Brainstem cavernous angioma in an octagenarian cardiopathic patient: anesthesiologic and neurosurgical challanges

Learning Track: 6. Neuroanaesthesiology Title: Brainstem cavernous angioma in an octogenarian cardiopathic patient: anesthesiologic and neurosurgical challenges Author(s): Urli T.1, Nicolini F.2, Giulioni M.2, Sturiale C.2, Zanello M.1 Institute(s): 1IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Anesthesia and Intensive Care, Bologna, Italy, 2IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Neurosurgery, Bologna, Italy Text: Background: Cerebral cavernous angiomas are uncommon diseases mostly affecting young and middle-aged people. Brainstem location can be related to severe complications both in cases of conservative or surgical management. Anesthesiologic concern is the hemodynamic instability due to manipulation of brainstem (dysrhythmias, hypertension, hypotension), and the risk of cranial nerves dysfunction. Case report: A 81-year-old male presented painful dysesthesias and gait instability. The Magnetic Resonance Imaging revealed a large hemorrhagic multicystic lesion in the medulla oblongata. The patient had a cardiac disease with previous heart surgery (biological prosthesis, Bentall procedure); the artificial aortic valve was degenerating with moderate regurgitation. According to patient will, surgical intervention was scheduled for reducing the brainstem compression and the risk of rebleeding. Preoperative anesthesiologic evaluation pointed out the high risk of the procedure. The anesthetic plan included: prone position, balanced anesthesia with midazolam, sevoflurane and remifentanil, endocarditis prophylaxis, and a hemodynamic management fit for a patient with aortic regurgitation. External pacemaker-defibrillator pads were applied in advance. Surgical resection was carried out until occurrence of sudden bradycardia with hypotension, managed with atropine. After a short stay in ICU, the patient was transferred to the ward and then to the rehabilitation unit. Postoperatively he presented hemiparesis, slowly improving after physical therapy. The histopathological analysis confirmed the diagnosis of cavernoma. Discussion: We found no previous report of brainstem cavernoma surgery in octogenarian cardiopathic patients, but advanced age is not a sufficient reason to deny surgical treatment if the patient may benefit. In this case the usual concern about intraoperative hemodynamic instability was increased by the type of cardiac valvulopathy: intraoperative dysrhythmias, especially bradycardia, can worsen the degree of aortic regurgitation and can precipitate left ventricular failure. The medical team weighted carefully risk benefit ratio as well as the patient wish. Learning points: Neurosurgery of brainstem cavernomas can be performed in selected elderly patients in Hospitals with specific neurosurgical and anesthesiologic experience. The presence of serious comorbidities should not rule out the possibility of anesthesiologic and surgical treatment. Preferred Presentation Type: Case report ________________________________________ Conference: Euroanaesthesia 2017 · Abstract: A-805-0061-00727 · Status: Draft