P024: CANNOT TALK, CANNOT WALK: A CASE REPORT OF A YOUNG HEALTHY MALE FOUND TO HAVE RAPIDLY PROGRESSING OSTEOSARCOMA
Reena S John, DO1, Jonah Zisquit, MD1, Crystal Lam, MD1, Vincent Sakk2; 1Kendall Regional Medical Center, 2Nova University
25 yo male with no significant PMH presented progressively growing scalp mass complaining of headaches, dizziness, speech arrest, and right sided weakness.
VS: BP: 160/107 RR:18 Tmax: 36.8 O2% 100RA
General: AAOx3 NAD
Head/Eyes: PERRLA, non-nobile, indurated 12x12cm, left temporal mass
CV: RRR NLS1,S2
Neuro: CNII-XII intact b/l
Case Report: 25 yo male with no significant PMH presented progressively growing scalp mass complaining of headaches, dizziness, speech arrest, and right sided weakness.
He reported a progressively growing, left sided cranial lesion over the past 2 years. He was told by another physician that it was most likely a lipoma. He first noticed the growth 2 years prior but experienced generalized pressure like headaches days prior to presentation, and speech arrest immediately before arriving to the ED. On physical exam there was an 12x12 cm cranial mass, extent of lesion unknown on physical exam. He did admit episodes of AMS, verified by his family members. CT angio head w/wo contrast revealed a left hemi cranial mass with aggressive features that favored primary neoplastic process with evidence of bone destruction at the left parietal bone. The perioperative diagnosis was a left temporal-parietal extra-axial tumor.
Management: Urgent Left temporal parietal craniotomy was planned in setting of neurological symptoms and altered mental status. Anesthesia was induced with midazolam and fentanyl, followed by propofol. Pt was paralyzed with rocuronium since no SSEP or MEP monitoring was required. Pt was maintained on sevoflurane < 0.5 MAC. Hypocapnia was maintained to decreases cerebral blood flow and reduce likelihood of cerebral edema. Dexamethasone was administered to reduce inflammation. As the calvarium was dissected, the surgeon commented on the malignant appearance of the tumor which invaded the calvarium and beyond into the dura. Due to the extensive nature of the mass, the patient was taken to the ICU intubated for close monitoring. Per neurosurgeon and pathology report, it was determined that the mass was a rapidly growing osteosarcoma.
Discussion: Increased intracranial pressure has been proven to have devastating outcomes such as brain herniation, infarction, and hemorrhage; management includes brain relaxation therapies.
The complex physiology of cerebral autoregulation of cerebral blood flow vary based on mechanism of increased ICP, and must be assessed perioperatively.
ICP is the key determinant of cerebral perfusion pressure, and multiple studies have confirmed sustained ICP>20mmg worsens outcomes
To avoid an increase in ICP during induction and intubation, it is important for the patient to be adequately anesthetized beforehand.
Mannitol therapy helps improve increased ICP, with limitations of renal insufficiency and hyperosmolarity, and dosing has been extensively reviews in literature.
Steroids can help reduce parenchymal edema, and have limited use in trauma, but are to be considered in patients with intracranial lesions.
Hyperventilation has been implemented to lower ICP, but proportionately decreases CBF, limiting its effectiveness.
Barbituates and hypothermia have been shown to have no benefits and improved outcomes in managing ICP.