Year : 2007 | Volume
: 51 | Issue : 3 | Page : 244--246
Emergency caesarean section in a patient with intracerebral tuberculoma
Ranju Gandhi1, Hemanshu Prabhakar2,
1 M.D. Senior Resident, Departments of Anaesthesiology and Intensive care and Neuroanaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
2 M.D. Assistant Professor, Departments of Anaesthesiology and Intensive care and Neuroanaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
Assistant Professor, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029
The incidence of tuberculosis in pregnancy ranges between 1-2% amongst hospital deliveries in the tropics. Tuberculosis of central nervous system accounts for about 5% of extra pulmonary cases and manifests as meningitis or uncommonly as tuberculoma. The management of intracerebral tuberculoma diagnosed during pregnancy should be same as that in non-pregnant subjects with antituberculous treatment. Emergency caesarean section in a patient with intracerebral tuberculoma poses unique challenges to the anaesthesiologist. There are no published reports on anaesthetic management of pregnancy with tuberculoma. We report the case of a woman with intracerebral tuberculoma presenting for emergency caesarean section. The anaesthetic goals in this patient were combined to that of principles of obstetrical anaesthesia to ensure a favourable maternal and fetal outcome. The anaesthetic technique chosen should prevent aspiration, avoid fluctuations in intracranial pressure, maintain stable haemodynamics, provide a sufficient depth of anaesthesia and good postoperative analgesia. We believe that general anaesthesia is the safest approach in such patients. We suggest general anaesthesia to be preferred over regional anaesthesia technique.
|How to cite this article:|
Gandhi R, Prabhakar H. Emergency caesarean section in a patient with intracerebral tuberculoma.Indian J Anaesth 2007;51:244-246
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Gandhi R, Prabhakar H. Emergency caesarean section in a patient with intracerebral tuberculoma. Indian J Anaesth [serial online] 2007 [cited 2020 Aug 13 ];51:244-246
Available from: http://www.ijaweb.org/text.asp?2007/51/3/244/61153
Tuberculosis (TB) remains an important public health problem worldwide that has been exacerbated by the HIV epidemic. TB kills more women in reproductive age group than all cases of maternal mortality combined, and it may create more orphans than any other infectious disease. The incidence of tuberculosis in pregnancy ranges between 12% amongst hospital deliveries in the tropics, being confined predominantly to the underprivileged sectors of society.
Tuberculosis of central nervous system(CNS) accounts for about 5% of extra pulmonary cases and manifests as meningitis or uncommonly as tuberculoma. Tuberculoma presents as one or more space occupying lesion and usually causes seizures and focal signs. TB meningitis (TBM) presents subtly as headache and mental changes or acutely as confusion, lethargy, altered sensorium and neck rigidity. Though there are reports of intracerebral neoplasms with pregnancy, there are no published reports on anaesthetic management of pregnancy with tuberculoma., We report the case of a woman with intracerebral tuberculoma presenting for emergency caesarean section.
A 25-year-old primigravida, weighing 67 kg and154 cm in height presented to labour room at 37 weeks of gestation. Antenatal ultrasound revealed an intrauterine growth retarded (IUGR) baby. Labour had been induced with prostaglandin E2 intracervically 12 hours earlier. On subsequent amniotomy, there was meconium stained liquor and she was planned for an emergency caesarean section. Preanaesthetic evaluation revealed history of grand mal seizure at 3rd month of pregnancy for which she was referred to a neurologist. As part of evaluation, plain and contrast enhanced magnetic resonance imaging (MRI) of brain was done and it showed large ill defined heterogenous mass in right temporal and frontal region with significant perifocal edema, mass effect and midline shift with herniation. Based on imaging appearance, tubercular etiology was suspected and antituberculous therapy (ATT) with 4 drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) was initiated, along with tab phenytoin 300 mg at night. A repeat MRI was done 5 weeks later which revealed multiple conglomerate disc enhancing lesion in right frontoparietal, temporal and left parieto-occipital lobes with perifocal edema causing midline shift to left. She did not have any recurrence of seizures. However her liver function tests became deranged 3 months after initiation of therapy and ATT was modified with addition of injection streptomycin 0.75 gm while pyrazinamide and rifampicin were stopped. Viral markers done for HIV, HBV and HCV were negative. She gave a recent history of cough with mild mucoid expectoration of 10 days duration. Physical examination including neurological examination and airway evaluation was normal. Her routine haematological and biochemical tests were within normal limits except liver enzymes which were mildly elevated.
Antiaspiration prophylaxis with ranitidine and metoclopramide were given along with tablet phenytion 300 mg. Informed high risk consent was obtained. Preinduction monitoring included heart rate, non invasive blood pressure, ECG, and pulse oximetry. She was preoxygenated with 100% oxygen. Rapid sequence induction was achieved with thiopentone 300 mg, lidocaine 2% (preservative free)100 mg along with suxamethonium 100 mg and trachea was intubated. Anaesthesia was maintained with isoflurane 0.7 MAC in 50:50 mixture of oxygen and nitrous oxide and vecuronium. A 1.96 kg male baby was delivered with APGAR score of 7, 9, 9 at 1, 5 and 10 minutes respectively. Induction to delivery interval was 25 minutes while uterine incision to delivery interval was 1 minute. After the delivery of baby, oxytocin drip was started and i.v. fentanyl 100 gg was given. Intraoperative vitals remained stable throughout and ventilation was adjusted to maintain end tidal carbon dioxide around 30 mmHg. Blood loss was 600 ml approximately, urine output was 300 ml and she received 1200 ml Ringer's lactate intraoperatively. Surgery lasted 80 minutes and trachea was extubated after reversal of neuromuscular blockade. The surgical wound was infiltrated with 8 ml of 0.25% bupivacaine and postoperative analgesia was provided with intramuscular injection of diclofenac sodium 75 mg and tramadol 50 mg 8 hourly. Twenty gg fentanyl bolus was also planned as rescue analgesic. Postoperatively she was advised antibiotics, steam inhalation, chest physiotherapy and continuation of ATT. Her further course was uneventful. However the baby was kept in neonatal intensive care unit in view of low birth weight and IUGR. He had persistent asymptomatic hypoglycemia and got discharged after 23 days of admission.
