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

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.