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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

	Abstract

TOP Abstract Introduction Clinical history Discussion References

 
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.

	Introduction

TOP Abstract Introduction Clinical history Discussion References

 
THE anesthetic management of labour and delivery for the term pregnant patient with a recently diagnosed intracranial tumour must be tailored to individual circumstances. This requires close communication between the neurosurgeon, obstetrician and anesthesiologist in order to ensure that all consultants appreciate the inherent risks and to permit the anesthesiologist to plan the anesthetic appropriately. Both general anesthesia and regional analgesia/anesthesia have been described with variable outcomes.^1–4 In order to ensure overall maternal and fetal wellbeing, the anesthetic technique chosen should avoid fluctuations in intracranial pressure (ICP), maintain stable hemodynamics and provide a sufficient depth of anesthesia and analgesia. We report the case of a woman with a large intracranial tumour associated with midline shift and brainstem compression to illustrate the process involved in determining the appropriate anesthetic technique for her situation.

	Clinical history

TOP Abstract Introduction Clinical history Discussion References

 
A 26-yr-old G2P1 at 33 weeks gestation presented to the Emergency Department following a generalized grand mal seizure lasting one to two minutes. Although she had intense nausea on the morning of the seizure, there was no preceding aura or associated urinary or fecal incontinence. The post ictal phase lasted approximately 20 min. Her past medical history was unremarkable except for a ten-year history of migraine headaches. Similarly, her pregnancy had been uneventful prior to the seizure. Specifically, there was no history of hypertension or features suggestive of pre-eclampsia. She was referred to the neurosurgery service for further evaluation.

Magnetic resonance imaging (MRI) of the brain revealed a 5-cm multi-lobulated extra-axial mass arising from the left choroidal fissure of the left mesial temporal lobe. The mass was seen to insinuate itself between the mesial temporal lobe and brainstem in the ambient cistern. The lesion extended superiorly to the body of the lateral ventricle, causing some left to right shift, compression of the brainstem, and encystment of the left temporal horn (Figure). The MRI signal characteristics of the lesion were highly characteristic of an epidermoid cyst.

View larger version (129K): [in this window] [in a new window]   FIGURE Magnetic resonance imaging with contrast (axial T2) demonstrating brainstem compression.

Physical examination revealed a young pregnant woman (height 163 cm, weight 78 kg), who was conscious and alert. The pulse rate was regular at 88 beats•min^–1 and the blood pressure was 120/80 mmHg. Heart and lung sounds were normal. The airway examination revealed adequate mouth opening, class 1 Mallampati visualization of pharyngeal structures and good neck movement. Following consultations between the neurosurgeon, obstetrician and anesthesiologist, a decision was made to perform elective Cesarean section under general anesthesia. The anesthetic goals included 1) control of intra-cranial pressure, 2) maintenance of hemodynamic stability, 3) prevention of gastroesophageal reflux, and 4) the provision of adequate postoperative analgesia. The anesthetic plan and options for postoperative pain control were discussed with the patient. Dexamethasone 4 mg per os q6hr was administered for 48 hr preoperatively to reduce the influence of the intracranial mass effect.

On the day of surgery, rescue medications for seizure control (midazolam, phenobarbitone and phenytoin) and vasopressors were readily available. With the patient in the supine position, left lateral tilt and 30° head up, iv and arterial lines were secured. The initial blood pressure was 131/78 mmHg and the mean arterial pressure (MAP) was 97 mmHg. The electrocardiograph revealed sinus rhythm with a heart rate (HR) of 79 beats•min^–1; oxygen saturation was 99%. Bilateral superior laryngeal nerve blocks were performed, using 1 mL of 2% lidocaine per site, for the purpose of blunting the hemodynamic response to laryngoscopy. The previous Pfannenstiel scar was infiltrated with 20 mL of 2% lidocaine. Preoxygenation and permissive hyperventilation were carried out for three minutes. Once the end-tidal CO₂ reached 28 mmHg, a bolus of remifentanil 1 µg•kg^–1 was administered intravenously. Gallamine 5 mg, thiopentone sodium 200 mg, and succinylcholine 200 mg were given in rapid succession. The airway was secured and following confirmation of correct placement of the tracheal tube, anesthesia was maintained with oxygen in air (1:1), desflurane, and a remifentanil infusion. The narcotic infusion was titrated from 1 µg•kg^–1•min^–1 to 0.5 µg•kg^–1•min^–1 and remained at this rate throughout. Desflurane was titrated to maintain the stability of the MAP at a target of 90 mmHg ± 20%. A non-depolarizing muscle relaxant was not required. Tidal volume and respiratory rate were adjusted to achieve low peak airway pressures and maintain the end-tidal CO₂ tension between 28–34 mmHg. An arterial blood gas sample confirmed the absence of an arterial to end-tidal CO₂ gradient (pH 7.4, PaCO₂ 35 mmHg, PaO₂ 457). The oxygen saturation remained between 98–99%.

