Acoustic neuroma in pregnancy: emergency cesarean section and definitive neurosurgery

Vestibular schwannoma unveiled by pregnancy: A case report and literature review

BACKGROUND

Vestibular schwannomas - benign tumours originating from the vestibular nerve - are rare during pregnancy. The intricate interplay between the gravid uterus, maternal physiology and neoplastic growth imposes complexities that demand a careful and tailored approach.

CASE REPORT

This article reports a case of a pregnant woman in her 30 s diagnosed with a large vestibular schwannoma exhibiting brainstem compression, peritumoral oedema and cranial nerve encasement at 36 + 5 weeks of gestation. A multi-disciplinary team collaborated to devise a treatment plan considering the delicate balance between fetal well-being and the urgent need for intervention. A conservative approach involving close monitoring, corticosteroid therapy to manage peritumoral oedema, and detailed fetal assessments was initially employed. As the patient neared full term, a carefully planned caesarean section was performed, followed by a successful craniotomy to resect the vestibular schwannoma. Both the mother and the newborn showed favourable outcomes postoperatively. In addition, a literature review of cases of vestibular schwannoma in pregnancy was undertaken to inform optimal management strategies and enhance understanding of this complex scenario.

CONCLUSION

This case highlights the complexity of managing vestibular schwannomas in pregnant women, and underscores the importance of a tailored, collaborative approach. The condition was resolved successfully, emphasizing the significance of timely diagnosis, meticulous planning and a patient-centred approach in these rare and intricate cases.

Large vestibular schwannomas presenting in the late state of pregnancy: a case report and literature review

Vestibular schwannomas in pregnancy have rarely been reported, and there is a lack of in-depth discussion on the experience of management of massive acoustic neuromas in pregnancy. Herein, we present a pregnant woman with a giant vestibular schwannoma and obstructive hydrocephalus who presented at 30 weeks of gestation. She was initially misdiagnosed as having a pregnancy-related reaction of headache, dizziness, and vomiting that had occurred 2 months earlier. After observation at home, her symptoms progressed at 30 weeks of gestation, and imaging findings revealed a brain tumor in the CPA region with secondary cerebella tonsil herniation and obstructive hydrocephalus, and she was transferred to our center for treatment. Consequently, we relieved her hydrocephalus with a ventriculoperitoneal shunt (V-P shunt) and used corticosteroids to simulate fetal maturation. After 10 days, her mental condition deteriorated, and her right limb muscle strength gradually decreased until grade 0 (MMT Grading). Finally, under a joint consultation with the Department of Neurosurgery, Obstetrics, and Anesthesiology, she underwent a cesarean section under general anesthesia and first-stage tumor removal at 31 weeks of gestation. Upon discharge, the previously observed neurological deficits, which were reversible and had manifested during her gestational period, had been successfully resolved, and the fetus had been conserved. The neuroimaging confirmed the complete tumor removal, while the neuropathologic examination revealed a vestibular schwannoma. Therefore, we recommend early diagnosis and treatment for these patients, especially people with headaches, vomiting, and sudden hearing loss during pregnancy. Herein, we concluded that our cases provide a valuable experience in the latest acceptable time frame for the operation to prevent irreversible neurological impairment and premature delivery in late pregnancy.

A pregnant woman with a giant bilateral parietal hemangiopericytoma underwent multiple surgeries and radiotherapy: a case report and literature review

Intracranial hemangiopericytoma is a rare invasive tumor originating from mesenchymal fibroblasts and is prone to local recurrence and distant metastasis. This study reports a case of a 27-year-old woman who presented with severe headache, nausea and vomiting for two weeks at thirty-three weeks of gestation. Cranial magnetic resonance imaging (MRI) demonstrated a giant lesion in the bilateral parietal lobe with a size of 5.12x9.19x6.03 cm and severe edema in the surrounding brain tissue. The patient underwent four operations and 3 gamma knife radiosurgery procedures and is recovering well now. The histopathology findings showed hemangiopericytoma and STAT6 and CD34 positivity after the first and second surgeries. Because of tumor progression, the patient received gamma knife radiosurgery at 1, 3, and 4 years after the first operation. Total tumor resection was achieved in the fourth surgery. Nevertheless, the patient showed malignant transformation to from low-grade to high-grade hemangiopericytoma.

