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Intracranial Neoplasm and the Parturient: Case Report Examining the Risks, Benefits, and Outcomes in Performing a Craniotomy and Tumor Resection from the Anesthetic Perspective
Abstract Number: SU-61
Abstract Type: Case Report/Case Series
30 y/o G4P3 at 32 weeks gestation with history of Grade 2 Oligoastrocytoma status post primary resection in 2014, hepatitis B, hypertension, and morbid obesity presented with episodic seizures and worsening chronic headaches with pregnancy progression. Imaging confirmed the previously resected Oligoastrocytoma had regained its original mass. Neurosurgery recommended urgent secondary resection. High-risk obstetrics recommended betamethasone, continuing levetiracetam and lacosamide per Neurology, and continuous fetal monitoring (CFM) during Intensive Care Unit admission and surgery.
Anesthesia was consulted for the Right Frontal Craniotomy. Recommendations included optimization of seizure medication, arterial line placement prior to induction with general anesthesia, intraoperative CFM, and Neonatal Intensive Care presence in case of emergent cesarean section (CS). Induction of anesthesia was with propofol, succinylcholine, and remifentanil followed by endotracheal intubation, mannitol, and sedation with minimal sevoflurane and remifentanil infusion. Craniotomy was performed with minimal blood loss and proactive blood replacement with Packed Red Blood Cells. The procedure was completed and did not require CS.
Intracranial neoplasm incidence in parturients is reported as 6.9/100,000 with surgical resection even less (1). Parturients with brain cancer typically demonstrate worse symptoms than non-pregnant patients due to water retention, vessel engorgement, and most importantly the hormonal effects of progesterone worsening malignancy growth and causing urgent presentation (2). In this case remifentanil was used instead of longer acting opioids to avoid respiratory depression in the neonate in case of CS. Although remifentanil rapidly crosses the placenta, it is eliminated almost entirely from both maternal and neonatal circulation by nonspecific plasma esterases (3). Mannitol was used to decrease brain bulk and intracranial pressure. Although it has been shown to cause fetal hypovolemia and electrolyte imbalance in animal studies, mannitol has been used safely in pregnant women for urgent situations such as this (4). This case report seeks to highlight the anesthetic management of parturients with intracranial neoplasms undergoing craniotomy.
1. Khurana T. J Anaesthesiol Clin Pharmacol. 2014 Jul;30(3):397-9.
2. Lynch JC. Br J Neurosurg. 2011 Apr;25(2):225-30.
3. Noskova P. BMC Anesthesiol. 2015 Mar 26;15:38.
4. Chang L. Can J Anaesth. 1999 Jan;46(1):61-5.