Anesthesia management in a pregnant woman with a giant temporoparietal anaplastic oligodendroglioma: a case report

Abstract

Background

Brain tumors during pregnancy are rare and pose unique challenges in diagnosis, management, and anesthetic care. This report is novel owing to the rare coexistence of a giant anaplastic oligodendroglioma with an ongoing pregnancy requiring urgent dual surgical interventions.

Case presentation

A 27-year-old, right‐handed, Middle Eastern Saudi woman at 35 weeks of gestation presented with neurological symptoms, including partial loss of consciousness, left-sided ptosis, and severe headaches. Imaging revealed a large left temporoparietal mass with significant midline shift, diagnosed as an anaplastic oligodendroglioma. She underwent an emergency cesarean section and craniotomy under general anesthesia. Postoperative recovery was uneventful for both the mother and the newborn.

Conclusion

This case highlights the critical importance of multidisciplinary coordination, individualized anesthetic planning, and timely surgical decision-making in managing complex neurosurgical cases during pregnancy. The combined obstetric–neurosurgical approach contributed to a favorable maternal and neonatal outcome.

Introduction

Pregnancy causes complex physiological changes, including significant alterations in metabolic, hormonal, cardiovascular, and other systems. While most pregnancies progress without complications, both preexisting or newly diagnosed medical conditions can significantly compromise maternal and fetal outcomes. Brain tumors during pregnancy are rare and serious conditions that require multidisciplinary coordination [1–4], meticulous assessment, and timely diagnosis and treatment to minimize any potential adverse outcomes for both mother and fetus. Increased blood volume and hormonal variations are two physiological changes that can exacerbate intracranial hypertension and other neurological symptoms linked to cerebral lesions during pregnancy, making diagnosis and treatment more difficult and challenging. A comprehensive assessment and a multidisciplinary approach are essential. There is little knowledge on the best methods for identifying and managing such cases because they are rare [3, 4]. Specifically, there is still a lack of evidence regarding the best time and method of delivery [5, 6], as well as whether treatment should begin during pregnancy or wait until after it is completed. A thorough understanding of both neurophysiological and obstetric anesthetic concepts is also necessary for the anesthesiologist to establish a balance between optimizing intracranial surgery conditions and keeping adequate uteroplacental perfusion while maintaining appropriate cerebral perfusion. This is the very first case report in Saudi Arabia where we discuss the anesthetic management and challenges in a parturient with a huge brain tumor, an oligodendroglioma, who underwent two major surgeries under general anesthesia on the same day (emergency caesarean section followed by brain tumor resection). This manuscript adheres to the applicable EQUATOR guideline.

Case report

A 27‐year‐old, right‐handed, Middle Eastern Saudi woman at the 35th week of gestation presented with a 4-month history of partial loss of consciousness and stiffness all over her body lasting for 10–15 minutes and intermittent headache and nausea. According to her spouse, she had been experiencing changes in comprehension and responsiveness. On examination, her vitals were within normal limits, and left-sided ptosis was evident, but no other neurological deficits were noted. Laboratory investigations were within normal limits. Her pregnancy history was unremarkable. Family history was significant for malignancy; her mother had died of colon cancer 5 years earlier, and her sister was undergoing active cancer treatment at the time of presentation. Obstetric ultrasonography revealed a single live fetus in cephalic presentation of normal size appropriate for gestational age. No abnormalities were detected in placental position or amniotic fluid volume. Preoperative brain computed tomography (CT) without contrast (Fig. 1) revealed a huge partially calcified lesion centered within the left parieto-temporal lobe with significant mass effect. Brain magnetic resonance imaging (MRI) with contrast showed a large intra-axial ill-defined solid mass within left temporo-parietal lobe surrounded by cerebral edema causing severe mass effect upon left lateral and third ventricles and brainstem, with shifting of midline structures about 13–14 mm toward the right side and uncal as well as mild subfalcine herniation with dilatation of right ventricle, mostly consistent with high-grade glioma. Dandy walker malformation was noted (Fig. 2).

Fig. 1.

Brain computed tomography without contrast demonstrating a huge partially calcified lesion centered within the left parieto-temporal lobe with subsequent significant mass effect and 1.4 cm midline shift, evolving lateral ventricle hydrocephalus, and impending left transtentorial herniation. The arrow indicates the partially calcified component of the lesion

Fig. 2.

