CLINICAL SPOTLIGHT
Heart, Lung and Circulation (2015) 24, e108–e111 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.02.022
Open Heart Surgery with Intracranial Meningioma: Case Report & Literature Review Munir Ahmad, MD, FRCSI 1*, Ahmed Al-Arifi, MD, FRCS, FCSHK 1, Hani K. Najm, MD, FRCS, FRCSC 1 King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia Received 7 August 2014; received in revised form 20 January 2015; accepted 28 February 2015; online published-ahead-of-print 14 March 2015
Meningiomas are generally considered slow growing tumours of arachnoid cell origin which remain asymptomatic for a long period of time and are usually managed conservatively by serial radiological follow-up. Only those lesions which show a potential for rapid growth are considered for surgical resection. Coronary artery bypass surgery usually involves use of cardiopulmonary bypass which incites varying degrees of systemic inflammatory response. Although some meningiomas are recognised by secretion of vasoactive substances leading to peri-lesion oedema, very little is known about the behaviour of asymptomatic meningiomas during a normal run of cardiopulmonary bypass where there is a significant rise in the plasma level of many vasoactive substances. We report the case of a 68 year-old male patient with asymptomatic meningioma who required urgent coronary artery bypass surgery leading to peri-lesion oedema and significant post-operative morbidity due to reversible neurological deficit. Keywords
Intracranial meningiomas Coronary artery bypass grafting Post-operative stroke Vasogenic cerebral oedema Cardiopulmonary bypass Systemic inflammatory response
Introduction The population of patients requiring open-heart surgery is progressively aging and the incidence of known and undiscovered co-morbid factors is also increasing. As intracranial meningiomas are usually slow growing tumours in the elderly, most of these patients are treated conservatively. However, if a patient with a known intracranial tumour requires cardiac surgery with the use of cardiopulmonary bypass, there is increased incidence of neurological complications and the intra-operative management becomes very crucial. Conversely, a previously undetected meningioma may lead to neurological morbidity in the absence of a cerebrovascular accident in the post-operative period of a cardiac surgical
patient. Mass-effect due to peri-tumoural oedema has been observed in some patients with potential reversibility and recovery of neurological deficit. We report a patient with previously undetected meningioma who required urgent coronary revascularisation on cardiopulmonary bypass leading to reversible neurological complications and discuss management options in the light of currently available literature.
Case Report A 68 year-old male patient presented to his local hospital with extensive anterior wall myocardial infarction. He continued to experience post-infarction angina and was thus
*Corresponding author at: Associate Consultant Cardiac Surgeon, King Abdulaziz Cardiac Center, MBC# 1404. PO Box: 22490. Riyadh 11426, Saudi Arabia. Tel.: +966558575940; fax: +966 11 8011111 Ext: 16515, Email:
[email protected] 1
King Abdulaziz Cardiac Centre, PO Box: 22490.Riyadh 11426. Saudi Arabia.
© 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Open Heart Surgery with Intracranial Meningioma
referred to the regional cardiac centre where angiography revealed critical coronary artery disease including critical left main coronary stenosis and proximal circumflex artery occlusion. There was no significant stenosis in the right coronary artery. His echocardiography revealed impaired left ventricular function with left ventricular ejection fraction reduced to 25%. In view of critical disease, an intra-aortic balloon pump was inserted and the patient was transported to our centre for further management. He was free of chest pain at admission and was stable with balloon pump support. Apart from a history of hypertension and diabetes, no other past medical history was noted. The clinical examination was unremarkable at admission with no neurological deficit. Laboratory work-up revealed a normal renal and hepatic profile, normal complete blood count, total serum albumin 36 g/L, total cholesterol 5.01 mmol/L, high density lipoprotein 0.75 mmol/L, low density lipoprotein 3.39 mmol/L, C-reactive protein 36.9 mg/L and erythrocyte sedimentation rate 111 mm/hour. The patient was accepted for urgent coronary artery bypass grafting and was scheduled for the next available operating list. Coronary artery bypass surgery was uneventful with left internal mammary artery graft to left anterior descending artery and saphenous vein grafts to diagonal and obtuse marginal arteries. Total cardio-pulmonary bypass time was 72 minutes and aortic cross-clamp time was 46 minutes. The patient was extubated on the first day after surgery with full neurological recovery and balloon pump support was removed. A few hours after extubation, however, he became confused and drowsy and the following day developed paralysis of both lower limbs and left upper limb. There was no dysarthria or visual impairment. Full neurological assessment was followed by brain CT scan. It revealed a meningioma in the left frontal region, 4.5 cm x 2.8 cm in size (Figure 1), with peri-tumour oedema causing focal mass effect and slight midline shift to the right (Figure 2). There was no evidence of recent cerebro-vascular accident. On the advice of neurology and neurosurgical teams, the patient was treated conservatively. Passive exercises and nasogastric feeding were instituted. Right lower limb made full recovery of power within the next two days. As the patient’s general condition improved, oral feeding was commenced and rehabilitation therapy was instituted. Over the next few weeks, the patient made progressive recovery of left upper and lower limbs. He was ambulant with minimal assistance and fully oriented seven weeks post-operatively when he was discharged from the hospital. The patient has been followed up by neurosurgery service of our institution for 27 months on conservative management and has not developed any further neurological problems.
