Follow your heart but don’t forget your brain – a case report of a serious intraoperative neutrally mediated hypertension

Research output: Contribution to journalMeeting AbstractAcademic


Background: Cardiovascular problems due to brain stem manipulation can present an anaesthetic challenge during surgery for resection of brain tumour located in the posterior cranial fossa.

Case report: A 65-year-old normotensive female presented with right sided
diminished visual and hearing acuity, balance problems and swallowing difficulty
caused by a supra and infra tentorial meningioma. She had initially undergone a
craniotomy via orbitofrontal approach to decompress N.III but due to incapacitating gait problems and dysphagia a decision was made to attempt a tumour debulking in the posterior cranial fossa.
She underwent TIVA with TCI propofol and remifentanil. Anaesthesia was
uneventful until the opening of the dura mater. Once the dissection of the brain stem started the patient’s blood pressure became increasingly unstable. Blood pressure surges – systolic blood pressure (SBP) rising from 100 mm Hg to peaks of 180 mm Hg in a matter of minutes- alternated with significant falls in SBP. Surgery had to be interrupted a number of times while the anaesthesiologist normalized the patients cardiovascular parameters through pharmacological and non-pharmacological means.
Discussion: Brain stem plays a central role in blood pressure control. Afferent
peripheral (N. X and N. IX) and central sensory cardiovascular information is
integrated in the nucleus tractus solitarius (NTS). It modulates the function of
primary sympathetic (SYM) and parasympathetic (PSYM) output centres namely
the rostral ventrolateral medulla (RVLM) and the nucleus ambiguous (nAmb)1
. These centres project to the end organs and modulate the blood pressure. Surgical manipulation of input, integration and output structures can alter the SYM/PSYM balance and cause rapid blood pressure changes2
Learning points: Surgery for resection of brain stem tumours can cause
intraoperative hemodynamic instability. Proper preparation and collaboration
between the anaesthesia and the surgical team are of paramount importance to
ensure optimal tumour resection while ensuring physiologic stability
Original languageEnglish
Article number06AP04-3
Pages (from-to)156
Number of pages1
JournalEuropean Journal of Anaesthesiology
Issue numbere-Supplement 56
Publication statusPublished - Aug-2018
EventEuroanaesthesia 2018 - Bella Conference Center, Copenhagen, Denmark
Duration: 2-Jun-20184-Jun-2018

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