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Anesthetic Considerations for a Parturient with Enlarging Left Frontoparietal Mass Causing Worsening Midline Shift
Abstract Number: FCH-544
Abstract Type: Case Report Case Series
No randomized controlled trials exist to compare the safety of neuraxial versus general anesthesia in pregnant patients with intracranial lesions. Tumors such as meningiomas can be hormone responsive, thereby enlarging during pregnancy and further presenting challenges with regards to timing of intervention. We present a case report of suspected meningioma in a parturient with worsening clinical and radiologic evidence of tumor burden.
38-year old woman presented at 19 weeks gestation with progressive vertigo and right hand clumsiness. A 5 x 5 x 4 cm left frontoparietal extra-axial mass was identified in the parasagittal region on non-enhanced MRI, most consistent with meningioma. After multidisciplinary collaboration, the initial plan was to proceed with term cesarean section and delay mass resection until 4 weeks postpartum. As pregnancy progressed, deteriorating neurological symptoms and associated new onset focal seizures required escalation of corticosteroid and antiepileptic therapy. Repeat MRI demonstrated increased effacement of the left lateral ventricle with progression of a left-to-right midline shift of 3mm.
At 37+4 weeks, a healthy boy was delivered by scheduled cesarean section under general anesthesia. Hemodynamic parameters were carefully controlled using invasive blood pressure measurement, while surrogate intraoperative ICP monitoring was done via ultrasound guided optic nerve sheath measurements. Bilateral Transversus Abdominis Plane blocks were performed in an effort to reduce postoperative opioid usage. Contrast MRI performed on postpartum day 3 showed significant enlargement of the mass, increased cerebral edema and worsening midline shift. She underwent expedited craniotomy and tumor resection on postpartum day 10 with a plan for continued adjuvant radiation therapy.
Enlarging intracranial pathology presents unique risks in the pregnant patient. We review the literature with regards to preferred timing of surgical resection and evaluate the risk of herniation when selecting an appropriate anesthetic technique.