Management and Outcome of Increased Intra Cranial Pressure (ICP) from Multiple Cerebral Ring Enhancing Lesions during Second Trimester: A Case Report
Abstract Number: 244
Abstract Type: Case Report/Case Series
Introduction: Breast cancer is the 2nd most common pregnancy associated malignancy. It has been reported to occur in 19.3 per 100,000 births(1). Of the 12.67% of women who develop breast cancer in their lifetime 12.7% are aged 20-44 years(2). Physiologic changes of pregnancy can delay the diagnosis of breast cancer by 2-7 months, and these cancers are mostly diagnosed at advanced stage with poor prognosis(3).
Case: A 28 year-old G6P4A1 at 29 3/7 weeks presented to the ER with loss of consciousness and supraventricular tachycardia following two weeks of nausea and vomiting (N&V). She was treated with adenosine and admitted for rehydration and further treatment and evaluation. Her status improved. Her echocardiogram, EKG, coagulation profile, metabolic panel, thyroid function tests and hepatic ultrasound were within normal limits; she had mildly elevated hepatic enzymes.
Five days later her N&V reappeared, associated with headache and mental status change to GCS of 11. A CT-scan revealed seven supra and infra-tentorial ring-enhancing lesions with significant edema and midline shift. Initial differential diagnosis was infectious disease vs. metastases. GCS of 7 from a possible herniation required emergent intubation (thiopental and succinylcholine) and hyperventilation. Central (CVP), arterial and intracranial pressures (ICP) were measured invasively. ICP of 38 mmHg was lowered to 18-21mmHg with 75 mg mannitol, 40 mg furosemide, 8 mg dexamethasone, a propofol and fentanyl infusion. An acute hyponatremia post mannitol infusion was treated with 3% saline infusion.
A 2 cm left breast mass biopsied showed poorly differentiated invasive ductal carcinoma. A chest x-ray revealed multiple round lesions.
Preterm labor 16 hours later raised ICP further. A c-section was done under continuous BP, CVP, ICP and BIS monitoring. ICP and MAP were maintained around 25 mmHg and 95 mmHg respectively. Phenylephrine was used to maintain CPP. Thiopental was used for cerebral protection and to lower ICP. Both ovaries had multiple masses. The life support was discontinued 3 days later for poor prognosis. The neonate required mechanical ventilation for 48 hours. He was discharged at 6 weeks age adequately reaching milestones.
Discussion: Breast cancer is the commonest source of brain metastasis in females, presenting as either high ICP or focal damage/irritation. The symptoms in this patient were obscured by other complications. Goals of maternal treatment and high ICP can compromise fetal wellbeing; 1. Uterine vasoconstriction with a PaCO2≤28mmHg, 2. Fetal depression from thipental given to lower ICP, and 3. Mannitol induced fetal hyperosmolarity with increased fetal sodium and decreased fetal lung fluid. Fetal survival in this case was unexpected. A c-section for fetal safety, as soon as mother is stable enough, should be considered.
1. Am J Obstet Gynecol 2003;189:1128-35 2. Surg Clin N Am 2007;87:417-430. 3. Clin Breast Cancer. 2009 Jun;9 Suppl 2:S73-81