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Cesarean Section In A Parturient With Impending Herniated Brain Tumor – An Anesthetic Challenge
Abstract Number: F-72
Abstract Type: Case Report/Case Series
Brain tumors in parturients are rare (1). Their presentation can be aggravated or unmasked by pregnancy(1). Potential herniation from a brain tumor is a major concern in constructing the anesthetic plan. Detailed consideration must be given to both maternal and fetal safety.
A 22 year G2P0 with a posterior fossa mass lesion (figure 1) presented at 22 weeks gestation with headache. She was observed closely with planned continuation of pregnancy. She returned at 34 weeks with worsening neurological symptoms. Emergency cesarean section was planned. General anesthesia was provided after placement of a preinduction arterial line. Remifentanil, lidocaine and esmolol were administered prior to induction. Rapid sequence induction (RSI) was performed with propofol and succinylcholine. A remifentanil infusion was initiated prior to extubation to facilitate smooth emergence and prompt assessment by neurosurgery. Brain biopsy and decompression of the posterior fossa tumor were performed two weeks post cesarean delivery. Both mother and baby did very well.
Impending herniation could be catastrophic for both mother and baby. A comprehensive anesthetic plan and smooth intraoperative management are essential to achieve excellent outcomes for both the mother and fetus. Fear of aggravation of brain stem herniation precluded neuraxial anesthesia. Use of general anesthesia was also associated with considerable risks. Airway management in pregnant women can be challenging (2). While there was concern with the possible elevation of ICP associated with succinylcholine, the benefits of using succinylcholine for RSI in this patient at risk for aspiration and difficult intubation were felt to outweigh the risk. Esmolol, lidocaine and remifentanil were used to blunt the hemodynamic response to intubation and emergence thereby decreasing the chance of elevated ICP/herniation. Careful anesthetic and surgical management with multidisciplinary collaboration led to successful cesarean delivery followed by successful tumor resection with excellent results for both mother and baby.
1. Abd-Elsayed AA, Diaz-Gomez J, Barnett GHet al. A case series discussing the anaesthetic management of pregnant patients with brain tumours. Version 2. F1000Res 2013 Mar 21 [revised 2013 Dec 11];2:92. doi: 10.12688/f1000research.2-92.v2. eCollection 2013
2. Wang LP, Paech MJ. Neuroanesthesia for the pregnant woman. Anesth Analg. 2008;107:193–200