Brain magnetic resonance imaging with contrast showing a large intra-axial ill-defined solid mass within left temporo-parietal lobe measuring about 7 cm × 6 cm × 5 cm in anterior–posterior, transverse, and craniocaudal dimensions, respectively, surrounded by cerebral edema causing severe mass effect upon left lateral and third ventricles and brainstem, with shifting of midline structures about 13–14 mm toward the right side and uncal as well as mild subfalcine herniation with dilatation of right ventricle, mostly consistent with high-grade glioma. Dandy walker malformation is shown (A–E) represented by hyperplasia of the vermis with cephalad rotation of the vermian remnant and enlarged posterior fossa with cystic dilatation of the fourth ventricle extending posteriorly. (A) Axial T2-weighted image demonstrating a large intra-axial irregular-shaped lesion centered within the left temporoparietal region, exhibiting heterogeneous hyperintensity with surrounding vasogenic edema. (B) Axial T1-weighted image showing the lesion to be isointense relative to normal brain parenchyma. (C) Axial post-contrast T1-weighted image demonstrating patchy heterogeneous enhancement of the lesion. (D) Diff usion-weighted imaging demonstrating mild diff usion restriction within the lesion. (E) Axial image demonstrating marked mass eff ect with eff acement of the left lateral ventricle, dilatation of the right lateral ventricle, rightward midline shift of approximately 1.4 cm, and impending left uncal herniation

Following the disclosure of her diagnosis, the patient exhibited profound grief, emotional withdrawal, and loss of interest in communication. An urgent psychiatric evaluation was requested, during which she was diagnosed with severe depression attributed to the psychological impact of her medical condition. No formal psychological interventions were initiated during this period. However, the patient remained under close one-to-one observation in the labor ward until the day of surgery, with continuous assessment and monitoring to ensure her safety. Immediate management involved commencing the patient on dexamethasone 4 mg every 6 hours and levetiracetam 500 mg every 12 hours. A multidisciplinary team meeting was arranged and involved a neurosurgical team, neuro-anesthesiologist, obstetrician, neonatologist, and psychiatrist to ensure maternal stabilization and to plan further management of her challenging condition in the context of ongoing pregnancy. The risk of developing worsening intracranial hypertension or tumor-associated complications was deemed to be high in the context of the size and position of the tumor. Consideration was given to delaying the caesarean section to improve fetal maturity and to provide the mother with an opportunity to complete the pregnancy. The patient remained actively involved in the decision-making process [2, 7] and was counseled regarding the rationale for intervention and the associated risks to her and her fetus. A thorough preoperative anesthesia assessment identified no risk of a difficult airway. The patient was classified as American Society of Anesthesiologists (ASA) physical status III. An invasive arterial line was established while the patient was awake. Cardiotocography (CTG) was applied for continuous fetal heart rate and uterine contraction monitoring. Left uterine displacement was always ensured to prevent aortocaval compression. Large-bore intravenous access was secured in both arms. Anesthesia was induced using a modified rapid sequence technique with propofol (2 mg/kg), fentanyl (2 mcg/kg), and rocuronium (1.2 mg/kg), and a 7.0-mm endotracheal tube was placed, with the aim of avoiding hypertension associated with laryngoscopy. Shortly after induction of anesthesia, cardiotocography (CTG) tracing became nonreassuring and raised the need for an immediate emergency cesarean section. A healthy baby girl was delivered within 5 minutes of skin incision; the total caesarean operative time was approximately 13 minutes from incision to closure. Uterotonic agents were given following placental delivery to promote uterine contraction and minimize blood loss, which was estimated at 400 mL. Following delivery, the patient was positioned supine, with her head secured in Mayfield pins, and craniotomy proceeded. General anesthesia was maintained with sevoflurane at minimal alveolar concentration of 1 in a 50% oxygen/air mixture. A craniotomy with tumor resection were performed over approximately 4 hours. Histopathological examination of the specimen confirmed the diagnosis of an anaplastic oligodendroglioma (World Health Organization [WHO] grade III, 1p/19q co‐deletion, isocitrate dehydrogenase [IDH] mutation).

