2019 FSA Posters

P062: PERIOPERATIVE SEIZURE MANAGEMENT AFTER INTRACRANIAL MASS RESECTION
Sharlene A Lobo, MD, Juan Ojeda, Nicholas Nedeff, MD; Kendall Regional Medical Center

Introduction: The patient is a 78 year old obese male with a past medical history of noncommunicating hydrocephalus s/p VP shunt, chronic subdural hematomas, prostate cancer, hypertension, diabetes mellitus who presented to the ER with complaints of progressive confusion, left hand numbness and tingling and difficulty walking due to left leg weakness. A CT scan of the brain revealed a subacute subdural hematoma with mass effect and compression of the right frontal lobe, with the possibility of an underlying mass. The patient was evaluated by the neurosurgery team and it was decided that a right frontal craniotomy with removal of the VP shunt, evacuation of subdural hematoma and possible mass excision would be performed.

Methods: The case was performed under general anesthesia, with induction using propofol and rocuronium and placement of a size 7.5 endotracheal tube. Preoperatively, an arterial line was placed for hemodynamic monitoring. After exposure, it was found that the chronic subdural hematomas were due to a large frontal epidural mass causing midline shift and compression on the right frontal lobe. The mass was sent for frozen section and determined to be metastasis of adenocarcinoma of the prostate. Resection and surgical manipulation presented a challenge due to labile blood pressure as well as a significant drop in blood pressure once the tumor was completely removed. This was managed by small boluses of phenylephrine and titration of volatile anesthetic and narcotics. Once the case concluded and the patient was spontaneously breathing with decreasing concentrations of volatile anesthetic, the patient began to have a seizure despite administration of intraoperative seizure prophylaxis. The decision was made to keep him intubated for airway protection and 4mg of Ativan was administered with no resolution. An additional 6mg of Ativan and 4mg of Midazolam was given and the seizure resolved. The patient was then transported to ICU and placed on an Ativan drip

Results: During the ICU course, the patient continued to have seizures, and was placed on 24 hour EEG. His continuous seizures were inadequately controlled with an Ativan, Midazolam, Pentobarbital, Propofol drips as well as twice daily dosing of Leviteracetam and Valproic Acid. A diagnosis of status epilepticus was made with a very poor prognosis. A discussion was had with the family and the decision to be placed on comfort measures was made. The patient passed away on post operative day 6.

Discussion: In a 2018 study published in the Journal of Neurosurgical Anesthesiology,  the overall incidence of intraoperative seizures was 2.3%. Risk factors for intraoperative seizures include seizure history, diagnosis of intracranial tumor, and temporal craniotomy. It was found that intraoperative prophylactic anticonvulsant use was protective. With the high risk of seizure development in this particular case, it’s possible that a better neurological outcome would have been obtained if the volatile anesthetic was not decreased and no attempt at extubation occured. Starting an Ativan or pentobarbital drip prior to development of the first seizure may have prevented the development of status epilepticus.