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Figure 1 Brain CT scan showing the meningioma in the left frontal region with midline shift.
Discussion Meningiomas account for approximately one-fourth of all primary central nervous system tumours, arising from arachnoid cells surrounding brain and spinal cord [1]. Ninety
Figure 2 Brain CT scan showing peri-tumour oedema in the left frontal area (arrow).
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percent of meningiomas are slow growing benign tumours. Surgical resection is required in symptomatic and rapidly growing meningiomas. Fractionated radiotherapy or stereotactic radiosurgery are used for meningiomas that are recurrent, surgically inaccessible, partially excised and either atypical or malignant [1]. Surgical resection is, however, challenging and may be associated with considerable morbidity and mortality especially in elderly patients [2]. Asymptomatic meningiomas account for up to 38% of the intracranial meningiomas and are more common in individuals older than 70 years and in females [3]. Most of these asymptomatic, incidentally discovered tumours have a very slow growth rate and remain asymptomatic over a long period of radiological follow up. Younger age and larger size of tumour at diagnosis were found as risk factors for rapid growth in many studies [4–7]. Thus, in the old age group, higher morbidity after surgical resection and slower rate of tumour growth combined with lower incidence of development of symptoms strongly favours a non-surgical approach with close radiological and clinical follow-up in asymptomatic meningiomas [6,8]. A small proportion of benign meningiomas called secretory meningiomas are known to secrete vasoactive substances and are associated with the presence of peri-tumoural cerebral oedema [9]. The pathogenesis of cerebral oedema surrounding these tumours is still poorly understood. A relationship of the brain oedema to female sex hormones was suspected in one study [10]. A limited number of individual case reports have emerged recently in the literature where the use of cardiopulmonary bypass in patients with known or previously undetected meningiomas has led to reversible or fatal neurological complications. Slavin ML reported acute remitting visual loss after coronary artery bypass grafting caused by a suprasellar meningioma [11]. Karisu et al. reported a case of delayed hemiplegia after mitral valve replacement caused by right hemisphere meningioma with peri-tumour oedema; treated by surgical excision [12]. Aleksic et al. reported retrospective analysis of 16 patients who underwent cardiac surgery with the use of cardiopulmonary bypass in the presence of radiologically confirmed meningiomas. They reported absence of any peri-operative neurological morbidity or direct effect on mid-term survival [13]. Chow HK et al. reported delayed onset of reversible paralysis of left arm and both lower limbs in a 60 year-old female patient with previously undetected temporo-parietal meningioma exhibiting peri-tumour oedema [14]. Sun H et al. reported two patients with posterior fossa meningiomas who developed fatal cerebral haemorrhage following open-heart procedures on cardiopulmonary bypass [15]. Elderly patients requiring urgent cardiac surgery who are known to have intracranial tumours remain a challenging group of patients. A team approach with the involvement of neuro-anaesthesia and neurosurgical team is recommended. Intra-operative measures to reduce the intracranial pressure including avoidance of hypercapnia and hyponatraemia, use
M. Ahmad et al.
of mannitol and steroids, and maintenance of higher perfusion pressures on cardiopulmonary bypass have been successfully employed [16]. Use of cardio-pulmonary bypass during open-heart surgery leads to activation of a cascade of inflammatory mediators resulting in varying degrees of systemic inflammatory reaction. We postulate that these inflammatory mediators may result in peri-tumour oedema in previously asymptomatic meningiomas especially those of secretory type and thus lead to the onset of neurological deficit after open-heart surgery. Various therapeutic options to counteract systemic inflammatory reaction may be considered more aggressively in patients with pre-existing meningiomas; including the option of off-pump, beating heart coronary artery surgery and hybrid procedures [17,18].
Future Perspective Future studies are needed to investigate the effect of inflammatory mediators released during cardiopulmonary bypass on the development of peri-tumour oedema in secretory and non-secretory meningiomas. A better understanding of the pathogenesis of cerebral oedema in these tumours is likely to help in the peri-operative management of patients with known meningiomas and may also help in the treatment of patients who develop neurological symptoms due to a previously undetected tumour. The role of therapeutic manipulations aimed at attenuating the pro-inflammatory effects of cardiopulmonary bypass in the management of these patients is also unknown and needs future investigation.
Acknowledgements No external financial support.
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