Expert ReviewManagement of brain tumors presenting in pregnancy: a case series and systematic review
Introduction
Women who present with brain tumors during their pregnancies require unique imaging and neurosurgical, obstetrical, and anesthetic considerations.1, 2, 3 Nearly every aspect of care is complicated by the presence of an intracranial neoplasm during pregnancy. Diagnostic parameters, surgical timing, method of delivery, and adjuvant treatment modalities are influenced by neurologic symptoms, gestational age, pathology, and overall prognosis.4,5 Although the risk of developing an intracranial tumor in a pregnant patient is roughly equivalent to the risk in a similar nonpregnant female,4,6, 7, 8 pregnancy does influence the pathophysiology of intracranial tumors.4,9 Pregnancy-related factors that may increase tumor growth and result in severe, debilitating illness include immunologic tolerance, hormone-mediated growth, and hemodynamic changes.4,9 In addition, the symptoms of increased intracranial pressure (ICP) caused by brain tumors, including nausea, emesis, and headache, may be confused with symptoms of normal pregnancy or other pregnancy-related conditions, making accurate diagnosis challenging.1,2 In this communication, we review our case series from 2009 to 2019, highlight several specific cases, provide expert considerations for patient management, and summarize the current literature on the treatment of these patients. These data allow us to suggest updated guidelines for the care of patients presenting with brain tumors in pregnancy.
Section snippets
Methods
We performed a retrospective medical record review of 9 patients who were diagnosed with brain tumors during pregnancy and underwent treatment at our institution between 2009 and 2019. Obstetrical, neurologic, anesthetic, histopathologic, imaging, and follow-up information were extracted from the electronic medical records. This project was conducted with institutional review board (IRB) approval and was exempt from patient consent because the information collected included only preexisting,
Results
The median age at presentation was 29 years (range, 25–38 years). The median gestational age at presentation was 20.5 weeks (range, 11–37 weeks). Intracranial tumors had a median size of 2.3×2.4 cm in the axial plane (range, 0.48–27 cm2). The patients’ ages, histopathologic diagnoses, presenting symptoms, delivery methods, surgical timings, adjuvant therapies, and clinical outcomes are presented in Table 1. In this series, 8 patients delivered healthy newborns, whereas 1 patient opted to
Discussion
Given the infrequency of intracranial neoplasm in pregnancy, there is no level I or II evidence to guide the management of pregnant patients with brain tumors (Table 2). The literature is limited to case series and isolated reports,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and although several authors have presented different algorithms for the care of these patients,2, 27, 28, 29, 3, 30, 36, 4,9,17,24,27, 28, 29,36 none has offered
Patient number 7: foramen magnum meningioma
A 34-year-old female presented to the emergency department at 13 weeks’ gestation with progressive, radiating neck stiffness, myelopathy, hemibody sensory changes, and weakness. A noncontrast MRI revealed a 2.1×2.4×3.5 cm foramen magnum meningioma (WHO grade I) resulting in severe brainstem and spinal cord compression (Figure 1, A, B, and C). The patient underwent a far lateral craniotomy and C1 and partial C2 laminectomy for the resection of the tumor (Figure 1, D). Pre- and postoperative
Conclusion
The presentation of a brain tumor during pregnancy requires a multidisciplinary team to plan, coordinate, and implement care. Generally, clinical strategies to ensure the health of the mother will also benefit the fetus. When the timing of intervention is flexible because of clinical stability, neurosurgical intervention would ideally be performed during the second trimester of pregnancy or after delivery. Anesthesia, fetal monitoring, positioning, possible concurrent emergency cesarean
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The authors report no conflict of interest.