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Tumefactive Multiple Sclerosis Presenting as Neurologic Deficits in Pregnancy
Abstract Number: T-65
Abstract Type: Case Report/Case Series
A 24 year-old female with a 23-week intrauterine pregnancy and a history of depression, morbid obesity, and tobacco abuse presented to the ED with new onset headache, dysarthria, and facial asymmetry. Head CT was negative for mass or hemorrhage. However, MRI revealed several intracranial lesions with increased T2 signal in the periventricular and sub-cortical white matter; the largest lesion in the right frontal lobe measuring 3.8x2.4x2.7cm. The presentation was consistent with an acute demyelinating process, most likely tumefactive multiple sclerosis (TMS). Oligoclonal bands in her CSF further supported the diagnosis. Despite aggressive steroid therapy, the patient continued to decline, developing profound left sided weakness. Repeat MRI showed an interval increase of the largest lesion, now measuring 5.3x4.3x4.9cm, with a new midline shift. At 32 weeks gestation, fetal testing revealed a non-reactive NST and reversed end-diastolic flow on US. She was delivered via cesarean delivery (CD) for breech presentation. Given imaging consistent with elevated intracranial pressure (ICP), general anesthesia using RSI technique was chosen. Anesthesia was maintained with a remifentanyl infusion and volatile agent. The surgery was uneventful and she was discharged on POD 4. We present a very rare form of multiple sclerosis (MS) in a pregnant patient with elevated ICP and the substantial anesthetic challenges associated with CD.
MS is a chronic, often relapsing–remitting disease thought to be of immunologic etiology characterized by a variety of neurological symptoms. TMS is a variant of MS distinguished by large demyelinating lesions which frequently cause mass effect, elevated ICP, and cerebral edema (1). Pregnancy has been found to be protective against the development of an MS flare, but the effects of pregnancy on TMS are unknown. While neuraxial anesthesia is safe in patients with MS, it is relatively contraindicated in the setting of elevated ICP given the risk of herniation and the resultant morbidity and mortality. In pregnancy, GA carries the increased risk of difficult intubation. In addition, hypertension and the associated increase in ICP during laryngoscopy and emergence are imperative to avoid in a patient with known elevated ICP. For these reasons, CD in a patient with TMS presents significant anesthetic challenges.
1) Kaeser DC et al. Tumefactive multiple sclerosis: an uncommon diagnostic challenge. J Chiropractic Med 2011;10: 29-35.