Clinical improvement and tumor regression in parturient with a brain tumor and intracranial bleeding after C-section with general anesthesia: A case report

Isngadi Isngadi; Ruddi Hartono; Andreas Willianto

doi:10.4103/bjoa.bjoa_250_22

CASE REPORT

Year : 2023 | Volume : 7 | Issue : 1 | Page : 51-55

Clinical improvement and tumor regression in parturient with a brain tumor and intracranial bleeding after C-section with general anesthesia: A case report

Isngadi Isngadi, Ruddi Hartono, Andreas Willianto
Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Brawijaya University, Dr. Saiful Anwar General Hospital, Malang, Indonesia

Date of Submission	11-Nov-2022
Date of Decision	18-Dec-2022
Date of Acceptance	30-Dec-2022
Date of Web Publication	6-Mar-2023

Correspondence Address:
Isngadi Isngadi
Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Brawijaya University, Dr. Saiful Anwar General Hospital, Malang
Indonesia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_250_22

Abstract

Brain tumors and intracranial bleeding are rare cases in pregnancy. Anesthesia management for a C-section with comorbidity remains challenging. We presented a 33-year-old woman (34–36 weeks pregnant) with the complaint of weakness in her right extremities, blurred vision, and ptosis of her left eye from a month before hospitalization. The brain computed tomography (CT) revealed a mass at the left parasellar region with a bleeding component and cerebral edema accompanied by subfalcine herniation. We conducted general anesthesia for cesarean delivery in a patient with a brain-protective technique. Brain CT revealed a decrease in the mass size and neither intracranial bleeding nor cerebral edema. In conclusion, general anesthesia management provided a good outcome in a parturient with a brain tumor and intracranial bleeding that underwent C-section. The mechanism of clinical improvement and tumor regression is unclear and requires further research, but it is believed that it is related to pregnancy hormones.

Keywords: Anaesthesia, brain, C-section, pregnancy, regression

How to cite this article:
Isngadi I, Hartono R, Willianto A. Clinical improvement and tumor regression in parturient with a brain tumor and intracranial bleeding after C-section with general anesthesia: A case report. Bali J Anaesthesiol 2023;7:51-5

How to cite this URL:
Isngadi I, Hartono R, Willianto A. Clinical improvement and tumor regression in parturient with a brain tumor and intracranial bleeding after C-section with general anesthesia: A case report. Bali J Anaesthesiol [serial online] 2023 [cited 2023 Mar 21];7:51-5. Available from: https://www.bjoaonline.com/text.asp?2023/7/1/51/371180

Introduction

Brain tumors and intracranial bleeding during pregnancy are rare, with 7 cases per 125.000 pregnancies and 5.8 cases per 100,000 pregnancies consecutively.^[1] The evidence of brain tumors during pregnancy’s diagnosis and management is limited. The available systemic review reports the case was from 20 years ago and results in the differences in the management of pregnancy and the diagnosis and treatment of the brain tumors.^[2]

Arteriovenous malformation (AVM) is responsible for about 50% of pregnant women’s subarachnoid hemorrhage (SAH) and is the third non-obstetric cause of maternal morbidity. AVM, even without rupture, can lead to the damage of the brain through the brain “steal phenomenon” or a decline in cerebral perfusion. The influence of pregnancy on the AVM remains debatable. However, the risk of the first rupture is 3.5% during pregnancy, which is similar to non-pregnant women.^[3] In this case report, we present the case of perioperative anesthesia management in a parturient who is diagnosed with a brain tumor and intracranial bleeding that underwent a Caesarean section (C-section).

Case Report

A 36-week parturient patient, 33 years old, presented with a brain tumor during her pregnancy. The patient came with a main complaint of weakness in her right extremities, blurred vision, and ptosis of her left eye a month before hospitalization [Figure 1]. The patient also has a history of asthma. Physical examination showed that the patient remained conscious, showed no changes in respiratory patterns with normal breath sounds, and the hemodynamic condition was stable, but we found ptosis of the left eye and right hemiparesis. The radiological examination from the previous hospital using brain computed tomography revealed a mass at the left parasellar region with a bleeding component and cerebral edema accompanied by subfalcine herniation, as seen in [Figure 2]. The mass was 2.55 cm × 3.5 cm × 3 cm in size, and the subdural hematoma was 10 mm thick in 3 slices. An elective cesarean delivery in a patient was then scheduled.

