Characteristics of intraoperative abnormal hemodynamics during resection of an intra-fourth ventricular tumor located on the dorsal medulla oblongata

Makoto Ideguchi, Koji Kajiwara, Koichi Yoshikawa, Hirokazu Sadahiro, Sadahiro Nomura, Masami Fujii, Michiyasu Suzuki, Makoto Ideguchi, Koji Kajiwara, Koichi Yoshikawa, Hirokazu Sadahiro, Sadahiro Nomura, Masami Fujii, Michiyasu Suzuki

Abstract

Abnormal hemodynamics during extirpation of a para-medulla oblongata (MO) tumor is common and may be associated with direct vagal stimulation of the medullary circuit. However, resection of tumors on the dorsal MO may also induce hemodynamic instability without direct vagal stimulus. The objective of this study was to examine the characteristics of hemodynamic instability unrelated to vagal stimulus during dissection of an intra-fourth ventricular tumor with attachment to the dorsal MO. A retrospective analysis was performed in 13 patients. Abnormal hemodynamics were defined as a > 20% change from the means of the intraoperative mean arterial pressure (MAP) and heart rate (HR). Relationships of intraoperative hemodynamics were evaluated with various parameters, including the volume of the MO. Six patients (46.2%) had intraoperative hypertension during separation of the tumor bulk from the dorsal MO. The maximum MAP and HR in these patients were significantly greater than those in patients with normal hemodynamics (116.0 ± 18.0 mmHg versus 85.6 ± 6.5 mmHg; 124.3 ± 22.8 bpm versus 90.5 ± 14.7 bpm). All six cases with abnormal hemodynamics showed hemodynamic fluctuation during separation of the tumor bulk from the dorsal MO. The preoperative volume of the MO in these patients was 1.11 cc less than that in patients with normal hemodynamics, but the volume after tumor resection was similar in the two groups (5.23 cc and 5.12 cc). This suggests that the MO was compressed by the conglutinate tumor bulk, with resultant fluctuation of hemodynamics. Recognition of and preparation for this phenomenon are important for surgery on a tumor located on the dorsal MO.

Conflict of interest statement

Conflicts of Interest Disclosure

The authors report no conflicts of interest concerning the work in this study.

Figures

Fig. 1
Fig. 1
Comparison of intra-operative mMAP and mHR (A) and maximal MAP and HR (B) between patients with abnormal and normal hemodynamics. *p = 0.002, **p = 0.008. HR: heart rate, MAP: mean arterial pressure, mMAP: mean intraoperative MAP, mHR: mean HR.
Fig. 2
Fig. 2
Elevation of intraoperative BP and HR in patients with abnormal (A) and normal (B) hemodynamics. BP: blood pressure, HR: heart rate, MAP: mean arterial pressure. *p = 0.02, **p = 0.009.
Fig. 3
Fig. 3
A, B: Pre- to post-operative volume changes of the medulla oblongata in patients with abnormal (A) and normal (B) hemodynamics. The closed (A) and open (B) squares with error bars (standard deviation) show the average volumes. C: Percentage increase in the preoperative volume in each group. *p = 0.026, **p = 0.002.
Fig. 4
Fig. 4
A–E: Preoperative (A: axial view, B: sagittal view) and postoperative (C: axial view, D: sagittal view) gadolinium-enhanced magnetic resonance imaging (MRI) and (E) anesthesia chart in an illustrative case. E: Bilateral-facing black arrows indicate a period of fluctuating blood pressure (BP) and heart rate (HR), and the black arrow indicates the points of maximal MAP and HR. ARTd: diastolic arterial pressure, ARTm: mean of arterial pressure, ARTs: systolic arterial pressure, NBPd: noninvasive diastolic blood pressure, NBPm: mean of noninvasive blood pressure, NBPs: noninvasive systolic blood pressure.

