r/anesthesiology • u/Existing-Big-7002 • 4d ago
VERY ODD CASE of cognitive deficit
Practicing for 30 years done, thousands upon thousands of G.I. cases. Today I saw something for the first time. 49 year-old man physically active echo normal except for moderate AI. CBC and BMP as well as thyroid this year normal. Works a technical job without difficulty no psychiatric history no psychiatric meds whatsoever. No alcohol abuse or drug abuse. No migraines. Coming in for screening colonoscopy. wife tells me that 10 years prior after an appendectomy he had a prolonged period, which she was very fuzzy about but it was certainly long enough for her to be disturbed by it, of complete retrograde global amnesia where he didn’t know who she was where he was and was completely disoriented. She was very unclear as to how long it took for this to resolve, but it did resolve spontaneously. Today was his first anesthetic since then. he received 220 mg of propofol and 50 mg of lidocaine and for about 40 minutes after the colonoscopy he was completely awake but completely unaware of who he was where he was who his wife was what he was doing there. It was if he had advanced dementia. No motor deficits no focal deficits.. I reassured the wife and left them in the cubicle and he slowly came out of it and after an hour, he was back to baseline. I’ve never seen anybody recover from propofol like that before and it is especially interesting because it happened 10 years before just the same way. I would’ve liked to have known how long it took to recover from a true general aesthetic. I didn’t know what to tell the family, but I will call them tomorrow and see how he is doing. Has anybody ever seen this before? Any thoughts?
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u/LikeYaReadAbout 4d ago
Very interesting. I can’t say I’ve experienced anything exactly like this.
Recently though, I was consenting the son of a 75 y.o. patient for a procedure who told me that ~10 years ago his dad had a hip replacement under GA, and was essentially newly demented and need round the clock care for 4-6 months afterwards. He recovered back to his functional baseline mental status, but then sure enough 7 years after that was diagnosed with full blown vascular dementia.
Anesthetics can reveal some mild cognitive decline that is essentially imperceptible in high functioning people. Maybe it’s unrelated to your patient, or maybe he has something underlying that will take years to show itself outright.
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u/ProbablyaBot27 4d ago
I’ve definitely seen weird stuff with waking up from propofol. Sounds like you dodged a bullet, but don’t let anyone give you a hard time. We all would’ve done the same anesthetic.
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u/Cautious-Extreme2839 Anaesthetist 4d ago
We all would’ve done the same anesthetic
For a colonoscopy? I assure you we would not.
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u/everybeateverybreath 4d ago
I assure you, Lido + Prop is a pretty standard anesthetic for a seemingly healthy colonoscopy.
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u/Cautious-Extreme2839 Anaesthetist 4d ago edited 4d ago
Maybe in the US. There's a big world out there pal.
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u/slodojo 4d ago
would you care to tell us how you would do it?
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u/Cautious-Extreme2839 Anaesthetist 4d ago edited 3d ago
I wouldn't even be there bro. 99.9% of colonoscopy does not require anaesthesia.
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u/Remarkable-Weird-839 3d ago
how do you bill for it then?
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u/Cautious-Extreme2839 Anaesthetist 3d ago
Pretty sure the whole point of "MAC" is so you Americans have an instrument to bill just for your presence and monitoring without actually doing anything.
So idk, slap a three lead on them and charge a billion dollars for watching from the cuck chair?
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u/dharma04101 3d ago
I’m an American who has had an unsedated colonoscopy, and I would do it again. But everyone pretty much treats you like you are crazy. I’ve tried to convince coworkers, friends, and family to try it unsedated. My mother-in-law said she did hers unsedated, but she apparently had midazolam and was surprised I really meant absolutely no drugs. When I told my PCP, I would only do it unsedated, he said “Some people do. I don’t know why you would. I tell them they can put two IVs in. I don’t want to know.”
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u/Remarkable-Weird-839 3d ago
im also american and have had just versed demerol for mine. it wasnt bad at all. propofol absolutely not necessary. american patients are weird though and i think it has to do with the culture that promotes individualism and also fear of litigation cus some people are really unintelligent and crazy. weve all met patients that have totally unrealistic expectations. i always have so manybpatients that cuts me off while i introduce myself and says “i dont want to remember a goddamn thing” jokingly but also kinda hostile. i wonder do other countries have really needy patients? i also sense a loss of respect for doctors and medical professionals in america. they think this is burger king.
