A pregnant female with a large intracranial mass: Reviewing the evidence to obtain management guidelines for intracranial meningiomas during pregnancy

Abstract

Introduction:Non-obstetric surgery for intracranial meningioma is uncommon during pregnancy and poses significant risks to both the mother and the fetus. We present a case of a parturient that presented with acute mental status changes and we illustrate the decision making process that resulted in a best-possible outcome.Case Description:A woman at 29-week gestation presented with acute language and speech deficits and deteriorating mental status after 2 weeks of headache. Imaging demonstrated a large intracranial mass. A multidisciplinary meeting was held to determine the best treatment plan. The decision was to proceed with caesarean delivery under epidural anesthesia to allow intraoperative monitoring of neurological function. Six hours after successful delivery, the patient had acute mental status changes and she was taken to the operating room immediately for resection of her tumor, which turned out to be a clear cell meningioma.Discussion:Cerebral meningioma is usually a slow-growing tumor; however, during pregnancy, the mass may expand rapidly due to hormonal receptor expression. The presentation of this patient would have normally led to urgent resection of the mass. But the complicating factor was her 29-week pregnancy as standard intraoperative treatment during neurosurgery is known to adversely affect the fetus. A multidisciplinary meeting was critical for this patient’s care, and is recommended by us when treating such patients.

Pregnant woman with an intracranial meningioma – case report and review of the literature

“…The first case of a pregnant woman with a brain tumor was described by Bernard in 1898. (1,2,3,4,5) The occurrence of a meningioma during pregnancy is also rare, comparable with that in non-pregnant women in the same age group.…”

“…The occurrence of a meningioma during pregnancy is rare because pregnant women tend to be young and healthy, so the general incidence of this pathology does not exceed that of nonpregnant women in the same age group. (1,2,3,4) In 1898, Bernard described the first case of a pregnant woman with a brain tumor. In 1937, Hagedoorn presented a documented study about the effects of pregnancy on intracranial meningioma.…”

“…(1,9,14) The acceleration of meningioma growth in the second or third trimesters of pregnancy may be determined also by the absence of Luteinising hormone and Follicle-stimulating hormone and by the falling level of Human chorionic gonadotropin in these stages of pregnancy. These observations were made in a vitro study on meningiomas by Boyle-Walesh, Shenkin and White in their paper published in 1995.…”

“…(1) The clinical presentation with signs and symptoms of elevated intracranial pressure, focal seizures, lateralising neurological deficits, abnormal funduscopic examination suggests the diagnosis of an intracranial mass and should not be confused with hyperemesis gravidarium, eclampsia or puerperal psychosis. (1,5) Magnetic resonance imaging of the brain is the method of choice for prompt diagnosis of meningioma during pregnancy. (1) The management strategy for intracranial tumors during pregnancy should be individualised and include mainly surgery.…”

“…(1,5) Magnetic resonance imaging of the brain is the method of choice for prompt diagnosis of meningioma during pregnancy. (1) The management strategy for intracranial tumors during pregnancy should be individualised and include mainly surgery. Surgery during pregnancy associates a great risk for fetus and also for the mother.…”