Case ReportManagement of Foramen Magnum Meningioma During Pregnancy: Literature Review and Case Report
Introduction
Foramen magnum meningiomas (FMMs) account for 2%–5% of all intracranial meningiomas.1 These tumors have a ratio of 2–3:1 in women versus men.2 Even though the occurrence of meningioma in pregnant women is not superior to that in nonpregnant women, pregnancy management of intracranial meningiomas presents certain challenges. For instance, diagnosis of hydrocephalus may be delayed if vomiting is perceived as part of classic gravity hyperemesis. In 1898, Bernard3 associated pregnancy with rapid growing tumors, but the first reported association between symptomatic meningiomas and pregnancy was by Cushing and Eisenhardt in 1938.4
FMMs often present with cranial nerve dysfunctions that may remain after surgery. Talacchi et al.1 reported greater onset incidence with X–XI and XII cranial nerves impairment. In their series, postoperative impairment because of cranial nerve dysfunction was mostly attributed to IX-X and XII cranial nerves. Cerebellar and long-tract symptoms are also frequently seen in these patients. However, these symptoms frequently improve postoperatively.1 For a long time, tumors located anteriorly in the foramen magnum were viewed as life-threatening lesions in which most cases were considered inoperable.5
The development of the far-lateral approach marked a new stage in the management of these tumors. This approach improves the lateral to medial exposure of the foramen magnum, augmenting access to the inferior clivus and anterior medulla. The approach was progressively developed in the 1980s when the classic retro sigmoid approach and midline suboccipital-C1 laminectomy were recognized as limited to provide adequate exposure for complex intra- and extradural tumors in the foramen magnum area and complex vertebrobasilar aneurysms.6 First described by Koos7 in 1985, but later detailed by Pernezcky,8 lateral suboccipital craniotomy settled the bases for development of the far-lateral approach. Perhaps Heros in 19869 contributed in a greater manner to its evolution by describing lateral suboccipital craniotomy with C1 laminectomy and drilling of the posterior condyle. Initially, this approach was prescribed for posteriorly located vascular pathology treatment, but then George et al.10 applied it in the resection of anteriorly located meningiomas of the cervicomedullary junction. Nowadays, total resection is achieved in 70%–96%.5
We present a case of FMM in a pregnant woman with gross total resection without the interruption of gestation. There is extensive literature regarding intracranial meningiomas during pregnancy; however, there are limited data on FMM in pregnancy. We would like to contribute our case to the literature and review currently published data.
Section snippets
Clinical Case
The patient is a 38-year-old woman with no significant medical history experiencing back and lateral neck pain since week 12 of pregnancy. At week 30, she saw a neurologist after presenting with progressive numbness in the right posterior aspect of the neck and right arm. Magnetic resonance imaging showed a dural-based lesion measuring 2.0 × 3.3 cm with significant mass effect in brainstem and cervicomedullary junction (Figure 1). The patient's symptoms were initially managed with steroid
Discussion
Management requires multidisciplinary decision-making. Elective cesarean section followed by resection or resection during pregnancy are both feasible options. Decisions on the best time for surgical intervention, interruption of pregnancy, and mode of delivery are difficult without current guidelines. All efforts are made toward prolonging gestation for as long as possible. To avoid increased intracranial pressure during delivery, cesarean section is generally preferred. If clinically
Intraoperative Monitoring and Anesthesia
The American College of Obstetricians and Gynecologists recommends the use of fetal heart rate monitoring whenever facilities and trained personal are available.19 The use of fetal heart rate monitoring is always preferred given its added value in detecting early hemodynamic instability, allowing optimization of maternal hemodynamics and oxygenation.20 Moreover, normal mother blood tension does not ensure actual correct fetal oxygenation, and secondary compression of umbilical cord may occur
Conclusions
Although resection of FMM in pregnancy is usually postponed until after delivery, it can still be performed successfully in cases of clinical deterioration. Rapid growing FMMs during pregnancy can be associated with steroids management. We believe a three fourths prone position of a pregnant patient is safe and adequate for far-lateral exposure of craniocervical lesions. Careful consideration should be applied in selection of hyperosmolar therapy and degree of hyperventilation.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.