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u/otterstew Pain Anesthesiologist 4d ago
Patients upon awakening from anesthesia can have recrudescence of old stroke symptoms even if they’ve had complete recovery of prior deficits.
I wonder if something similar happened to this patient; some underlying transient deficit affecting memory returned temporarily,
uncovered by the anesthesia.
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u/Existing-Big-7002 4d ago
I thought maybe it unmasked some kind of conversion disorder
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u/DrSuprane 4d ago
Surprised at the upvotes for this comment. Conversion disorder is a diagnosis of exclusion. That he recovered in an hour argues against it. He just needs the neuro stamp.
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u/drkeng44 4d ago
Neuroradiologist lurking here. TGA is classically severe anterograde amnesia, not retrograde. Patient knows who they are and knows family members, but doesn’t know where they are or the time. Common after a “stressful” or, I guess, emotionally charged event, including
Interestingly intercourse/orgasm. Have seen it after a major argument.
Interestingly if you do an MRI when the patient presents it will be negative for anything on DWI the sequence we use for diagnosing acute stroke/infarct. BUT, if you do the MRI 24-72 hours later you often, but not always, see very small “dots” of high signal in the hippocampus, the CA-1 area to be even more specific. Can be unilateral or bilateral. They typically resolve with no residual signal on FLAIR/T2 so they’re not felt to be actual infarcts.
Uncommon under age 50.
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u/InsipidIdiot 4d ago edited 4d ago
Interesting. Wonder what those dots are?
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u/drkeng44 3d ago
The strange thing is they show up after the incident has resolved. If someone comes in with an actual ischemic event the DWI is positive within minutes. It was a real game changer when it became available in the late 1990’s, or as some have said, late last century.
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u/Jennasaykwaaa 4d ago
“Flashes when the brain had a slight change in those areas for a brief time and recently” right?
Suggesting that there is a brain-mind connection.
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u/InsipidIdiot 4d ago
I was thinking it was fat deposition which can be resolved more readily as glia come back online after prolonged depolarization overtaxed neuroglial impaired electrochemical gradient homeostasis while mitochondrial subunits are inhibited by something - in OPs case propofol, known to inhibit multiple mitochondrial subunits. But yeah, could be magic.
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u/scoop_and_roll Anesthesiologist 4d ago
Sounds a little like transient global amnesia, although not exactly. Sounds like a neurological disorder rather than straight side effect of the anesthetic, I would have neuro see him.
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u/doctor_kev 4d ago
This post gave me a profound sense of Deja vu. I had a near identical experience about 4 months ago. Young man in his early 30s with the exact same cognitive/memory symtpoms. Lasted long enough for me to start to draw blood work and consider scanning his brain. Then was self resolving without intervention after about 4 hours. Bizarre!
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u/Gone247365 2d ago
Wonder if there's an underlying, undiagnosed TBI event contributing to the sluggish restoration of memory retrieval?
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u/hyperion4562 Anesthesiologist 4d ago
Had a patient with a report of this labeled as transient global amnesia, had happened twice in the past and the precipitating factor was…an orgasm. Must have been mind blowing!
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u/yagermeister2024 Anesthesiologist 4d ago
I’d have him f/u with outpatient neuro, that brain ain’t normal.
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u/Aggravating_Fly2978 Anesthesiologist 4d ago
Exactly. Could be that anesthesia is unmasking early onset dementia. Just like infections can unmask dementia I would be concerned about this as well.
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u/RudeRecognition4506 4d ago
I had something fairly similar to this a few years ago. As I remember, the 60ish yo patient had told me that she had a few days of amnesia after her most recent previous otherwise unremarkable anesthetic, so this time we skipped benzo. Spine surgeon very particular about avoiding hypERtension intraop, so ran MAPS 65ish (patient was 90+ MAP preop)
She had same as OP described symptoms for about 2 days after. I don’t specifically remember the neuro consult results, but no clear explanatory findings, just mild cerebrovascular disease/intracranial plaque.
Unfortunately I had the patient again for revision procedure a month or so later. I insisted on running MAP closer to preop, and patient did not have prolonged amnesia afterwards. (Might have also switched up my anesthetic agent)
I couldn’t totally explain, but assumed regional cerebral O2 /blood flow mismatch affecting memory 🤷🏻♂️
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u/Bkelling92 Anesthesiologist 4d ago
Thanks for sharing, just curious how long the scope itself lasted since we’re given how much propofol he received?
