Man-in-the-barrel syndrome as a neurovascular manifestation after cardiac surgery: report of two cases

Context: The Man-in-the-barrel syndrome is characterized by brachial diparesis with preserved lower limb strength. This syndrome is an uncommon presentation of ischemic stroke. Cardiac surgery with or without cardiopulmonary bypass (CPB) favors hemodynamic and embolic mechanisms of stroke. Case reports: Case 1 - A 51-year-old hypertensive male presented acute bilateral upper limb weakness in the immediate postoperative period of surgical correction of atrial septal defect. CPB was not performed. Neurological examination showed grade III brachial diparesis with right-sided central facial palsy. Brain magnetic resonance imaging revealed diffusion restriction in the right pre-central gyrus, right occipitotemporal junction, and in the left perirolandic area. Case 2 – A previously healthy 53-year-old man presented grade III brachial diparesis with left-side central facial palsy in the immediate postoperative period for correction of Stanford type A aortic dissection. Surgical procedure included a synthetic tube, aortic valve repair, and 116 minutes of CPB. Brain magnetic resonance imaging showed diffusion restriction in the centrum semiovale bilaterally. None of the patients had significant stenosis of intracranial or extracranial vessels in the angiographic studies. Both patients had good recovery of upper limb function with rehabilitation. We believe that hypoperfusion associated with cardiac surgery led to watershed cerebral infarction. Conclusions: The Man-in-the-barrel syndrome is a rare complication of cardiac surgery. This clinical presentation is associated with watershed stroke.