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General Anesthesia for Cesarean Delivery in a Parturient with Meningioma causing Intracranial Mass Effect
Abstract Number: F-36
Abstract Type: Case Report/Case Series
A 28 year old G3P2 parturient with inadequate prenatal care was transferred to our facility at 31 WGA with a 2 week history of headache, altered mental status, and ataxic gait. Prior to this pregnancy, she had two normal spontaneous vaginal deliveries at term without neuraxial anesthesia and without complication. The patient had no significant past surgical history, but did have a past medical history significant for hepatitis C and a questionable history of seizures. MRA of the brain at the time of admission showed a 7 x 5 x 6 cm extra axial mass over the left frontal lobe with bone erosion, mass effect, subfalcine and right transtentorial herniation, a 1.4 cm midline shift, and an acquired Chiari I malformation.
Upon admission the neuro critical care, obstetric anesthesiology, maternal fetal medicine, and neurosurgical teams were consulted. She was admitted to the neuro intensive care unit and was placed on levetiracetam, dexamethasone, and mannitol. A collaborative decision was made to resect the meningioma prior to delivery. However, the day prior to her scheduled surgery, the patient was noted to have rupture of membranes and subsequently went into preterm labor. She was emergently transferred to the labor & delivery unit for cesarean delivery under general endotracheal anesthesia. Rapid sequence induction was performed with propofol and cisatracurium secondary to the unpredictability of the rocuronium supply at that time. The patient had a preexisting dorsalis pedis arterial line, and left internal jugular central line was placed after induction. Several efforts were made throughout the case to minimize sympathetic outflow and further elevation of ICP. Esmolol was given on induction, low-normal PaCO 2 was maintained, and furosemide and mannitol were given after delivery. Intravenous ibuprofen was administered and a TAP block was performed prior to emergence in effort to minimize narcotics and therefore respiratory depression postoperatively. At the end of the case the patient was responsive and extubated without difficulty. On POD #6 the patient had embolization of the superficial temporal artery. On POD #7 craniotomy with stealth navigation was performed. Final pathology revealed a choroid meningioma (WHO grade II) with prominent vascular network. The patient was discharged on POD #12. At 3 week follow-up, her only complaints were mild memory loss and headache, which eventually resolved.