A live 2830 g female infant was delivered eight minutes following the skin incision. The infant was actively resuscitated for two minutes with oxygen, bag and mask ventilation and naloxone 0.3 mg given intramuscularly. Respiratory efforts were augmented with continuous positive airway pressure for approximately four minutes. The Apgar scores were 6/1 and 9/5.

Following delivery, an infusion containing 20 units•L^–1 oxytocin was commenced. Benadryl 25 mg and ondansetron 4 mg were administered intravenously to reduce the likelihood of postoperative nausea and vomiting. The preemptive multi-modal pain management strategy, which had begun with pre-incision skin infiltration, was continued with intraoperative instillation of 100 mL of 0.4% lidocaine at closure of the peritoneal cavity, im ketorolac 40 mg, and rectal acetaminophen 1000 mg prior to emergence from anesthesia. Intraoperative blood loss was estimated to be 400 mL and was replaced with 1200 mL of 0.9% saline. At the completion of surgery, the patient was extubated awake on the operating table within five minutes of discontinuing the desflurane. The remifentanil infusion was stopped immediately prior to extubation. The MAP increased transiently to 111 mmHg, the end-tidal CO₂ to 40 mmHg and the HR to101 beats•min^–1.

The patient was monitored during transport to the Intensive Care Unit (ICU). On arrival, the blood pressure was 145/79 mmHg, MAP 104 mmHg, HR 83 beats•min^–1 and oxygen saturation 99%. She was alert, talking and pain free. The postoperative analgesic orders included acetaminophen 1000 mg q8hr, morphine 1.5–3 mg intravenously prn and rectal naproxen 500 mg q12hr. Midazolam and a nasopharyngeal airway were kept by the bedside at all times. Dexamethasone 4 mg po was continued for the first postoperative day and gradually tapered over the next 48 hr. Her ICU stay was uneventful and neurovital signs remained stable. She was transferred to the postpartum ward on the second day. Her only opioid requirement throughout the entire postoperative period consisted of a single dose of 2 mg morphine. She was discharged on the fourth day postpartum. Immediately after discharge, the patient suffered a second generalized seizure. She was placed on anticonvulsants and has remained seizure-and symptom-free. Because of the location of the lesion, the patient has undergone a series of perioperative investigations, including neuropsychological testing, language assessment and functional imaging as a prelude to an eventual resective neurosurgical procedure.

	Discussion

TOP Abstract Introduction Clinical history Discussion References

 
The incidence of brain tumour in pregnant women is not known. An epidemiological survey showed the incidence in the United States to be between 3.4 per 100,000 in the age bracket of 15–24 yr and increasing to 6.9 and 6.8 per 100,000 in the age brackets of 25–34 and 35–44 respectively.⁵ Rarer still is an intracranial epidermoid cyst, a slow growing congenital tumour. It is believed to result from inclusions of epithelial elements within the neural groove at the time of neural tube closure, between the third and fifth week of embryonic life.^{6, 7} Intracranial epidermoid cysts commonly affect the cerebellopontine angle, the parapituitary area, the chiasmal region and the temporal lobe of the cerebral hemisphere.⁸ Due to the variable location of the tumour, symptoms are referable to compression of the adjacent neural structures and result in focal neurological dysfunction or obstruction of the cerebrospinal fluid (CSF) pathway.⁹ The tumour may also leak or rupture into the subarachnoid space or ventricular system, causing chemical meningitis.⁸ In a series of 33 patients reported by Yamakawa et al.,¹⁰ five patients had the epidermoid cyst in the cerebral hemisphere. There was a female preponderance, with 3:2 frontal/temporal lobe location in these patients. Similar to our patient, seizures as the presenting feature were common to all.

