Intraoperative fatal pulmonary embolism during resection of a parasagittal meningioma.
A 21-year-old female had a history of headache with vomiting and diplopia for about five months. Ophthalmic examination demonstrated right eye temporal, left eye nasal limitations of visual field. The brain CT scan without intravenous contrast showed a parieto-occipital parasagittal mixed density mass, with compression of the left lateral ventricle and midline shift. An MRI scan showed a 6.3x7.9x7.5 mm solid mass with heterogeneous enhancement and a meningeal tail sign after gadolinium administration. Cerebral angiography was performed via the femoral artery, which showed the tumour was supplied by the bilateral internal carotid arteries, bilateral vertebral arteries, left occipital artery, left superficial temporal artery and left middle meningeal vessels. The late venous phase showed persistent capillary blush, posterior third of sagittal sinus occlusion and poor filling of the bilateral transverse sinus. Superselective embolisations of the left occipital artery, superficial temporal artery and middle meningeal artery were taken with absorbable gelatin sponge particles.
With the patient in the lateral prone position, craniotomy was performed. The blood pressure decreased significantly after the flap across the centre line was formed. In addition, extensive bleeding appeared on the ragged skull surface. Bone wax haemostasis and blood transfusion were undertaken immediately. Two burr holes at each side of the sinus were drilled. The bone was removed for about 12x12 cm, which adhered to the dura mater near the sagittal sinus tightly. A piece of tumour tissue was attached to the removed bone. About two and half hours later, when the bone was removed, the systemic blood pressure decreased to 70/50 mmHg and the heart rate increased to 110/min. Resuscitation with rapid blood transfusion, rehydration and inotropic drugs were commenced immediately, with return of the central venous pressure to normal. However, the blood pressure continued to decline and pulse pressure narrowed. The patient's lateral prone position was changed to supine position. The patient was treated with closed chest cardiac massage and scalp incision suture. Transoesophageal echocardiography showed a solid mass in the right ventricular outflow tract and the left ventricular volume load was decreased significantly (Figure 1). There was no response to heparin 125,000 U and urokinase 1,000,000 U. The patient died shortly afterwards. Her family refused autopsy. Pathological examination demonstrated tumour histology compatible with a meningioma.
[FIGURE 1 OMITTED]
Intraoperative fatal pulmonary embolism of the parasagittal meningioma was confirmed by transoesophageal echocardiography in this case. The interval from surgical intervention to clinical presentation of pulmonary embolism was about two and half hours. No effect had been achieved with management of heparin and urokinase. We therefore consider that in this patient, pulmonary embolism may have been caused by tumour emboli shedding from the sagittal sinus. Some researchers have used the insertion of vena caval filters to prevent major pulmonary embolism (1,2). The pros and cons of the use of such filters deserves further clinical study.
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(2.) Goldhaber SZ. Pulmonary embolism. N Engl J Med 1998; 339:93-104.
(3.) Inci S, Erbengi A, Berker M. Pulmonary embolism in neurosurgical patients. Surg Neurol 1995; 43:123-128.
(4.) Levi AD, Wallace MC, Bernstein M, Walters BC. Venous thromboembolism after brain tumor surgery: a retrospective review. Neurosurgery 1991; 28:859-863.
(5.) Colli BO, Carlotti CG Jr, Assirati JA Jr, Dos Santos MB, Neder L, Dos Santos AC. Parasagittal meningiomas: follow-up review. Surg Neurol 2006; 66 (Suppl 3):S20-27.
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|Author:||Gaoyu, C.; Hua, F.; Kaizhi, L.; Yanli, G.; Yi, H.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Clinical report|
|Date:||Sep 1, 2008|
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