At the conclusion of surgery, a bilateral transversus abdominis plane (TAP) block was performed for postoperative pain control. Neuromuscular blockade was reversed with neostigmine and glycopyrrolate. The patient was successfully and smoothly extubated and transferred to the neurological critical care unit for close monitoring in a fully awake and comfortable state. Her postoperative neurological examination was unremarkable. She was transferred to the intensive care unit. Postoperative imaging demonstrated interval improvement in the degree of midline shift; however, persistent hyperintensity along the superior and posteromedial margins of the surgical cavity raised concern for residual disease. Following recovery, the patient received her first cycle of chemoradiotherapy and remained under close oncology follow-up. Despite treatment, subsequent evaluations indicated progression of the residual lesion, consistent with tumor recurrence. During this period, the psychiatry team continued to provide psychoeducation and supportive management. Her mental state gradually improved without any safety concerns, and she was ultimately deemed stable, allowing the psychiatry service to formally sign off from her care.

Discussion

Oligodendroglioma is a primary central nervous system (CNS) tumor. This means that it begins in the brain or spinal cord. Diagnosing an oligodendroglioma requires finding two genetic alterations: an IDH mutation and a very specific change in the tumor cells’ chromosomes, where the short arm of chromosome 1 and the long arm of chromosome 19 are lost (also known as a 1p/19q co‐deletion). They account for roughly 3% of all primary brain tumors [8] and are more common in adults, particularly those aged 40–60 years. Presenting symptoms can vary on the basis of location, growth rate, and tumor size. Diagnosis of an intracranial tumor may be delayed in pregnancy [1, 4]; given that intracranial expansive-associated symptoms (headache, nausea, and vomiting) are frequent during pregnancy, these symptoms may be misattributed to physiological changes of pregnancy and elevated levels of progesterone, which may precipitate growth of intracranial tumors as well as trigger flaring of symptoms. Assisted vaginal delivery may be achieved, but cesarean delivery (CD) is performed if there is elevated intracranial pressure or an obstetrical indication. Neurosurgical intervention during pregnancy [5, 6] should occur in cases where malignancy is suspected and where there is neurological deterioration due to either decompensated hydrocephalus requiring ventricular drainage or intracranial herniation [5]. Psychological distress following diagnosis is not uncommon [9] and may be particularly profound in a pregnant individual facing life-threatening illness. Our patient’s suicide attempt underscores the importance of early psychiatric involvement and mental health support as integral components of perinatal neuro-oncologic care. The anesthetic management of a pregnant patient with a high-grade intracranial tumor requires meticulous planning [2, 7], multidisciplinary coordination, and individualized care. This case illustrates the complexities of balancing maternal neurological stability with fetal viability, while addressing urgent surgical needs and psychological distress. Meticulous anesthetic management is needed for a controlled airway. Induction agents were chosen to minimize increases in intracranial pressure (ICP) (for example, propofol/fentanyl), with neuromuscular blockade using non-depolarizing agents such as rocuronium. Rapid sequence induction with cricoid pressure was used to reduce aspiration risk, as is standard in obstetric anesthesia. Hyperventilation was cautiously employed to lower PaCO₂ and reduce ICP, but excessive hypocapnia was avoided owing to its potential to impair uteroplacental blood flow. Careful titration of anesthetics, maintenance of normovolemia, and smooth emergence were essential to avoid fluctuations in ICP and hemodynamics. The decision regarding the timing and mode of delivery in such cases depends on gestational age, fetal viability, maternal neurological status, and urgency of neurosurgical intervention. In this case, early delivery allowed for subsequent definitive neurosurgical and oncologic management while minimizing risks to the fetus. The successful outcome highlights the importance of integrating obstetric, neurosurgical, anesthetic, and psychiatric expertise to navigate such high-risk scenarios. Timely intervention, patient-centered decision-making, and adherence to fundamental anesthetic principles were key to optimizing both maternal and neonatal outcomes [10].

Conclusion

This case highlights the role of coordinated multidisciplinary care in managing complex neurosurgical conditions during pregnancy. The anesthetic management of a parturient patient with a brain tumor requires proper assessment and meticulous planning. Timely surgical intervention and tailored anesthetic management were essential in achieving favorable maternal and fetal outcomes.

Author contributions

All authors contributed equally to the patient management, manuscript writing, and final approval of the version to be published.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

All relevant data supporting the conclusions of this case report are included within the article.

Declarations

Ethics approval and consent to participate

This case report has been approved by the Institutional Review Board at King Fahad Medical City.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.