The relationship between pregnancy and intracranial epidermoid tumour is not clear. The average age of onset of symptoms was 21 yr (ranging from 11–37) in one study and symptoms appeared earlier in those patients with tumours in the cerebral hemisphere.¹⁰ The onset of symptoms in our patient during pregnancy may be entirely coincidental and independent of the pregnancy. Alternatively, the accompanying pregnancy may have accelerated the growth of the tumour leading to compression on the surrounding neural structures. A body of literature exists, which indicates that the hormonal milieu of pregnancy may influence the growth of some intracranial tumours.^11–14 Postulated mechanisms include increased blood volume, redistribution of total body water between the intracellular and extracellular fluid compartments and the influence of steroid hormones.^11,12 These changes may result in increased tumour size and consequent compression on surrounding structures. Roelvink et al.¹² speculated on an apparent correlation between the blood progesterone level and the manifestation of the central nervous system tumours. In the present case however, the appearance of tumour symptoms only in the third trimester argues against progesterone as the sole hormonal influence.

The neurosurgical management of a pregnant patient with a newly diagnosed brain tumour should be based on neurosurgical principles, the obstetrical management should be based on obstetrical principles, and rarely will the two represent competing issues. The course of pregnancy is influenced by the gestational age at diagnosis and the neurological status of the patient. The pregnancy may progress to term if the patient is in a stable neurological state. Nevertheless, declining neurological function has prompted emergency Cesarean section and craniotomy.^2,15 Our patient was in a stable neurological state with a term pregnancy. Accordingly, the neurosurgeon favoured postponing tumour removal until the postpartum period.

In the term neurologically stable patient, opinion varies on the preferred method of delivery. Some suggest vaginal delivery while others favour elective Cesarean section.^1–4 This divergent view is occasioned by the differences in tumour size and location. In those patients with a tumour of sufficient size to exert a mass effect the clinical management remains a challenge. Tewari et al.¹⁵ suggested expeditious Cesarean section. The pains of labour and the consequences of bearing down in the second stage of labour do result in marked increases in CSF pressure.¹⁶ Epidural analgesia may eliminate the pain of labour but may lead to an increase in intracranial pressure with the injection of local anesthetic agent into the epidural space.¹⁷ Epidural anesthesia is therefore potentially hazardous for such patients.

The risk of accidental dural puncture during the identification of the epidural space, though low in experienced hands, is another concern.¹⁸ The subsequent risk of tentorial herniation following a potential dural puncture with a 17-gauge epidural needle in a patient with compromised intracranial compliance is unknown. Similarly, subarachnoid anesthesia could result in tentorial herniation consequent upon loss of CSF from the dural defect. Patients reputed to be at highest risk of lumbar puncture-induced herniation are those with temporal lobe mass lesions associated with shift and brain stem compression,¹⁹ as was the case in our patient. The hemodynamic changes associated with spinal anesthesia are undesirable in these patients. In addition, meningitis has been reported following both uneventful combined spinal epidural technique ²⁰ or in association with spontaneous rupture of the epidermoid cyst into the subarachnoid space.⁸ Postoperative development of meningitis from the tumour may be blamed on a rather benign spinal technique.

General anesthesia, adapted to specific management goals, was our choice for the surgical delivery of this patient. The anesthetic plan should ensure overall maternal and fetal wellbeing, forestall fluctuations in ICP and maintain hemodynamic stability. At the same time, a sufficient depth of anesthesia and a rapid recovery are essential. We achieved this with desflurane and remifentanil anesthesia. Desflurane, a fluorinated inhalation agent, has been shown to have a good maternal and neonatal safety profile.²¹ We were able to titrate the desflurane and remifentanil to maintain control over MAP. These agents also allowed for the patient's rapid recovery.

Postoperative pain control should form a major goal in the planning of the anesthetic management of a patient with raised ICP. Techniques or pharmacological agents that will minimize or eliminate the side effects of opioids are the most desirable. The administration of remifentanil in our patient meant an absence of residual opioid analgesia in the postoperative period. A multi-modal analgesia approach was chosen to allow adequate control of pain with minimal side effects.²² The preincisional skin infiltration, intraperitoneal deposition of local anesthetic agent, administration of a non-steroidal anti-inflammatory drug and acetaminophen were attempts at treating pain at the various sources of nociception. Preincisional infiltration with local anesthetic interferes with initiation of pain in the periphery and consequent central sensitization. This results in attenuation of the inflammatory response to surgical trauma.²³ The role of intraperitoneal deposition of local anesthetic in antinocioception has been studied in cholecystectomy and appendectomy patients with conflicting outcomes.^24,25 The contribution of the peritoneum to post Cesarean section pain is unclear at the present time and comparison with other surgical procedures is not valid due to differences in tissue injury to the peritoneum.

