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Midline shift of both the brain and trachea: a Cesarean delivery in the setting of increased ICP and a mediastinal mass
Abstract Number: S4C-3
Abstract Type: Case Report/Case Series
A 20y/o primigravid woman at 38w EGA with a history of neurofibromatosis II and complete bilateral sensorineural hearing loss presented with dysphagia, difficulty swallowing secretions, and shortness of breath. Imaging revealed a right cerebellar pontine angle schwannoma with compression of both the brainstem and spinal cord at the C2-C3 level, as well as a mediastinal mass that encircled the esophagus and trachea, with resultant rightward deviation of the larynx below the cords. Given concern for increased intracranial pressure (ICP) and possible brainstem herniation with Valsalva during the second stage of labor, the patient was scheduled for an elective Cesarean delivery.
The risks and benefits of neuraxial versus general anesthesia were debated extensively, and posed a significant clinical dilemma. Unfortunately, provision of either general or neuraxial anesthesia introduced the significant risk of morbidity and mortality. Administration of neuraxial anesthesia in the setting of increased ICP and mass effect risked devastating brainstem herniation with puncture of the dura. Alternatively, induction of general anesthesia in the setting of a mediastinal mass could cause both airway and cardiovascular collapse. Ultimately, she underwent a primary Cesarean delivery under general anesthesia after performing an awake fiberoptic intubation. A thoracic surgeon and rigid bronchoscope were immediately available in the room, and personnel for cardiopulmonary bypass were on standby.
Preoperatively, two 18g IVs and a radial arterial line were placed. Glycopyrrolate was administered intravenously to decrease oral secretions. Her oropharynx was anesthetized by soaking viscous lidocaine on tongue depressor swabs and advancing them to the tonsillar pillars. She gargled viscous lidocaine and received a 4% lidocaine aerosolized breathing treatment during transport to the operating room.
Upon arrival in the operating room, communication with the patient was limited as she was unable to read lips through surgical masks. Patient anxiety necessitated dexmetatomidine sedation for intubation. Awake oral fiberoptic intubation with a wire-reinforced ETT was performed and placement confirmed with fiberoptic visualization of the carina, auscultation of breath sounds, and capnography. An inhalation induction ensued, and spontaneous ventilation was maintained throughout the case. She remained hemodynamically stable throughout the procedure. A multimodal approach to postoperative pain control was achieved via intraoperative use of dexmetatomidine, lidocaine, and ketamine infusions followed by ultrasound-guided bilateral transverse abdominus plane blocks prior to extubation. The patient emerged from general anesthesia and had an uncomplicated post-Cesarean recovery. Upon discharge, she received cochlear implants to assist with verbal communication, and outpatient consultation with neurosurgical colleagues recommend surgical excision of her intracranial tumors.