A circumscribed focal granulomatous mass of tubercular origin affecting the brain parenchyma and acting as a space occupying lesion is designated as a tuberculoma. It can occur as a single or multiple lesion, varying in size from less than one to several centimeters in diameter, affecting any part of the brain including the brainstem, the thalamus, the lateral ventricle and the aqueduct associated with varying degrees of perifocal oedema, and meningeal reaction. Extra-parenchymatous intracranial tuberculomas have been reported in the pituitary gland, optic chiasma, superior orbital fissure and cerebellopontine angle.
Treatment of CNS tuberculosis is with antituberculous therapy for atleast 18 months. Initially 3 drugs (isoniazid, rifampicin, ethambutol, pyrazinamide or streptomycin) are given for 3-4 months followed by two drugs for the remaining period. Although detailed teratogenicity data are not available, pyrazinamide can probably be used safely during pregnancy and is recommended by World Health Organization. Streptomycin is the only antituberculous drug documented to have harmful effects on the human fetus (congenital deafness). Patients should be educated about signs and symptoms of drug induced hepatitis (INH, rifampicin, pyrazinamide) and a careful watch including evaluation of liver function tests at regular intervals is essential. For patients with symptomatic hepatitis and those with marked elevation of liver enzymes, treatment should be stopped and drugs reintroduced one at a time after liver function has returned to normal. In our patient streptomycin was added after development of drug induced hepatitis as it is non hepatotoxic. High incidence of focal or generalized seizures both in cases of TBM and intracranial tuberculomas dictates prophylactic use of antiepileptic drugs. It is necessary to monitor serum anticonvulsant level in case of phenytoin as there is risk of toxicity for patients receiving isoniazid. Rarely a paradoxic expansion of the leison may occur during anti-tuberculous treatment with subsequent reduction in size.  A short course of corticosteroids along with antituberculous drugs is especially recommended for patients with intracranial tuberculomas manifesting clinical evidence of raised intracranial pressure and/or radiological evidence of moderate or severe perilesional oedema. Surgical intervention is indicated when vision or life is threatened due to severely elevated intracranial pressure, lack of desired clinical/radiological response to adequate medical therapy or when diagnosis is in doubt. It may include open or stereotactic biopsy, aspiration of an abscess, partial excision, total excision or ventriculo-peritoneal shunt for any co-existent hydrocephalus. A full course of medical therapy started in the preoperative period is mandatory irrespective of nature of surgery undertaken.
In routine clinical practice computed tomogram and/ or MRI remain the sheet anchor of diagnosis of neurotuberculosis and is seen as contrast enhanced ring leisons. However, it may not always be possible to differentiate a tumour, a fungal granuloma or an abscess from a tuberculoma. The onset of symptoms in our patient during pregnancy may be either coincidental or pregnancy might have led to development of CNS TB. Pregnancy, puerperium and diabetes mellitus have been cited as predisposing factors for intracranial tuberculoma in a recent review of 102 cases.
The anaesthetic goals in a patient with intracerebral space occupying lesion (SOL) should be combined to that of principles of obstetrical anaesthesia to ensure a favourable maternal and fetal outcome. The anaesthetic technique chosen should prevent aspiration, avoid fluctuations in intracranial pressure, maintain stable haemodynamics and provide a sufficient depth of anaesthesia and postoperative analgesia. The risks of increased intracranial pressure and full stomach must be weighed while planning general anaesthesia for caesarean section. One must avoid drugs which lower seizure threshold such as ketamine, enflurane and meperidine. We did not consider subarachnoid block for our patient as there is high risk of lumbar puncture induced herniation especially with temporal mass lesion associated with shift and brain stem compression. Other problem associated is risk of hypotension which can decrease cerebral perfusion or aggravate brain shifts. An alternative could have been epidural block. However, it also carries the risk of accidental dural puncture which can lead to acute neurological deterioration.  In the presence of increased intracranial pressure (ICP) or reduced cerebral compliance, extradural injection may result in an increase in ICP. Further, onset of block takes time and is not appropriate in the setting of emergency situation like fetal distress as seen in our patient. Caudal anaesthesia has been used to reduce the risk of dural puncture. However, it provides inadequate analgesia in 10-20% of patients and also requires larger doses of local anaesthetic, which results in greater risk of maternal toxicity. Women with active epilepsy may have an increased risk of convulsion during labour if they receive extradural analgesia and use of this technique in a patient with intracranial SOL may carry the same risk.
To conclude we present the successful anaesthetic management of a parturient with tuberculoma for emergency caesarean section. We believe that general anaesthesia is the safest approach in such patients. We suggest general anaesthesia to be preferred over regional anaesthesia technique.
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