Ann Thorac Surg 2012;93:653-656. doi:10.1016/j.athoracsur.2011.06.097
© 2012 The Society of Thoracic Surgeons
Case Reports
Fatal Hemorrhagic Infarction of Posterior Fossa Meningioma During Cardiopulmonary Bypass
Hai Sun, MD, PhDa,
Donald A. Ross, MDa,b,*
a Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
b Portland Veterans Medical Center, Portland, Oregon
Accepted for publication June 30, 2011.
* Address correspondence to Dr Ross, Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Ave, CH8N, Portland, OR 97239 (Email: rossdo{at}ohsu.edu).
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Abstract
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Few publications address cardiac surgery in the presence of meningioma. Individual complications include transient visual loss from a suprasellar meningioma, hemiparesis after mitral valve replacement with recovery after resection, and non-fatal hemorrhage into a posterior fossa meningioma. The largest report of 16 patients with known meningiomas over 11 years suggested a benign course, with no new neurologic symptoms and no required resection of a meningioma over an average follow-up of 31 months. In 2 cases we report a presumed posterior fossa meningioma led to fatal outcome after cardiac surgery performed on bypass. Possible causes and future considerations are discussed.
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Introduction
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Asymptomatic meningiomas are commonly discovered in the era of magnetic resonance (MR) imaging. The elderly are especially likely to harbor undetected meningiomas. Many such incidental meningiomas are followed without intervention. The finding of an incidental meningioma has been reported in 0.28% of people in their sixth decade and 1.6% of people in their seventh decade of life. We report 2 patients with asymptomatic petrous face meningiomas, one known about and one not previously detected, who experienced fatal hemorrhagic infarction of the tumor after an otherwise uncomplicated cardiac surgery done on cardiopulmonary bypass.
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Case Reports
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Patient 1
An 84-year-old man who could not undergo magnetic resonance imaging because of retained shrapnel was known to have at least two meningiomas. He had undergone resection of a large right occipital World Health Organization grade I meningioma 2 years earlier at another institution. A second tumor on the left petrous face and tentorial incisura was deemed high risk for resection and was under observation. A computed tomography (CT) scan in January 2011 did not show any interval enlargement of the tumor (Fig 1). He underwent coronary artery bypass grafting and aortic valve replacement with a porcine valve 3 months after the head CT scan. His blood pressure was extremely labile during and immediately after the operation. During the procedure, he was anticoagulated with a heparin infusion and his activated coagulation time (ACT) level was monitored and maintained in the target range. His ACT during the coronary artery bypass grafting and valve replacement portion of the surgery was 629, which was within the target range for the procedure. His anticoagulation was reversed at the end of the procedure with protamine (ACT 150, which was also within the target range), but he continued to bleed clinically at the surgical site. An additional 60 mg of protamine was administered despite a normal ACT. He continued to bleed after surgery and was further transfused with packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets. He initially awoke from the procedure and was at his neurologic baseline for 2 days, but then become progressively somnolent. Examination showed no response to voice or command and weak withdrawal of the lower but not the upper extremities consistent with a cruciate paralysis. A CT scan revealed a large left petrous face low attenuation mass with adjacent hemorrhage and edema with marked compression and distortion of the brainstem and incipient hydrocephalus (Fig 2). A ventriculostomy was placed and drained at 15 cm above the tragus. He remained deeply comatose. When he did not improve after 5 days of aggressive support, support was withdrawn and he immediately died.
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Fig 1. Axial, unenhanced computed tomography scan taken 3 months before cardiac surgery showing a large, left petrous face mass with mild mass effect on the fourth ventricle, reportedly unchanged from a scan from 2 years earlier.
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Fig 2. Axial, unenhanced computed tomography scan revealed a large left petrous face low attenuation mass with adjacent hemorrhage and edema with marked compression and distortion of the brainstem and incipient hydrocephalus.
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Patient 2
A 72-year-old woman with no previous history of headaches or neurological complaints underwent coronary bypass grafting for atherosclerotic occlusive disease. The procedure was uncomplicated. She was kept intubated and sedated the night of her surgery. The next morning, the sedation was discontinued in preparation for extubation. The patient, however, did not awaken. She was given additional time to emerge from the sedation. When she was still not awake 2 days postoperatively, a non-contrast head CT was obtained. This showed massive obstructive hydrocephalus secondary to a large, low attenuation, sessile mass arising from the left petrous face and consistent with a meningioma. A ventriculostomy was placed and cerebrospinal fluid drained at 10 cm above the tragus. After a week of drainage, she had not improved and remained deeply comatose. After consultation with the family, support was withdrawn and she died.
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Comment
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There are few publications addressing cardiac surgery in the presence of a meningioma [1–6]. Individual case complications reported include transient visual loss from a suprasellar meningioma [5], hemiparesis 2 days after mitral valve replacement requiring resection of a parasagittal meningioma with recovery of neurologic function [3], and hemorrhage into a posterior fossa meningioma [4]. The last, while somewhat similar to our cases, responded to nonoperative management and was later treated with radiosurgery. The largest group of patients reported is 16 patients with a known preoperative diagnosis of meningioma, accumulated over an 11-year period and studied retrospectively [1]. Nine tumors were falcine, four convexity, and three cerebellopontine angle in location. Only 1 patient received perioperative dexamethasone at the recommendation of a neurosurgical consultant. No patient reported any new neurologic symptoms related to their meningioma and none required resection of their meningioma over an average follow-up period of 31 months.
