Another case from my files

[ProRealDoc]

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Octogenarian with hx of CVA and left sided hemiparesis now with large frontal lobe meningioma causing significant mass effect, edema and midline shift scheduled for resection. No cardiac issues (nml EF) but endorses 80-pack/yr hx of smoking. No PFTs available.

While being evaluated for prior hx of CVA via CTA, a large free floating thrombus in RICA with 80% stenosis was noted extending from RICA origin into proximal cervical RICA. Patient is on integrilin and heparin.

Patient is scheduled by primary service and assigned to you as first AM round.

Now what?

 

[Planktonmd]

Octogenarian with hx of CVA and left sided hemiparesis now with large frontal lobe meningioma causing significant mass effect, edema and midline shift scheduled for resection. No cardiac issues (nml EF) but endorses 80-pack/yr hx of smoking. No PFTs available.

While being evaluated for prior hx of CVA via CTA, a large free floating thrombus in RICA with 80% stenosis was noted extending from RICA origin into proximal cervical RICA. Patient is on integrilin and heparin.

Patient is scheduled by primary service and assigned to you as first AM round.

Now what?

Is she scheduled for CEA or for brain surgery?

 

[ProRealDoc]

Is she scheduled for CEA or for brain surgery?

meningioma resection

 

[Planktonmd]

meningioma resection

Well, I think she should be scheduled for a CEA.

 

[dhb]

I agree, brain surgery won't be very usefull if he embolizes. Is there a possibilty of doing the procedures sequentially?

 

[2win]

Octogenarian with hx of CVA and left sided hemiparesis now with large frontal lobe meningioma causing significant mass effect, edema and midline shift scheduled for resection. No cardiac issues (nml EF) but endorses 80-pack/yr hx of smoking. No PFTs available.

While being evaluated for prior hx of CVA via CTA, a large free floating thrombus in RICA with 80% stenosis was noted extending from RICA origin into proximal cervical RICA. Patient is on integrilin and heparin.

Patient is scheduled by primary service and assigned to you as first AM round.

Now what?

I agree with the answers posted (as CEA first...) - if it s not possible I would suggest balloon occlusion above the thrombus (if the colateral circulation is OK). See the work at UIC neurosurgery - Dr. Charbel the pioneer for this procedure.
2win

 

[Noyac]

Take care of the thrombus first. Park her if the ICU for a day or two and then go for the meningioma.

 

[ProRealDoc]

patient shows up to your OR on DOS. Anticoagulants were held night before and coags have normalized. Patient is hard of hearing and very somnolent as primary team decided to load him with xanax for agitation the night before. He is also hard of hearing.

patient is brought to OR and after monitors are placed, BP is 205/98 and he begins to complain of chest pain. EKG shows NSR. Patient takes his hand to left chest wall and states "my chest hurts a lot"


This is a real case.

now what?

 

[ProRealDoc]

Take care of the thrombus first. Park her if the ICU for a day or two and then go for the meningioma.

It was attempted but vascular team wants meningioma taken care of first and neurosurgery agrees to proceed. Now this patient is assigned to your OR.

 

[2win]

It was attempted but vascular team wants meningioma taken care of first and neurosurgery agrees to proceed. Now this patient is assigned to your OR.

May I ask - why do they want the meningioma out first? What's the medical reasoning for that?
they are the same ones that give benzos for this patient?

 

[Planktonmd]

patient shows up to your OR on DOS. Anticoagulants were held night before and coags have normalized. Patient is hard of hearing and very somnolent as primary team decided to load him with xanax for agitation the night before. He is also hard of hearing.

patient is brought to OR and after monitors are placed, BP is 205/98 and he begins to complain of chest pain. EKG shows NSR. Patient takes his hand to left chest wall and states "my chest hurts a lot"


This is a real case.

now what?

A patient in the OR having chest pain is basically a patient that does not need elective brain surgery today.
Apply O2 100%, get a 12 lead EKG, give a beta blocker, give NTG.... you know the drill
once he is stable enough ship him back to the ICU and call the primary team so can give him more Xanax.

 

[huktonfonix]

patient shows up to your OR on DOS. Anticoagulants were held night before and coags have normalized. Patient is hard of hearing and very somnolent as primary team decided to load him with xanax for agitation the night before. He is also hard of hearing.

patient is brought to OR and after monitors are placed, BP is 205/98 and he begins to complain of chest pain. EKG shows NSR. Patient takes his hand to left chest wall and states "my chest hurts a lot"


This is a real case.

now what?

they sedated a patient with a large brain mass to the point of being somnelent? way to push him along the compliance curve (elastance, whatever you wanna call it) . Gotta weigh the risks/benefits of all three now. risk of stroke/MI/brian mass. As far as the need for CVA, what does his left carotid and collateral circulation look like. If he has a left hemiparesis, it sounds like he had a large R CVA in the past. The chest pain could run the range from stable angina brought on from stress to PE to anxiety. Unless he is actively herniating (which he isnt since hes complaining of chest pain) then you have time to get someone to figure out the chest pain and rule out the bad stuff as others have stated.

