skip to main content

ICU Management of Post-Craniotomy Patients with Schwannoma Vestibular Tumor Removal

Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University/RSUP Dr. Sardjito, Yogyakarta, Indonesia

Received: 1 Nov 2023; Revised: 12 Feb 2024; Accepted: 19 Feb 2024; Available online: 28 Feb 2024; Published: 31 Jul 2024.
Open Access Copyright 2023 JAI (Jurnal Anestesiologi Indonesia)

Citation Format:
Cover Image
Abstract

Background: Vestibular schwannoma (VS) is a relatively common tumor that arises from the vestibulocochlear nerve (CN VIII) and represents 80% of cerebellopontine angle (CPA) masses. CPA tumors are mostly benign, slow growing with low malignant potential (~1%). VS have rarely been reported, and there is a lack of in-depth discussion on the experience of management of massive acoustic neuromas in ICU. It represents the case in which the patient presented with obstructive hydrocephalus and progressive neurological deficits. The purpose of this case report is to understand the management of post-operative patients with VS with several comorbidities in the ICU.

Case: We present a 53 years old woman with a giant VS and obstructive hydrocephalus. An imaging findings revealed a brain tumor in the CPA region and obstructive hydrocephalus. Consequently, she relieved her hydrocephalus with a ventriculoperitoneal shunt (VP shunt). After 1.5 years, her mental condition deteriorated, and her left limb muscle strength gradually decreased. Under a joint consultation with Department of Neurosurgery and Anesthesiology, she underwent tumor removal. Upon discharge, the previously observed neurological deficits, which were reversible had been successfully resolved. The neuroimaging confirmed the complete tumor removal, while the neuropathologic examination revealed a VS.

Discussion: If untreated, an acoustic neuroma can grow large enough to cause pressure on the brain stem. The tumor can block the flow of cerebrospinal fluid (CSF) between the brain and the spinal cord, causing a buildup of the fluid in the brain. Because the skull is a closed structure, excess fluid in the brain (hydrocephalus) can press against the brain, causing unsteady movement and lack of coordination (ataxia), headaches and confusion. Patients with brainstem compression had significantly longer mean LOS than patients without. Also, the dissection of the facial nerve from the tumor in order to preserve it can sometimes cause swelling, which can result in weakness or paralysis (complete or partial loss of muscle function). This is usually temporary but can take weeks to months to recover. After the operation, the patient was treated in the ICU, a ventilator was installed,

insulin was given to regulate blood sugar and anti-hypertension medication for maintaining blood pressure. During treatment in the ICU, adequate fluids and nutrition are provided. Monitoring is carried out on cardiovascular function, hemodynamics and respiration by monitoring blood pressure, electrocardiogram (ECG), oxygen saturation. The patient was moved to high care unit  (HCU) after being treated for 3 days in the ICU.

Conclusion: Postoperative therapy is more focused on supportive therapy, including maintaining the airway, regulating blood sugar, blood pressure and providing mechanical ventilation to maintain adequate oxygenation.

Note: This article has supplementary file(s).

Fulltext View|Download |  Graphical Abstract
ICU MANAGEMENT OF POST-CRANIOTOMY PATIENTS' SCHWANNOMA VESTIBULAR TUMOR REMOVAL
Subject Acoustic neuroma, Cerebellopontine angle, Diabetes mellitus type 2, Hydrocephalus, Vestibular schwannoma
Type Graphical Abstract
  Download (3MB)    Indexing metadata
 common.other
CTA
Subject
Type Other
  Download (707KB)    Indexing metadata
Keywords: acoustic neuroma; brainstem compression; cerebellopontine angle; diabetes mellitus type 2; hydrocephalus; vestibular schwannoma

Article Metrics:

