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Goal oriented general anesthesia for Cesarean section in a parturient with a large intracranial epidermoid cyst

[L'anesthésie générale spécialement conçue pour une césarienne chez une parturiente qui présente un important kyste épidermoïde intracrânien]

Charles Imarengiaye, MBBS FWACS^*, Judith Littleford, MD BSc FRCPC^*, Sharon Davies, MD BSC FRCPC^*, Kamal Thapar, MD PhD FRCSC and John Kingdom, MD FRCSC

^* From the Department of Anesthesia, Mount Sinai Hospital, the
Department Of Surgery, Division of Neurosurgery, Toronto Western Hospital, University Health Network, and the
Department Of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Canada.

Address correspondence to: Dr. Charles Imarengiaye, Department of Anesthesia, Mount Sinai Hospital, Room 1514, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada. Phone: 416-586-5270; Fax: 416-586-8664; E-mail: esepat{at}hotmail.com

Purpose: To illustrate the anesthetic management of a term parturient with a large brain tumour scheduled for Cesarean section.

Clinical features: A 26-yr-old woman presented at 33 weeks gestation with a generalized grand mal seizure. Magnetic resonance imaging demonstrated a 5-cm multi-lobulated extra axial mass compatible with an epidermoid cyst, arising from the left temporal lobe associated with shift of the midline structures and compression of the brainstem. She remained stable neurologically until elective Cesarean section at 38 weeks. Immediately prior to induction of general anesthesia, the proposed incision site was infiltrated with lidocaine and the supraglottic structures anesthetized with bilateral superior laryngeal nerve blocks. Remifentanil, thiopentone sodium and succinylcholine were administered in a rapid sequence fashion following voluntary hyperventilation to an endtidal CO₂ of 28 mmHg. Anesthesia was maintained with desflurane in oxygen/air and an infusion of remifentanil. Postoperative pain control was achieved using a multi-modal approach which included intraperitoneal deposition of local anesthetic, im ketorolac and rectal acetaminophen prior to emergence followed by regular administration of naproxen and acetaminophen for 72 hr.

Conclusion: In a parturient with a large intracranial tumour, general anesthesia combined with multi-modal balanced analgesia met the predefined anesthetic management goals and was associated with a favourable outcome.

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