 

[Noyac]

It was attempted but vascular team wants meningioma taken care of first and neurosurgery agrees to proceed. Now this patient is assigned to your OR.

Tough ****.

Vascular had better give me one hell of a reason to want the meningioma out first.

They are just dumping the case on you and neuro but neuro is too happy to operate on even a corpse to see the light. Now you need to be the voice of reason.

Then the guy has chest pain on the table. Well that doesn't really matter. If he didn't have the thrombus and he still had a mass effect from his meningioma I'd do the case. We all know how to treat chest pain much less ST depression. But this guy needs that thombus attended to IMO.

Either way, if yo do the neuro part and he has an event they will blame the thromus and if you do the thombus and he has an event they will blame the neuro. But either way, you are there and in the mix. The case sucks.

 

[djipopo]

can one of the attendings explain to me why the prevailing belief seems to be to treat the thrombus before the meningioma?

i understand that both are very serious issues affecting this patient but it sounds like the pt has signs of elevated icp and herniating could be a big risk, thus the need for urgent(?) intervention.

however, the thrombus is a big problem too, given the risk of embolism, which may have happened already and if the pt goes for resection of the mass, anticoagulation would have to be held which increases the risk of propagation of the thrombus.

that said, if you were to do a CEA how would you do it??? if you wanted to do it under local you probably won't be able to monitor neuro status in this guy and you would be limited in terms of how much, if any, sedation you could give in order to avoid increasing ICP any further. the other option would be a GA with some degree of hyperventilation +/- neuromonitoring or a NIRS monitor.

AND now what about this c/o chest pain? the elevated BP could be a compensatory effect for an elevated ICP from the xanax that some fool gave him, would you still treat it? would you still give aspirin if he's going to have 2surgical procedures soon? how about NTG? don't you worry about the vasodilation causing elevated ICP --> herniation?

please help me sort these issues out, i just want to learn and better my practice!

 

[2win]

can one of the attendings explain to me why the prevailing belief seems to be to treat the thrombus before the meningioma?

i understand that both are very serious issues affecting this patient but it sounds like the pt has signs of elevated icp and herniating could be a big risk, thus the need for urgent(?) intervention.

however, the thrombus is a big problem too, given the risk of embolism, which may have happened already and if the pt goes for resection of the mass, anticoagulation would have to be held which increases the risk of propagation of the thrombus.

that said, if you were to do a CEA how would you do it??? if you wanted to do it under local you probably won't be able to monitor neuro status in this guy and you would be limited in terms of how much, if any, sedation you could give in order to avoid increasing ICP any further. the other option would be a GA with some degree of hyperventilation +/- neuromonitoring or a NIRS monitor.

AND now what about this c/o chest pain? the elevated BP could be a compensatory effect for an elevated ICP from the xanax that some fool gave him, would you still treat it? would you still give aspirin if he's going to have 2surgical procedures soon? how about NTG? don't you worry about the vasodilation causing elevated ICP --> herniation?

please help me sort these issues out, i just want to learn and better my practice!

"pt has signs of elevated icp and herniating could be a big risk, thus the need for urgent(?) intervention." - to be treated with a ventricular shunt.
Now - let's say that you proceed with the case I will treat it as a neuro case - though I would use transcranial doppler to asses eventually the emboli from the thrombus. And again this is for the sake of prognosis and documentation because if indeed they will migrate and patient will have a stroke - I wouldn't change my anesthesia. but maybe I'll look better in the front of a jury...

 

[Planktonmd]

Both surgeries are urgent the debate is which one is more urgent:
A slowly progressing meningioma or a floating thrombus in the carotid?
The mass effect and the edema around the meningioma did not happen over night and most likely are not going to kill this patient within the next few days.While the thrombus can decide to obstruct the flow or migrate more distally any time.
I did not see the "signs of herniation" that you mentioned in the original post.
As for which anesthetic to use for the CEA the answer is: good old GA and avoiding any crazy things that could cause significant ICP increases (don't intubate half awake, don't let him hurt too much, keep the BP under control, hyperventilate a little...) you know all these things I am sure.
You definitely don't want to do carotid surgery awake on an agitated disoriented 80 Y/O.
I like your theory about Xanax ---> High ICP ---> High BP ---> Chest pain
But could this simply be an MI happening in front of your eyes?
I am sure we agree that it is a fair possibility and we need to treat this possibility, so the question is how do we treat a possible acute myocardial ischemia in this patient:
We do all the things we need to do in any patient with acute myocardial ischemia because our priority is to not let him have an MI before any of these talented surgeons can get to operate on him.
If you need NTG give NTG, trust me the brain will be OK.
Aspirin is OK too, he probably is on Aspirin already or at least I hope so.
I wouldn't give him a thrombolytic agent though if I were you 😀