  1. Jackson C, Creighton FX. Accoustic Neuroma (Vestibular Schwannoma). John Hopkins Medicine. 2023
  2. Ostrom QT, Gittleman, H., Fulop, J., Liu, M., Blanda, R., Kromer, C., Wolinsky, Y., Kruchko, C., Sloan, JSB. CBTRUS statistical report: primary brain and central nervous system tumors diagnosed in the United States in 2008–2012. Neuro Oncol. 2015;17 Suppl 4 (Suppl 4): iv1-iv62
  3. Lak, Asad M. Yusuf S Khan. Cerebellopontine Angle Cancer. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 Jan
  4. Niknafs YS, Wang AC, Than KD, Etame AB, Thompson BG, Sullivan SE. Hemorrhagic vestibular schwannoma: review of the literature. World Neurosurg. 2014;82(5):751-6. doi: 10.1016/j.wneu.2013.02.069
  5. Yang X, Liu J, Zhang Y, Richard SA. Tumor-associated hemorrhage in patients with vestibular schwannoma. Acta Neurochir (Wien). 2018;160(8):1563-9
  6. Mathkour M, Helbig B, Mccormack E, Amenta PS. Acute presentation of vestibular schwannoma secondary to intratumoral hemorrhage: A case report and literature review. World Neurosurg. 2019; 129:157–63
  7. Moscovici S, Limb R, Azriel A, Briggs R, Hall N, Kaye AH. Repeated spontaneous intra-tumoural and subarachnoid haemorrhage in an anticoagulated patient with a previously-irradiated vestibular schwannoma: Case report. J Clin Neurosci. 2020;73:323–5
  8. Lin D, Hegarty JL, Fischbein NJ, Jackler RK. The prevalence of “incidental” acoustic neuroma. Arch Otolaryngol Neck Surg. 2005;131(3):241-244
  9. Hatam J, Mokhtari M, Ahmadi SA, Bahrami E, Mirsalehi M, Mohebbi S, et al. Acute hemifacial and hemiparesis caused by hemorrhagic vestibular schwannoma; A case report. Clin Neurosci J. 2022;9:e6
  10. Lee SH, Choi, SK., Lim, YJ., Chung, HY., Yeo, JH., Na, SY., Kim, SH., Yeo, SG. Otologic manifestations of acoustic neuroma. Acta Otolaryngol. 2015. 135(2):140-6
  11. Leon J, Trifiletti, DM., Waddle, MR., Vallow, L., Ko, S., May, B., Tzou, K., Garcia, HR., Lundy, L., Chaichana, K., Vibhute, P., Peterson, JL. Trends of the initial management of vestibular schwannoma in the United States. J Clin Neurosci. 2019;68:174-178
  12. Huang MY, Vermeulen S. Clinical perspectives regarding patients with internal auditory canal or cerebellopontine angle lesions: surgical and radiation oncology perspectives. Semin Ultrasound CT MR. 2003 Jun;24(3):124-32
  13. Huang, X., Xu, J., Xu, M., Chen, M., Ji, K., Ren, J., Zhong, P. Functional outcome and complications after the microsurgical removal of giant vestibular schwannomas via the retrosigmoid approach: a retrospective review of 16-year experience in a single hospital. BMC Neurol 17, 18 (2017)
  14. Springborg JB, Poulsgaard L, Thomsen J. Nonvestibular schwannoma tumors in the cerebellopontine angle: a structured approach and management guidelines. Skull Base. 2008 Jul;18(4):217-27
  15. Woo PY, Lam PL, Ip YH, Chan TS, Ng OK, Kwan MC, Wong HT, Wong AK, Chan KY. "When the Benign Bleed" Vestibular Schwannomas with Clinically Significant Intratumoral Hemorrhage: A Case Series and Review of the Literature. Asian J Neurosurg. 2021 Feb 23;16(1):221-227
  16. Almosnino G, Sikora MJ, Farrokhi FR, Schwartz SR, Zeitler DM. Tumor-Related and Patient-Related Variables Affecting Length of Hospital Stay Following Vestibular Schwannoma Microsurgery. Ann Otol Rhinol Laryngol. 2022 May;131(5):535-543
  17. Yawn RJ, Nassiri AM, Harris JE, Manzoor NF, Godil S, Haynes DS, Bennett ML, Weaver SM. Reducing ICU Length of Stay: The Impact of a Multidisciplinary Perioperative Pathway in Vestibular Schwannoma. J Neurol Surg B Skull Base. 2021 Feb 4;83(Suppl 2):e7-e14

Last update:

No citation recorded.

Last update: 2024-11-04 20:51:48

No citation recorded.