In summary, the management of the pregnant patient with a brain tumour must be individualized. This requires a multidisciplinary approach. Well-defined management goals should be outlined and the anesthetic technique tailored to meet these goals. Both regional and general anesthesia have inherent risks. Inasmuch as the choice of anesthetic technique is important for such patients, adequate postoperative pain control is equally relevant in the perioperative period. We report the successful use of general anesthesia, combined with multi-modal balanced analgesia, for the management of a pregnant patient with a mass effect secondary to a large intracranial tumour.

University of Toronto Department Celebrates its 50th Anniversary This year marks the 50th anniversary of the Department of Anaesthesia at the University of Toronto, for on October 25, 1951, the university Board of Governors unanimously passed a motion to establish an autonomous department in the University. It became the second anaesthesia department to become an independent university department in Canada, the McGill department having been created in 1945. The Toronto department was founded as an independent department because of its prominence in research, and it continues to play an important part in a research-intensive university. Anaesthesia as a specialty had been recognized in the university as long ago as 1907, when Samuel Johnston had been appointed as lecturer in the Faculty of Medicine. The strength of research in the early years is evident in the work on inhalational anaesthesia in the 1920s, particularly the studies of William Easson Brown on ethylene and George Lucas and Velyien Henderson on cyclopropane. A subdepartment of anaesthesia was established in the Department of Therapeutics in 1934, and in the following years the knowledge base of the specialty continued to expand under such notable chiefs as Harry Shields and Rod Gordon. Then, on September 6, 1951, in a letter concerning anaesthesia to the president of the University of Toronto, Dean MacFarlane stated that "for various reasons it seems unwise to make a subdepartment of this specialty, either under medicine or surgery". Dr. MacFarlane stressed that the rationale for the decision was that while "research in the field of anaesthesia is frequently carried on in association with the Department of Pharmacology ... Anaesthesia has made considerable advances in the past 15 years. Since 1951, the Department of Anaesthesia at the University of Toronto has made significant contributions to the growth of the knowledge base of anaesthesia. Important research included the pharmacogenetics of succinylcholine metabolism, the recognition of malignant hyperthermia, the use of intraoperative hypothermia, respiratory mechanics during anaesthesia, the treatment of freshwater drowning, and other fields that influence current practice. Many leaders in the specialty have graduated from the program with characteristic excellence in the clinical practice of anaesthesia. More recently, the endowed professorship in obstetrical anaesthesia was established, as well as two research chairs (Siemens Chair in Pediatric Anaesthesia and Fraser Elliott Chair in Cardiovascular Anaesthesia). The 50th anniversary of a historically significant department provides the opportunity to reflect and appreciate the contribution of anaesthetists who paved the way for us today. Robert Byrick MD FRCPC Professor and Chair Department of Anaesthesia University of Toronto

 

Revision received July 9, 2001. Accepted for publication May 16, 2001.

	References

TOP Abstract Introduction Clinical history Discussion References

 
1 Atanassoff PG, Alon E, Weiss BM, Lauper U. Spinal anaesthesia for caesarean section in a patient with brain neoplasma (Letter). Can J Anaesth 1994; 41: 163–4.[Medline]

2 Chang L, Looi-Lyons L, Bartosik L, Tindal S. Anesthesia for cesarean section in two patients with brain tumours. Can J Anesth 1999; 46: 61–5.[Abstract/Free Full Text]

3 Finfer SR. Management of labour and delivery in patients with intracranial neoplasms. Br J Anaesth 1991; 67: 784–7.[Abstract/Free Full Text]

4 Goroszeniuk T, Howard RS, Wright JT. The management of labour using continuous lumbar epidural analgesia in a patient with a malignant cerebral tumour. Anaesthesia 1986; 41: 1128–9.[Medline]

5 Walker AE, Robins M, Weinfeld FD. Epidemiology of brain tumors: the national survey of intracranial neoplasms. Neurology 1985; 35: 219–26.[Abstract/Free Full Text]

6 Hoff JT, Boland MF. Central nervous system. In: Greenfield LJ, Mulholland MW, Oldman KT, Zelenock GB, Lillemoe KD (Eds.). Surgery: Scientific Principles and Practice, 2^nd ed. Philadelphia: Lippincott-Raven Publishers, 1997: 2165–97.

