Anesthetic management of a symptomatic sphenoid wing

Anesthetic management of a symptomatic sphenoid wing meningioma
resection after delivery of 27 weeks intrauterine fetus : Case Report
Víctor Rivero, MD, Myrna Morales, MD, Hector Torres, MD. Anesthesiology Department, University of Puerto Rico School of Medicine, San Juan
INTRODUCTION
Meningioma is a common tumor in the female population. Among
all cranial meningiomas, 20% are localized in the sphenoid wing
making it challenging for resection due to proximity to carotid
arteries. Meningioma development during pregnancy is comparable
with that in non-pregnant women of the same age group. However,
pregnancy makes patients more susceptible for tumor growth. By
means of molecular studies, estrogen and progesterone receptors
have been identified in this malignancy. Due to this concern, cranial
tumors that grow faster during pregnancy require urgent resection.
CASE REPORT
We report a 31 year old intrauterine pregnant patient at 27 weeks
with a symptomatic large sphenoid wing meningioma. She was
G2P1 which presented for obstetric follow up complaining of
increasing intensity headache not alleviated with over the counter
nor prescribed analgesics. Mostly complaining of persistent
generalized headache originating within the left retro-orbital
region, dizziness, difficulty walking, nausea, vomiting, and loss of
memory. MRI was performed, revealing a large sphenoid wing mass
with midline shifting, as well as evidence of intracranial
hypertension (Fig. 2-3). Upon examination patient had motor
aphasia and dysarthria. Patient was oriented in person but not in
place and time. Cesarean section and tumor resection was
scheduled for same day by Obstetricians, Neurosurgeons, and
Neuroanesthesia service. Steroids for fetal lung maturity were
given. She was taken to operating room (OR), standard ASA
noninvasive monitoring, as well as radial artery catheter was
placed. A rapid sequence smooth induction for an emergent
cesarean section was granted with propofol and succinylcholine.
General anesthesia maintenance was achieved with sevoflurane,
1
2
cisatracurium, and fentanyl for the first part, then used sufentanil.
Immediately after an uncomplicated cesarean section, a central
venous catheter was placed and patient was prepared for
Neurosurgery intervention. A left frontotemporal craniotomy was
performed for radical tumor excision. During surgery patient lost
approximately six liters of blood which were replaced with PRBC,
FFP, Platelets, and crystalloids. At the end of surgery patient was
transferred to the Neurosurgical Intensive Care Unit orotracheally
intubated for hemodynamic monitoring and neuroprotection. She
was discharged on the postoperative day 5.
4
DISCUSSION
The management of pregnant patients with brain tumors in the
sphenoid area is a great challenge to obstetricians, neurosurgeons
and neuroanesthesiologists. In this patient urgent intervention was
mandatory due to worsening symptoms and progression of
neurologic deficits. The presence of a symptomatic sphenoid wing
meningioma combined with the anticipated changes of pregnancy
makes this an interesting and challenging case.
6
REFERENCES
3
5
Fig. 1 IUP 22 WGA ultrasound.
Fig. 2-3 Preop MRI T1 : Axial,
Coronal, and Sagittal images.
Fig. 4-5 Post op CT : Planar
and axial images.
Isla A, Alvarez A, Gonzalez A, Garcia–Grande A, Perez–Alvarez M, Garcia–
Blazquez M. Brain tumor and pregnancy. Obstet Gynecol. 1997;89:19–23.
Kanaan IJ, Kanaan H. Management strategy for meningioma in pregnancy: A
clinical study. Skull Base. 2003;13:197–203.
Sahu S, Lata I, Gupta D. Management of pregnant female with meningioma for
craniotomy. J Neurosci Rural Pract 2010;1:35-7.
Kasper EM, Hess PE, Silasi M, Lim KH, Gray J, Reddy H, Gilmore L, Kasper B. A
pregnant female with a large intracranial mass: Reviewing the evidence to
obtain management guidelines for intracranial meningiomas during
pregnancy. Surg Neurol Int 2010;1:95.
Balki M, Manninen PH. Craniotomy for suprasellar meningioma in a 28-week
pregnant woman without FHR monitoring. Can J Anaesth 2004;51:573-6.