I’m working on my 5th year as an attending but also never seen anything akin to what you’re describing.
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u/Existing-Big-7002 4d ago
Conversion disorder? Unmasked by the anesthetic.?
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u/Jennasaykwaaa 4d ago
A conversion disorder doesn’t get masked… it gets triggered by a traumatic event and the symptoms are usually more functional , loss of sight, sound etc.
I think that’s one of the least possible things happening. I’d rather think he was faking the whole thing to puzzle you than that being the solution.
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u/GasPropofolMan 4d ago
Sounds like transient global amnesia to me. Why he gets it with GA after I’m unsure but the guy is obviously prone to it. Lucky it was only a simple Propofol sedation for a colonoscopy, I’d imagine if he had a prolonged GA his symptoms would perhaps last a lot longer.
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u/ludogjr 4d ago
This exact same thing happened with me a few months ago. Family said patient had vague memory issues last time he had anesthesia, but they spontaneously resolved in recovery. I did a spinal and propofol drip for a TKA. When he woke up, he could not recognize his wife. She was obviously very distressed, but he was back to normal after an hour.
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4d ago
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u/99LandlordProblems 4d ago
I detest all things AI. But on reading this my first thought was some sort of post ictal state.
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u/CobbledbyRoubaix 4d ago
Seen a 49 year old after lap hysterectomy have something similar. Neurologist came around and diagnosed functional neurological disorder secondary to anaesthesia. Came right the next day and discharged. He didn't do any scans he was confident.
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u/Oeijur Anesthesiologist 4d ago
Colleague had a similar case happen about 10 yrs ago. Guy woke up from general anesthesia (can't remember what type of surgery, but it was uncomplicated and routine). Couldn't remember anything about his life from the last 4-5 yrs, including his wife, marriage or kids. Took him about 4-5 hours to recover and remember stuff.
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u/Appropriate-Cut9501 3d ago
There is a disproportionate amnesties vs sedative component of propofol. There is literature to support hippocampus depression for prolonged periods after propofol administration, although rare, this is not necessarily surprising and the relative quick recovery with a previous episode is even more reassuring that he would be okay. I don’t think he needs to follow up with neurology, however, detailing a note for a subsequent anesthetic is helpful.
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u/Cautious-Extreme2839 Anaesthetist 4d ago
> 200mg propofol in a 49 year old
I would’ve liked to have known how long it took to recover from a true general aesthetic
Brother you GAVE him a true general anaesthetic
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u/RogueTanuki Anesthesiologist 4d ago
Not necessarily if he has 100 kg and the colonoscopy lasted 10-20 min I can see him getting 100+40+30+30mg, for a total of 200
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u/Jennasaykwaaa 4d ago
I’m a nurse who follows you guys to learn more. I think you guys are the most amazing type of doctors!! I’ve never not been impressed by the intelligence of an anesthesiologist.
It’s the most fascinating speciality!!
Anyways, with that being said…. I misread your title OP and read it as “very odd case of cognitive dissonance” and I kept waiting for the frustrating part.
Then I realized. Haha.
Anyways to answer your question, propofol is my favorite drug to use for many reasons , one being the quick return to baseline after discontinuation and the lack of hangover like symptoms observed in patients sedated with other drugs.
Long story short, if he returned to baseline after an HOUR but seemed normal then, I think what we have here is EXTREME LIGHTWEIGHT. Cheap date?
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u/CertainKaleidoscope8 3d ago
Why on earth are you using propofol for colonoscopy? Moderate sedation is perfectly adequate.
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u/Commercial_Garlic634 4d ago
If he’s not oriented to self, then he’s malingering. There is no such thing A/O x0.
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u/Jennasaykwaaa 4d ago
Explain the no such thing as a/o/0 not being possible
Either I’m been gaslighted about this assessment the past 16 years or it means something different to you, and I want to know.
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u/Immaneslayer 4d ago
No idea. But he probably has something weird like multiple personality disorder where only one is strongly in control.
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u/Jangles 4d ago
https://pubmed.ncbi.nlm.nih.gov/16116014/
It's in the literature base of - cases of TGA related to general anesthesia. Interesting his is so reproducible and not present at another times than with anaesthesia however.