Nice questions.djipopo

can one of the attendings explain to me why the prevailing belief seems to be to treat the thrombus before the meningioma?

i understand that both are very serious issues affecting this patient but it sounds like the pt has signs of elevated icp and herniating could be a big risk, thus the need for urgent(?) intervention.

however, the thrombus is a big problem too, given the risk of embolism, which may have happened already and if the pt goes for resection of the mass, anticoagulation would have to be held which increases the risk of propagation of the thrombus.

that said, if you were to do a CEA how would you do it??? if you wanted to do it under local you probably won't be able to monitor neuro status in this guy and you would be limited in terms of how much, if any, sedation you could give in order to avoid increasing ICP any further. the other option would be a GA with some degree of hyperventilation +/- neuromonitoring or a NIRS monitor.

AND now what about this c/o chest pain? the elevated BP could be a compensatory effect for an elevated ICP from the xanax that some fool gave him, would you still treat it? would you still give aspirin if he's going to have 2surgical procedures soon? how about NTG? don't you worry about the vasodilation causing elevated ICP --> herniation?

please help me sort these issues out, i just want to learn and better my practice!

 

[huktonfonix]

Both surgeries are urgent the debate is which one is more urgent:

I did not see the "signs of herniation" that you mentioned in the original post.

Agreed. Again, if hes talking to you, the chance that he is actively herniating is very low.

 

[Jeff05]

as much as we don't WANT to do the case, the consult is for anesthesia - not deciding when this patient will get what surgery.

as long as the surgeons know that this patient will be hypercoagulable after surgery and that thrombus can extend and break off causing a massive CVA, they can go ahead. although, patient is already compromised on that side.

since the patient has AMS, his family needs to be consented - they must know that morbidity and mortality is potentially high. his long h/o COPD may warrant prolonged mech vent.

at the same time there are the hemodynamics of a CEA - possible postop hypotension which could compromise CPP (if not attended to appropriately).

my idea:
preinduction a line. hyperventilate slightly - Et30. etomidate and a touch of propofol for induction. lido. fentanyl. NDMB. keep BP up with phenylephrine if needed. keep that MAP up and ICP down. try to extubate at the end.

 

[ProRealDoc]

So now pt's BP is over 200s systolic and c/o chest pain. I change ECG monitors to all leads and still NSR with normal ST segments showing. Patient asked where pain is and points to left chest wall. When question on nature of pain he said "hurts when I breath". Patient is also coughing and producing lots of green sputum.

Despite that, 160mcg of nitro given, with no resolution of pain. Esmolol given, I drop an aline and patient continues to c/o chest pain when breathing. BP down to 160s now. Neurosurgery attending standing by and asks "what do you guys want to do". I say, pain appears pleuritic in nature.

Given no hx of cardiac issues and clean echo, attending agreed and we go to sleep. Patient had tumor removed and showed no deficits post op.

 

[Planktonmd]

my idea:
etomidate and a touch of propofol for induction. lido. fentanyl. NDMB. keep BP up with phenylephrine if needed. keep that MAP up and ICP down. try to extubate at the end.

Why do we need to give the patient a mixture of induction agents?

 

[Planktonmd]

So now pt's BP is over 200s systolic and c/o chest pain. I change ECG monitors to all leads and still NSR with normal ST segments showing. Patient asked where pain is and points to left chest wall. When question on nature of pain he said "hurts when I breath". Patient is also coughing and producing lots of green sputum.

Despite that, 160mcg of nitro given, with no resolution of pain. Esmolol given, I drop an aline and patient continues to c/o chest pain when breathing. BP down to 160s now. Neurosurgery attending standing by and asks "what do you guys want to do". I say, pain appears pleuritic in nature.

Given no hx of cardiac issues and clean echo, attending agreed and we go to sleep. Patient had tumor removed and showed no deficits post op.

So, what is the point?
Is it that sometimes even if our plan makes no sense the patient might still surprise us and survive?

 

[2win]

So, what is the point?
Is it that sometimes even if our plan makes no sense the patient might still surprise us and survive?

I think the point is - pleuritic pain- possibility of PE..

 

[huktonfonix]

I think the point is - pleuritic pain- possibility of PE..

I was thinking along the lines of an infectious process with the green sputum.

 

[ProRealDoc]

I was thinking along the lines of an infectious process with the green sputum.

🙂