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Posterior fossa craniotomy for brainstem glioma resection in patient at 25 weeks gestation with factor V Leiden and a patent foramen ovale
Abstract Number: SU-32
Abstract Type: Case Report/Case Series
A 27 year old G3P1011 at 25 weeks gestation with a past medical history of Factor V Leiden and patent foramen ovale (PFO) presented for neurosurgical resection of a symptomatic, enlarging tectal brain mass. Multidisciplinary management was coordinated among neurosurgery, obstetrics, obstetric anesthesiology, cardiology, and hematology. A posterior fossa craniotomy was planned.
A filter was placed by interventional radiology in the inferior vena cava prior to the day of surgery. On the day of surgery, an obstetric nurse was present in the operating room (OR) for continuous fetal monitoring. After rapid sequence induction and intubation, an arterial line and 2 large-bore peripheral intravenous catheters were placed. A central line was placed due to history of PFO. A precordial Doppler was utilized for diagnosis of air embolism. Total intravenous anesthesia was administered due to intraoperative neurophysiological monitoring. Neurosurgery placed a lumbar cerebrospinal fluid drain for management of intracranial pressures. Patient positioning was modified from sitting to left lateral to prevent aortocaval compression and venous air embolism in the setting of the PFO. Sequential compression devices on bilateral lower extremities were utilized throughout the operation. The intraoperative course was uneventful, and the patient and fetus remained stable throughout. She was extubated and recovered in the neuro intensive care unit.
Discussion: Tumors of the central nervous system occur in 6:100,000 women. Symptoms may present in pregnancy or become exacerbated with tumor growth (due to tumor estrogen and progesterone receptors), edema, increased vascularity, or immunotolerance associated with pregnancy. Symptoms of increased intracranial pressure can mimic symptoms of early pregnancy or preeclampsia/eclampsia, such as nausea, vomiting, headache, or seizures. Recommendations for neuroanesthetic management in pregnancy are mostly based on case reports or small studies. Optimal management begins with preoperative multidisciplinary planning among obstetrics, neurosurgery, and obstetric anesthesiology, and should include discussion of appropriate management of the tumor and timing of tumor resection (before or after delivery, or simultaneously with cesarean delivery). The importance of multidisciplinary management is highlighted in this case.
Wang et al. Anesth Analg. 2008;107:193-200.
Kazemi et al. J Neurosurg Anesthesiol. 2014;26:234-40.