Figure 1: Clinical findings before surgery (left), 1 month after the surgery (middle), and 3 months after the surgery (right)

Click here to view

Figure 2: Head computed tomography scan with contrast before the surgery

Click here to view

We administered intravenous (IV) methylprednisolone 125 mg and nebulized Ventolin and ipratropium bromide for asthma prevention, as well as IV metoclopramide 10 mg and ranitidine 50 mg. The patient was pre-oxygenated (100% O₂, five minutes) and administered 60 mg iv lidocaine and 200 mcg of fentanyl for five minutes before intubation. The induction of muscle relaxation was performed by giving the patient propofol and vecuronium. After intubation, we used a sevoflurane and O₂ mixture to maintain anesthesia. Furthermore, EtCO₂ of 28–32 mm Hg was used to preserve ventilation.

The baby was delivered five minutes after the anesthesia induction with APGAR scores of 8 in the first minute and 9 at five minutes. After the baby and placenta were delivered, 20 IU oxytocin was given on a slow drip in 500 mL Ringer lactate. Intraoperatively, the blood pressure was maintained at MAP 60–65 mm Hg, heart rate at 80–90 beats per minute, and oxygen saturation 97%–99%. 400 mL of blood was lost during the surgery. After the C-section, we extubated and transferred the patient to the intensive care unit with breathing spontaneously after the C-section. Syringe fentanyl 30 mcg/h and metamizole 100 mg per eight hours were given for postoperative pain control in the intensive care unit.

The result of brain magnetic resonance imaging-magnetic resonance angiography showed a reduced mass, and no aneurism was found [Figure 3]. The head computed tomography scan revealed a decrease in mass size of 1.6 cm × 1.8 cm × 3.7 cm at follow-up visits of 3 months [Figure 4]. During three-month follow-up visits, the patient could walk and lift her baby.

Figure 3: magnetic resonance imaging and magnetic resonance angiography head 1 month after the surgery

Click here to view

Figure 4: Head computed tomography scan with contrast 3 months after the surgery

Click here to view

Discussion

Meningioma has a faster growth during pregnancy and its growth mechanism remains controversial. The sex hormone seems to associate with meningioma growth as the rate of its growth increases during the luteal phase of the menstruation cycle and pregnancy. The perioperative anesthesia management, in this case, was challenging and needed full consideration to achieve a positive outcome. The goal of anesthesia management is to maintain the balance between maternal and fetal circulation with consideration of the physiological effects of pregnancy on several variables, such as size of tumor, autoregulation, circulation of maternal cerebral, and pressure of cerebral perfusion. There are limited evidence-based recommendations in the management of neuroanesthetics in pregnancy. The concerns of maternal safety, fetal safety, and avoidance of preterm labor and delivery are important.^[4]

General anesthesia is needed in most neurosurgical procedures and the induction of rapid sequence is recommended early within the second trimester to reduce the aspiration risk.^[5] Total IV anesthesia with propofol, balanced IV, and volatile anesthesia can be used for reasonable choices in general anesthesia. The anesthesia induction may require a medium dose of fentanyl (2–5 mcg/kg). The esmolol (short-acting beta-blockers) and lignocaine also can be used. However, beta-blockers correlate with fetal bradycardia and the use of lignocaine is less effective than remifentanil. Ketamine in high doses is able to increase uterine tone.^[5]

During pregnancy, several volatile anesthetics such as isoflurane and sevoflurane are recommended to maintain anesthesia. Moreover, those anesthetic agents also provide cerebral protection by maintaining cerebral autoregulation, decreasing the cerebral metabolic rate, and having minimal effect on intracranial pressure.. During pregnancy, the minimum alveolar concentration (MAC) of volatile anesthetics is decreased by 25%–30%. Because of that, anesthetic agent witch possibly affects cerebral function must be avoided.^[6] Premedication drugs were given to promote gastric emptying and prevent asthma exacerbation during the procedure. In this report, fentanyl, lidocaine, propofol, and sevoflurane (maintenance) were used. Those drugs were used in accordance with the neuroanesthesia principle in order to prevent increased blood pressure and intracranial pressure during intubation. Lidocaine was used to suppress sympathetic response in intubation. Deep extubation was used in this patient to minimize the risk of coughing or straining, which can increase intracranial pressure and brain hemorrhage.

