Abstract Details

ATL is an uncommon condition that results from white matter damage, often secondary to chemotherapeutic agents, environmental toxins, and drug abuse. Sevoflurane can cause neurocognitive and developmental impairments, especially in infants and children. In animal models, it has been shown to cause alteration in normal brain function and neuronal cell apoptosis. However, it has not been previously reported to cause ATL.

To present a patient with rare acute toxic leukoencephalopathy (ATL) after elective surgery.

We present a healthy 22-year-old female who underwent elective plastic surgery with an uneventful intraoperative course. Postoperatively, she had no spontaneous respiration or response to stimuli. Initial CT brain showed subtle basal ganglia hypodensities. MRI brain completed a few hours later revealed restricted diffusion involving the bilateral basal ganglia, perirolandic and occipital cortices, and brainstem with left basal ganglia hemorrhage. Repeat MRI brain and C/T-spine after 48 hours showed significant evolution of this acute process resulting in restricted diffusion throughout the bilateral subcortical white matter extending into the brainstem, cerebellum and spinal cord. Sevoflurane was the only inhaled anesthetic used. Sufentanil, Dexmedetomidine, and Versed were used in minimal doses. Vitamin B12, thiamine, drug screen, heavy metals, alcohol and hypercoagulable labs were normal. Plasma amino acids, urine organic acids, and acylcarnitine profile were concerning for hepatocellular impairment but without apparent metabolic disorder. Imaging and labs did not show hepatic injury. Whole-exome sequencing and neuropathologic correlation remain underway.

To our knowledge, this is the first reported case of ATL after an elective surgery. We hypothesize that ATL resulted from an idiosyncratic reaction to Sevoflurane in the setting of a genetic predilection. Our case highlights what we believe to be an adverse reaction to a traditionally safe anesthetic. Further research is needed to identify this mechanism of injury in a potentially at-risk population.