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Awake Craniotomy for A Parturient with Thalamic Intracranial Hemorrhage and Frontal Lesion: The Role of Neuro-Obstetric Anesthesiologist for Maternal Fetal Medicine
Abstract Number: S-37
Abstract Type: Case Report/Case Series
A 37 year-old G2P1 31 weeks pregnant female presented to an outside hospital with on week of persistent headache. CT scan revealed a 3.4cm right thalamic intracranial hemorrhage with a 1.2cm hemorrhagic lesion in the left subcortical front lobe. Patient developed nausea and vomiting with right pupil dilation and increased somnolence. Neurosurgical team performed a left external ventricular drain to release the obstructive hydrocephalus. She was given dexamethasone 6mg q6h for both fetal lung maturity and prevention of brain edema. She was subsequently transferred to our Neuro ICU for further workup with the concern of a metastatic source and definitive care for the immature fetus. Upon arrival, she presented with dilated right pupil and right ptsosis with category-I fetal heart tracing. Initial obstetrical plan was to delivery the fetus via cesarean upon completion of steroid treatment followed by neurosurgical team performing a craniotomy and left frontal lesion biopsy in order to facilitate further workup of the intracranial lesions. A multidisciplinary meeting with representation of neurosurgical, ICU, obstetrical, neuro-obstetric anesthesia teams were gathered, during which the neuro-obstetric anesthesia team offered awake craniotomy for neurosurgeon to remove the frontal lesion while obstetrical team performing intra-operative continuous fetal heart monitor and standby for stat cesarean delivery in case of fetal distress. The plan was unanimously taken by all teams. Awake craniotomy was performed with intravenous infusion of propofol, dexmedetomidine, remifentanil, phenylephrine and ephedrine with patient’s blood pressure maintained at baseline level. Fluid volume repletion was directed with Vigileo FloTrac EV-1000 monitor. Neurosurgical team was able to perform an excisional biopsy of the entire frontal lesion while the fetal heart tracing was stable throughout the procedure. At the time of this abstract submission, both maternal and fetal conditions are stable. We are waiting for surgical pathology report.
Ethical dilemma frequently raises in complicated maternal fetal medicine cases. To balance the risk and benefit of maternal and fetal factors around obstetrical vs neurosurgical approaches require an overall view of the patient’s conditions. Anesthesiologists are often strategically placed in the center of this frame of team work, which may lead to a better resolution. In this case, obstetrical team worries that further diagnostic study may harm the fetus and prefers an preemptive delivery. Neurosurgical team worries any potential hemodynamic swing may trigger secondary bleeding intracranially. With all this concerns, an awake craniotomy was elected by all team to be the best approach. While patient’s vital signs closely monitored and maintained, excision of the frontal lesion was performed safely.
Abd-Elsayed AA, et al. F1000Research 2013.
Biais M, et al. Critical Care 2009.