Accelerated growth of orbital schwannomas during pregnancy does not correlate with sex hormone- or growth factor receptor status

Purpose: Until now, three cases of growth of an orbital schwannoma during pregnancy have been published. We aim to provide additional insight in the effect of pregnancy on orbital schwannomas. Methods: We present two additional cases of accelerated growth of orbital schwannomas during pregnancy and investigate receptor expression profiles for estrogen, progesterone, androgen, VEGF, EGF, FGF, PDGF-Rβ and ki-67 in the two pregnant cases and six non-pregnant cases. Results: Case 1: A 26-year-old woman developed unilateral exophthalmos during pregnancy, with normal visual acuity and ocular motility. During a subsequent pregnancy, again the exophthalmos progressed. MRI showed a mass suggestive of schwannoma. After delivery, resection of the lesion was performed through an anterior approach. Pathology confirmed schwannoma. The expression profile was positive for estrogen- and FGF receptors and ki-67, but negative for progesterone-, androgen- and other growth factor receptors. Case 2: A 24-year-old woman presented with diplopia and unilateral pain during pregnancy. She had normal visual acuity, but a mild exophthalmos and elevation deficit. MRI revealed an extraconal mass suggestive of schwannoma. After delivery, resection was performed through an anterior approach. Pathology confirmed the diagnosis. The expression profile was positive for ki-67, but negative for sex hormone- and growth factor receptors. In the six non-pregnant cases the expression profiles varied, with only one subject showing a strong expression of estrogen-, progesterone- and androgen receptors. Conclusions: Orbital schwannomas can experience growth during pregnancy. The underlying mechanism remains unclear as hormone- and growth factor expression profiles show no correlation to the pregnant state.

Obstetrical Outcomes of Head and Neck (Nonthyroid) Cancers: A 27-Year Retrospective Series and Literature Review

Objective  To describe the clinical presentation and obstetrical outcomes of nonthyroid head and neck cancers (HNCs), and to review literature on this rare condition in pregnancy. Study Design  Pregnant women with nonthyroid HNC were identified retrospectively from 1990 to 2017. Maternal, neonatal, pregnancy, and demographic data were collected. A review of the literature from January 1980 to May 2018 was performed. Results  Over the 27-year time period, 16 women with history of nonthyroid HNC were identified (9 diagnosed during and 7 diagnosed before current pregnancy). The cases were analyzed in detail and the most updated review of management of each type of HNC was provided. Conclusions  HNCs are rare with diagnosis and management challenges during pregnancy. In this series, the cases diagnosed and managed previously to pregnancy presented better perinatal outcomes than the cases presented during pregnancy. The maternal outcomes appeared similar for HNC diagnosed before or after pregnancy.

Neurosurgical anesthesia for a pregnant woman with macroprolactinoma: A case report

RATIONALE

Being required to perform neurosurgery on a pregnant woman is rare, but occasionally unavoidable. In these cases, clinical anesthesiologists are confronted with conflicting information and few evidence-based guidelines.

PATIENT CONCERNS

Here, we describe the successful anesthetic management of a 24-week pregnant woman with macroprolactinoma who underwent endonasal transsphenoidal resection of pituitary adenoma.

DIAGNOSES

According to the prolactin (PRL) level and magnetic resonance imaging (MRI) results, the patient was diagnosed with macroprolactinoma and kept stable after taking the regular bromocriptine treatment. However, after stopping the drug by herself because of pregnancy, her tumor increased in size and she suffered from vision loss. Surgery was recommended as soon as possible to lessen the compression in the eye. However, the anesthetic management was a considerable risk due to the increased chance of maternal mortality, intrauterine growth restriction, or preterm labor.

INTERVENTIONS

We held a multidisciplinary meeting before the operation and made a detailed plan for how to proceed. During the operation, our team ensured intensive monitoring, provided adequate oxygen, and achieved haemodynamic stability. Anesthetics like sufentanyl, rocuronium, propofol, and desflurane were carefully chosen in order to ensure the safety of both the mother and fetus.

OUTCOMES

Under the careful and successful anesthetic management, the pregnant woman underwent the surgery smoothly and neither the mother nor baby experienced any pre- or postoperative complications. At the 38th week of gestation, the patient received a cesarean section and the baby had developed normally.

LESSONS

Neurosurgeries in pregnancy are sparse, and careful planning with cross-disciplinary specialists was needed in advance of the operation. Moreover, when dealing with such surgeries, we should consider the safety of both the mother and fetus, which is challenging but important.