In the two cases we report here, the presence of a presumed posterior fossa meningioma led to fatal outcome after cardiac surgery performed on bypass. The patient in the first case suffered hemodynamic instability and postprocedural bleeding diathesis requiring aggressive reversal of anticoagulation, while there were no apparent intraoperative and perioperative adverse events during the second case. Possible causes of tumor swelling and infarction may include relative hypotension while on bypass resulting in poor perfusion to the tumor, decreased plasma osmolality with a resulting increase in peritumoral brain edema, a hypercoagulable state after reversal of anticoagulation at the end of the procedure, and increased blood brain barrier permeability during cardiopulmonary bypass [7]. Meningiomas are often quite vascular and may therefore undergo therapeutic embolization before resection. After successful embolization, tumors are known to swell from cytotoxic edema and other processes related to necrosis, including upregulation of some vascular endothelial growth factor RNA isoforms [8]. Meningioma resective surgery is therefore usually scheduled to follow shortly after embolization so that the edema does not become symptomatic.
Some authors have recommended mild hypocapnea, perioperative dexamethasone administration, and use of hypertonic saline during cardiac surgery in patients with known meningiomas [2], but it is speculative as to whether any of these interventions would have altered our patients' outcomes. Some have undertaken off pump coronary artery bypass grafting to avoid complications with a known tumor, but not all cardiac surgeries can be performed off bypass [6].
It is difficult to make recommendations about future similar cases. The unfortunate outcome of the two cases reported here certainly highlights the risk associated with patients with posterior fossa meningioma undergoing cardiac surgery on bypass. It would not, however, be cost-effective to recommend cranial imaging on every patient undergoing cardiopulmonary bypass as meningiomas are common in older patients. Even if every posterior fossa mass were detected preoperatively, not all such tumors can be resected with acceptable neurologic morbidity and many patients scheduled for cardiac surgery are elderly or have significant medical comorbidities and, therefore, may not be candidates for resection of these tumors before repair of their cardiac pathology. Consideration should be given to off bypass surgery where feasible, the use of perioperative steroids, maintenance of high normal serum osmolality, adequate cerebral perfusion, careful reversal of anticoagulants, and avoidance of intraoperative and perioperative hemodynamic instability. Noninvasive intraoperative monitoring of central nervous system function with motor evoked potentials, somatosensory evoked potentials, or electroencephalography might be useful in patients with known intracranial masses, but would not be cost-effective for use in all cardiac surgery cases. Early postoperative brain imaging of patients not awakening promptly from cardiac anesthesia and of patients with known intracranial masses could be recommended, as early discovery of complications such as cerebellar hemorrhage and acute hydrocephalus is crucial since there may be only a brief window of time during which the patient might be salvaged. Immediate detection of a symptomatic posterior fossa mass could lead to life saving ventriculostomy or posterior fossa decompression.
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Acknowledgments
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The authors thank Shirley McCartney, PhD, for editorial assistance and Andy Rekito, MS, for illustrative assistance.
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References
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- Aleksic I, Sommer SP, Kottenberg-Assenmacher E, et al. Cardiac operations in the presence of meningioma Ann Thorac Surg 2009;88:1264-1268.[Abstract/Free Full Text]
- Grigore AM, Grocott HP, Newman MF. Anesthetic management of a patient with a brain tumor for cardiac surgery J Cardiothorac Vasc Anesth 2000;14:702-704.[Medline]
- Kurisu K, Hisahara M, Ando Y, Tominaga R. An unusual manifestation of brain tumor: development of delayed hemiplegia after cardiopulmonary bypass J Card Surg 2007;22:417-418.[Medline]
- Maeda K, Gotoh H, Chikui E, Furusawa T. Intratumoral hemorrhage from a posterior fossa tumor after cardiac valve surgery–case report Neurol Med Chir (Tokyo) 2001;41:548-550.[Medline]
- Slavin ML. Acute remitting visual loss after coronary artery bypass surgery caused by a suprasellar meningioma Am J Ophthalmol 1987;104:434-435.[Medline]
- Tashiro T, Zaitu R, Nakamura K, et al. Off-pump CABG for a patient with a brain tumor Ann Thorac Cardiovasc Surg 2000;6:193-195.[Medline]
- Harris DN, Oatridge A, Dob D, Smith PL, Taylor KM, Bydder GM. Cerebral swelling after normothermic cardiopulmonary bypass Anesthesiology 1998;88:340-345.[Medline]
- Ellis JA, D'Amico R, Sisti MB, et al. Pre-operative intracranial meningioma embolization Expert Rev Neurother 2011;11:545-556.[Medline]
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Abstract
Introduction