The use of inhalation anesthetic in C-section must be used with concern to avoid disruption of the uterus's blood flow. For general anesthesia maintenance, a concentration below 1 MAC is effective. Pain management is essential because poor postoperative pain management can increase intracranial pressure in this patient. For this reason, we used an opioid combined with nonsteroidal anti-inflammatory drug (NSAID) to control the pain. After intracranial surgery during pregnancy (> 23 weeks of gestation), drugs that potentially cause fetal and cerebral complications must be avoided. NSAID and cyclooxygenase1 and cyclooxygenase2 potentially affect platelet function and cause bleeding after intracranial surgery.^[7]

The regression of brain tumors and clinical improvement was also reported by Chakravarthy et al.^[8] as the Houdini effect. The mechanism remains unclear, but it is believed that there is a relationship between hormonal pregnancy factors (progesterone and estrogen) with tumor growth. The decrease in those hormone levels will reduce the tumor size, improving the patient’s clinical condition.^[8] Another hormone that increases during pregnancy such as prolactin also suspects the growth of meningiomas since it has a pivotal function in osmoregulation.^[9],[10]

Conclusion

General anesthesia management provided a good outcome in a parturient with a brain tumor and intracranial bleeding that underwent C-section. The mechanism of clinical improvement and tumor regression is unclear and requires further research, but it is believed that it is related to pregnancy hormones.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

References

1.	Bader AM Neurologic and neuromuscular disease. In: Chestnut DH, Wong CA, Tsen LC, Kee WDN, Beilin Y, Mhyre J, editors. Chestnut’s Obstetric Anesthesia: Principles and Practice. 5th ed. Philadelphia, PA: Elsevier/Saunders; 2014. p. 1129-34.
2.	Shiro R, Murakami K, Miyauchi M, Sanada Y, Matsumura N Management strategies for brain tumors diagnosed during pregnancy: A case report and literature review. Med Kaunas Lith 2021;57:613.
3.	Carvalho CS, Resende F, Centeno MJ, Ribeiro I, Moreira J Anesthetic approach of pregnant woman with cerebral arteriovenous malformation and subarachnoid hemorrhage during pregnancy: Case report. Braz J Anesthesiol 2013;63:223-6.
4.	Xia Y, Ma X, Griffiths BB, Luo Y Neurosurgical anesthesia for a pregnant woman with macroprolactinoma: A case report. Medicine (Baltimore) 2018;97:e12360.
5.	Satirlar ZO, Inan G Anesthesia for the parturient with intracranial and spinal surgery. In: Gunaydin B, Ismail S, editors. Obstetric Anesthesia for Co-morbid Conditions. Cham: Springer International Publishing; 2018. p. 99-116.
6.	Koerner IP, Brambrink AM Brain protection by anesthetic agents. Curr Opin Anaesthesiol 2006;19:481-6.
7.	Østensen ME, Skomsvoll JF Anti-inflammatory pharmacotherapy during pregnancy. Expert Opin Pharmacother 2004;5:571-80.
8.	Chakravarthy V, Kaplan B, Gospodarev V, Myers H, De Los Reyes K, Achiriloaie A Houdini tumor: Case report and literature review of pregnancy-associated meningioma. World Neurosurg 2018;114:e1261-5.
9.	Saraf S, McCarthy BJ, Villano JL Update on meningiomas. The Oncologist 2011;16:1604-13.
10.	Laviv Y, Ohla V, Kasper EM Unique features of pregnancy-related meningiomas: Lessons learned from 148 reported cases and theoretical implications of a prolactin modulated pathogenesis. Neurosurg Rev 2018;41:95-108.