Large Vestibular Schwannomas Presenting during Pregnancy: Management Strategies

Objective Large vestibular schwannomas rarely present in pregnant women. Diagnosis and management of these tumors during pregnancy present a therapeutic challenge. Methods A 20-year-old primigravida woman at 26 weeks' gestation was transferred to our facility with gait imbalance, left facial weakness, left ear hearing loss, and recent nausea and vomiting. Magnetic resonance imaging revealed a large left cerebellopontine angle mass with extension into the left internal auditory canal and compression of the fourth ventricle resulting in mild hydrocephalus. The patient was admitted with a plan for early delivery at 32 weeks followed by tumor resection. One week later, the patient's headache and neurologic symptoms worsened due to increased hydrocephalus; a ventriculoperitoneal shunt was placed. The next day, an emergent cesarean delivery was performed due to worsening respiratory status. Four days later, a tracheostomy and percutaneous endoscopic gastrostomy tube were placed due to dysphagia. Eight days after the delivery, the mass was resected with a left retrosigmoid approach without complications. Immunohistochemistry confirmed vestibular cellular schwannoma on cranial nerve VIII showing unusually high mitotic activity. Results The patient was discharged to inpatient rehabilitation on postoperative day 12 without new neurologic deficit. At 1 month, the patient was swallowing without aspiration. Her facial sensation had returned, her facial weakness remained stable, and her gait was significantly improved. Conclusion If the patient is neurologically stable, the best option is to delay resection until after delivery. If resection is necessary during pregnancy, the optimal time is during the second trimester.

Sudden hearing loss and pregnancy: a review

Background:

Acute hearing loss is a distressing albeit rare occurrence in pregnancy. Due to its infrequent presentation, little is known of its cause, and the best management is unclear.

Objective:

To present a summary of current knowledge regarding sudden hearing loss in pregnancy and its management, by reviewing the published literature.

Data sources:

The following electronic databases: PubMed (MEDLINE), Ovid (MEDLINE), all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE and CCTR) and Embase; plus a hand search of reference lists of retrieved papers.

Study selection and data extraction:

All papers retrieved using key word searches for ‘sudden hearing loss and pregnancy’ and ‘sudden deafness and pregnancy’ were reviewed. Due to the scarcity of literature, all studies identified were included in this review.

Data synthesis and conclusions:

All retrieved papers were reviewed. Sudden hearing loss is a rare occurrence during pregnancy, leading to a dearth of literature due to limited clinical experience. Audiological investigation findings for such patients remain equivocal. Recovery can be spontaneous during the postpartum period. In patients who require medical treatment, a dextran 40 infusion can be employed. There remains scope for further research, in the form of larger studies, to ascertain the best management option for this clinical problem.

Accelerated Growth of an Orbital Schwannoma During Pregnancy

An incidentally diagnosed unilateral orbital mass in a 34-year-old woman grew at an accelerated rate during pregnancy with deterioration of visual function. Removed early after delivery by a transcranial approach, the tumor was histologically diagnosed as a richly vascularized cystic schwannoma containing red blood cell components. The accelerated tumor growth was attributed to intratumoral hemorrhage. Although acoustic schwannomas have been reported to enlarge during pregnancy, this phenomenon has only been described once for orbital schwannomas. Because this type of tumor may enlarge during pregnancy and threaten visual function, surgery should not be delayed.

Medical history, cigarette smoking and risk of acoustic neuroma: an international case-control study

Acoustic neuroma (vestibular schwannoma) is a benign tumor of the vestibulocochlear nerve. Its recorded incidence is increasing but risk factors for this tumor have scarcely been investigated. We conducted a population-based case-control study of risk factors for acoustic neuroma in the UK and Nordic countries, including 563 cases and 2,703 controls. Tumor risk was analyzed in relation to medical history and cigarette smoking. Risk of acoustic neuroma was significantly raised in parous compared with nulliparous women (OR = 1.7, 95% CI: 1.1-2.6), but was not related to age at first birth or number of children. Risk was not associated with a history of allergic disease, past head injury, past diagnosis of a neoplasm or birth characteristics, but was significantly raised for past diagnosis of epilepsy (OR = 2.5, 95% CI: 1.3-4.9). Tumor risk was significantly reduced in subjects who had ever regularly smoked cigarettes (OR = 0.7, 95% CI: 0.6-0.9), but the reduction applied only to current smokers (OR = 0.5, 95% CI: 0.4-0.6), not ex-smokers (OR = 1.0, 95% CI: 0.8-1.3). The reduced risk of acoustic neuroma in smokers and raised risk in parous women might relate to sex hormone levels, or smoking might suppress tumor growth, but effects of parity and smoking on timing of diagnosis of the tumor are also a potential explanation. The raised risk in relation to past diagnosis of epilepsy might be a surveillance artefact or imply that epilepsy and/or antiepileptic medication use predispose to acoustic neuroma. These findings need replication by other studies and possible mechanisms need to be clarified.