7 Netsky MG. Epidermoid tumors. Review of the literature. Surg Neurol 1988; 29: 477–83.[Medline]

8 Abramson RC, Morawetz RB, Schlitt M. Multiple complications from an intracranial epidermoid cyst: case report and literature review. Neurosurgery 1989; 24: 574–8.[Medline]

9 Rosenblum MK, Bilbao JM, Ang LC. Neuromuscular system. Central nervous system. Peripheral nerves. Skeletal muscles. In: Rosai J (Ed.). Ackerman's Surgical Pathology, vol. 2. St. Louis: Mosby, 1996.

10 Yamakawa K, Shitara N, Genka S, Manaka S, Takakura K. Clinical course and surgical prognosis of 33 cases of intracranial epidermoid tumors. Neurosurgery 1989; 24: 568–73.[Medline]

11 Isla A, Alvarez F, Gonzalez A, García-Grande A, Perez-Alvarez M, García-Blazquez M. Brain tumor and pregnancy. Obstet Gynecol 1997; 89: 19–23.[Abstract]

12 Roelvink NCA, Kamphorst W, van Alphen HAM, Rao BR. Pregnancy-related primary brain and spinal tumors. Arch Neurol 1987; 44: 209–15.[Abstract]

13 Vaquero J, Marcos ML, Martínez R, Bravo G. Estrogen- and progesterone-receptor proteins in intracranial tumors. Surg Neurol 1983; 19: 11–3.[Medline]

14 Lee L-S, Chi C-W, Chang T-J, Chou M-D, Liu H-C, Liu T-Y. Steroid hormone receptors in meningiomas of Chinese patients. Neurosurgery 1989; 25: 541–5.[Medline]

15 Tewari KS, Cappuccini F, Asrat T, et al. Obstetric emergencies precipitated by malignant brain tumors. Am J Obstet Gynecol 2000; 182: 1215–21.[Medline]

16 Marx GF, Zemaitis MT, Orkin LR. Cerebrospinal fluid pressure during labour and obstetrical anesthesia. Anesthesiology 1961; 22: 348–56.

17 Hilt H, Gramm H-J, Link J. Changes in intracranial pressure associated with extradural anaesthesia. Br J Anaesth 1986; 58: 676–80.[Abstract/Free Full Text]

18 Datta S. Anesthetic and Obstetric Management of High-Risk Pregnancy, 2^nd ed. St. Louis: Mosby, 1996: 134–67.

19 Thapar K,Taylor MD, Laws ER, Rutka JT. Brain edema, increased pressure, and vascular effects of human brain tumors. In: Kaye AH, Laws ER Jr (Eds.). Brain Tumors: An Encyclopedic Approach, 2^nd ed. Churchill Livingstone, 2001: 189–216.

20 Bouhemad B, Dounas M, Mercier FJ, Benhamou D. Bacterial meningitis following combined spinal–epidural analgesia for labour. Anaesthesia 1998; 53: 290–5.[Medline]

21 Abboud TK, Zhu J, Richardson M, Peres da Silva E, Donovan M. Desflurane: a new volatile anesthetic for cesarean section. Maternal and neonatal effects. Acta Anaesthesiol Scand 1995; 39: 723–6.[Medline]

22 Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. Anesth Analg 1993; 77: 1048–56.[Free Full Text]

23 Ejlersen E, Andersen HB, Eliasen K, Mogensen T. A comparison between preincisional and postincisional lidocaine infiltration and postoperative pain. Anesth Analg 1992; 74: 495–8.[Abstract/Free Full Text]

24 Pasqualucci A, De Angelis V, Contardo R, et al. Preemptive analgesia: intraperitoneal local anesthetic in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study. Anesthesiology 1996; 85: 11–20.[Medline]

25 Colbert S, O'Hanlon DM, Courtney DF, Quill DS, Flynn N. Analgesia following appendicectomy - the value of peritoneal bupivacaine. Can J Anaesth 1998; 45: 729–34.[Abstract/Free Full Text]

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