an air bolus at operation.

Careful operative technique is paramount to prevention of subarachnoid–pleural fistulas. When nerve roots are divided close to the cord posteriorly, the divided roots should be examined for evidence of dural leak. If a dural tear is identified at operation, direct ligation with absorbable sutures should be done. Occasionally, it may be helpful to obtain a neurosurgical consultation when performing en-bloc resections that will include transverse processes and portions of the vertebral body. If a leak is identified postoperatively, treatment consists of direct suture ligation or muscle flap closure of this space to eliminate the risk of fistulous tract development. Once the fistula is identified the patient should also be treated with antibiotics to prevent further complications including meningitis. Occasionally additional chest tube placement combined with lumbar or lumboperitoneal drainage is therapeutic.

	Footnotes

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Address reprint requests to Dr Krasna, Division of Thoracic Surgery, University of Maryland Medical System, 22 S Greene St, Box 167, Baltimore, MD 21201.

	References

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1. Ginsberg RJ, Martini N, Zaman M, et al. Influence of surgical resection and brachytherapy in the management of superior sulcus tumor.Ann Thorac Surg 1994;57:1440–5.[Abstract]
2. Assietti R, Kibble MB, Bakay RAE. Iatrogenic cerebrospinal fluid fistula to the pleural cavity.Neurosurgery 19934;33:1104–8.
3. McLaughlin JS. Positional and incisional complications of thoracic surgery. In: Waldhausen JA, Orringer MB, eds. Complications in CT surgery. St. Louis: Mosby, 1991:20–8.
4. Attar S, Hankins J, Krasna MJ, Turney SZ, McLaughlin JS. Paraplegia following thoractomy: report of twenty-five cases [Abstract]. Proc Penn Assoc Thorac Surg 1993.
5. Higgins CB, Mulder DB. Traumatic subarachnoid–pleural fistula: case report.Chest 1972;61:189–90.
6. Frantz PT, Battaglini JW. Subarachnoid–pleural fistula: an unusual complication of thoracotomy.J Thorac Cardiovasc Surg 1980;79:873–5.[Abstract]
7. Bartter FC, Schwartz WB. The syndrome of inappropriate secretion of antidiuretic hormone.Am J Med 1967;42:790–806.[Medline]
8. Ross EJ. Extrapulmonary syndromes associated with neoplasms of the lung. In: Fishman AP, ed. Pulmonary diseases and disorders, 2nd ed, vol 3. New York: McGraw-Hill, 1989:1955–69.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark J. Krasna Joseph S. McLaughlin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boyev, P. Articles by McLaughlin, J. S. Search for Related Content PubMed PubMed Citation Articles by Boyev, P. Articles by McLaughlin, J. S.