Intracranial Tumour

Complicating Pregnancy

Presentor : Dr. Shilpa

Designation : Fellow, HRP and Perinatology

Hospital : Fernandez Hospital, Hyderabad

Date of Presentation : 09.06.2009

Case Details

Mrs. M, Aged 27 yrs, Para2, Live2

Delivered twice in Fernandez Hospital

1st delivery - July2007

2nd delivery - April 2009

Both pregnancies complicated by intracranial

tumour.

First Pregnancy

Registered at 17 wks

No of visits 09

Normotensive

LMP 9/10/2006

EDD 16/07/2007

First Pregnancy - History

OBS. History: Conceived with treatment

Past History: No significant medical or surgical

history

Investigations

21/02/2007: (at booking visit)

TSH 1.39uIU/ml

Hb10.9 g/dl

GCT 128 mg/dl

CUE- NAD

HIV & HBsAg Negative

Delivery Details

Admitted on 02/07/2007 @ 38 weeks GA

Premature rupture of membranes

Fetal Scan –AFI 4cm

Patient in labour requesting epidural analgesia

GTCS during epidural dosing, `ABC’ initiated,

patient stabilized

Conscious & alert in 5 min

BP 130/80mm Hg, DTR brisk

Urine showed 2+ protein

Delivery Details

Enigma…

Could this be due to :

Inadvertant intravenous bolus of local anesthetic

causing seizure ?

– ? Intrapartum Eclampsia

Management

? Intrapartum eclampsia –Inj.MgSO4, IV, 4gm

loading dose followed by 1gm/hr maintenance

infusion

Emergency LSCS was decided

Intra Operatively

Patient had a generalized tonic clonic seizure

2 episodes of vomiting

Regained consciousness in 3mins

Epidural block: Dermatomal level of T6 was present

Intraop Dilemmas!

Is it LA toxicity?

Is it intrapartum eclampsia?

Is it CSVT / Seizures?

Is there any other IC pathology / epilepsy?

Any dyselectrolytemia?

Delivery Details

Surgery done under EPIDURAL ANAESTHESIA

uneventfully

Delivered an alive baby girl weighing 2.29KGS

APGAR- 08/09/09

Intra OP Investigations

Preeclampsia profile- LDH, Uric acid, S. Creatinine,

Platelets, LFT-normal

S. electrolytes normal

WBC Count 13,200/cmm

Postop Period Detailed History

H/O gradual onset of neuro deficit since 7th month

of pregnancy

Loss of balance

Loss of smell

Decreased palpebral fissure size

Slurred speech

Altered taste

Decreased hearing in left ear over 2 months

Symptoms not progressing or regressing since onset

Postop Period Detailed History

No H/O :

Seizures in the past

Headache / fever

Bladder / bowel disturbances

Motor or sensory loss

Postop Period Detailed History

Examination On POD-0

Pulse 80/min, BP 90/70mm Hg, RR 18/min

Mental functions normal except Dysarthria

Pupils NSRL, Fundus bilateral papilloedema

Left eye partial ptosis

Horizontal nystagmus Rt gaze>Lt gaze

Left LMN VII Nerve palsy

Examination

DTR brisk bilaterally, Plantars

Other motor/sensory normal

Ataxia, Gait wide based

No meningeal signs

Other systems unremarkable

Impression

VII,VIII CN +/- I CN involvement

Ataxia

CerebelloPontine Angle lesion

– ?Infective

– ?Neoplastic

Physician’s Advise

Stop MgSo4

Consider antiepileptic if further seizures

LMWH after neuroradiology

Neurophysician opinion

MRI Brain plain and contrast

Postpartum Period

Uneventful

MRI Brain not done due to financial problems

Risks explained

Discharged on 06/07/2007 on 4th POD

10-07-07: MRI Brain

Left Vestibular Schwannoma

measuring 4.3 x 3.4 cms

with Obstructive Hydrocephalous!!!

Left Vestibular schawnnoma with

Obstructive hydrocephalus!!!!!!!!

Left Vestibular schawnnoma with

Obstructive hydrocephalus!!!!!!!!

Follow up

Seen by neurosurgeon

Tab Phenytoin100mg 1---2

Tab Decadron 4mg 1---1

July 2007

Tumour resection @CARE Hospital on 24-07-07

Pseudomeningocoele: Occipital craniectomy site

Lt hemiparesis post op - recovery over 3months

Antiepileptic drugs X 1year

Post OP CT Brain

4th ventricle deformed by an isodensity

3rd and both lat. Ventricles- mild dilatation

VP shunt in situ

Lt. occipital pseudo meningocoele

Tumour HPE Report

Cellular lesion- elongated cells with wavy nuclei in

palisades

Verrocay bodies seen with paucicellular areas

Thin walled blood vessels

No mitosis, giant cells, necrosis

Features consistent with Schwannoma, CPangle

Repeat Cect Brain- 1/08/2008

Ventricular shunt tube in situ on left side

Enhancing soft tissue in the left CP angle at the

Internal Auditory Canal 13X9 mm–Possible

recurrence / residual tumour

Left occipital region -Pseudomeningocele

Second Pregnancy

Registered at : 13 Weeks

No. of Visits : 08

Normotensive

LMP 6/8/08

EDD 13/5/09

Second Pregnancy

ANC period – uneventful

Routine investigations normal

Antenatal Scans

NT scan on 06/11/2008: Single live fetus of 13+1

weeks with nuchal translucency 1.6mm (Adjusted

risk of Trisomy 21 1:12603)

TIFFA scan at 21 weeks of gestation- single live fetus

with no anomalies.

Growth scan at 32 weeks of gestation- average for

gestational age fetus.

Multidisciplinary care involving

Neurosurgeon, Obstetrician, Physician,

Anesthesiologist and Pediatrician was planned

Examination at Term

Left nasal discharge

Left occipital soft & cystic

swelling

(pseudomeningocoele)

Left facial palsy LMN type

Right sided nystagmus

Power normal on Right

side; 4/5 on Left side

Reflexes ++/++

No meningeal /

cerebellar signs

Fundus normal

MRI Brain: 10/04/2009

Recurrent /residual left CP angle mass

consistent with an acoustic schwannoma.

Large pseudo meningocoel

MRI Brain: 10/04/2009

Delivery Plan

Planned for El. LSCS at 37 completed weeks

In view of Previous LSCS with residual Intracranial

Tumour

Under graded epidural anesthesia

BUT….

Delivery Details

Admitted on 16/04/2009 @ 36+1 weeks of

gestation in early labour

An emergency LSCS was decided

Epidural anesthesia- uneventful

Delivered an alive baby boy weighing 2.64KGS

APGAR- 08/09/09

Postpartum Management

Postoperative period uneventful

Antibiotics

Thromboprophylaxis for 3 days

Discharged on 4th POD

Follow up

After 3weeks: Asymptomatic

Pseudomeningocoele size reduced

Advised neurosurgeon follow up