References

    1. Akimura T, Furutani Y, Jimi Y, Saito K, Kashiwagi S, Kato S, Ito H: Essential hypertension and neurovascular compression at the ventrolateral medulla oblongata: MR evaluation. AJNR Am J Neuroradiol 16: 401– 405, 1995.
    1. Blessing WW: Depressor neurons in rabbit caudal medulla act via GABA receptors in rostral medulla. Am J Physiol 254: H686– H692, 1988.
    1. Brown DL, Guyenet PG: Electrophysiological study of cardiovascular neurons in the rostral ventrolateral medulla in rats. Circ Res 56: 359– 369, 1985.
    1. Cameron SJ, Doig A: Cerebellar tumours presenting with clinical features of phaeochromocytoma. Lancet 1: 492– 494, 1970.
    1. Ciriello J, Hochstenbach SL, Roder S: Central projections of baroreceptor and chemoreceptor afferent fibers in the rats, in Robin I, Barraco A. (eds): Nucleus of the Solitary Tract. Boca Raton, Florida, CRC Press, 1993, pp 35– 50
    1. Dampney RA: Functional organization of central pathways regulating the cardiovascular system. Physiol Rev 74: 323– 364, 1994.
    1. Dampney RA, Blessing WW, Tan E: Origin of tonic GABAergic inputs to vasopressor neurons in the subretrofacial nucleus of the rabbit. J Auton Nerv Syst 24: 227– 239, 1988.
    1. Dampney RA, Goodchild AK, Tan E: Identification of cardiovascular cell groups in the brain stem. Clin Exp Hypertens A 6: 205– 220, 1984.
    1. Doba N, Reis DJ: Acute fulminating neurogenic hyper-tension produced by brainstem lesions in the rat. Circ Res 32: 584– 593, 1973.
    1. Frank H, Schobel HP, Heusser K, Geiger H, Fahlbusch R, Naraghi R: Long-term results after microvascular decompression in essential hypertension. Stroke 32: 2950– 2955, 2001.
    1. Gajjar D, Egan B, Curè J, Rust P, VanTassel P, Patel SJ: Vascular compression of the rostral ventrolateral medulla in sympathetic mediated essential hypertension. Hypertension 36: 78– 82, 2000.
    1. Geiger H, Naraghi R, Schobel HP, Frank H, Sterzel RB, Fahlbusch R: Decrease of blood pressure by ventrolateral medullary decompression in essential hypertension. Lancet 352: 446– 449, 1998.
    1. Goldstein DS, Levinson PD, Zimlichman R, Pitterman A, Stull R, Keiser HR: Clonidine suppression testing in essential hypertension. Ann Intern Med 102: 42– 49, 1985.
    1. Guyenet PG: Role of the ventral medulla oblongata in blood pressure regulation, in Loewy AD, Spyer KM. (eds): Central Regulation of Autonomic Functions. New York, Oxford University Press, 1990, pp 145– 167
    1. Guyenet PG, Filtz TM, Donaldson SR: Role of excitatory amino acids in rat vagal and sympathetic baroreflexes. Brain Res 407: 272– 284, 1987.
    1. Hedderwick SA, Bishop AE, Strong AJ, Ritter JM: Surgical cure of hypertension in a patient with brainstem capillary haemangioblastoma containing neuropeptide Y. Postgrad Med J 71: 371– 372, 1995.
    1. Ideguchi M, Kajiwara K, Yoshikawa K, Kato S, Ishihara H, Fujii M, Fujisawa H, Suzuki M: Continuous hypertension and tachycardia after resection of a hemangioblastoma behind the dorsal medulla oblongata: relationship to sympathetic overactivity at the neurogenic vasomotor center. J Neurosurg 113: 369– 373, 2010.
    1. Jannetta PJ, Gendell HM: Clinical observations on etiology of essential hypertension. Surg Forum 30: 431– 432, 1979.
    1. Jeske I, Morrison SF, Cravo SL, Reis DJ: Identification of baroreceptor reflex interneurons in the caudal ventrolateral medulla. Am J Physiol 264: R169– R178, 1993.
    1. Jeske I, Reis DJ, Milner TA: Neurons in the barosensory area of the caudal ventrolateral medulla project monosynaptically on to sympathoexcitatory bulbospinal neurons in the rostral ventrolateral medulla. Neuroscience 65: 343– 353, 1995.
    1. Langford HG, Sanford R, Smith R: Neurogenic hypertension in man: Reis, Barman-Gebber, or Carey syndrome. J Hypertens 5: S467– S469, 1987.
    1. Lee NJ, Park IS, Koh I, Jung TW, Rhyu IJ: No volume difference of medulla oblongata between young and old Korean people. Brain Res 1276: 77– 82, 2009.
    1. Luft AR, Skalej M, Schulz JB, Welte D, Kolb R, Bürk K, Klockgether T, Voight K: Patterns of age-related shrinkage in cerebellum and brainstem observed in vivo using three-dimensional MRI volumetry. Cereb Cortex 9: 712– 721, 1999.
    1. Luft AR, Skalej M, Welte D, Kolb R, Klose U: Reliability and exactness of MRI-based volumetry: a phantom study. J Magn Reson Imaging 6: 700– 704, 1996.
    1. Makino Y, Kawano Y, Okuda N, Horio T, Iwashima Y, Yamada N, Takamiya M, Takishita S: Autonomic function in hypertensive patients with neurovascular compression of the ventrolateral medulla oblongata. J Hypertens 17: 1257– 1263, 1999.
    1. Mancini M, Mainenti PP, Speranza A, Liuzzi R, Soscia E, Sabbatini M, Ferrara LA, Federico S, Salvatore M: Accuracy of sonographic volume measurements of kidney transplant. J Clin Ultrasound 34: 184– 189, 2006.
    1. Mitchell JR, Karlik SJ, Lee DH, Fenster A: Computer-assisted identification and quantification of multiple sclerosis lesions in MR imaging volumes in the brain. J Magn Reson Imaging 4: 197– 208, 1994.
    1. Morrison SF, Callaway J, Milner TA, Reis DJ: Rostral ventrolateral medulla: a source of the glutamatergic innervation of the sympathetic intermediolateral nucleus. Brain Res 562: 126– 135, 1991.
    1. Morrison SF, Reis DJ: Reticulospinal vasomotor neurons in the RVL mediate the somatosympathetic reflex. Am J Physiol 256: R1084– R1097, 1989.
    1. Nathan MA, Reis DJ: Chronic labile hypertension produced by lesions of the nucleus tractus solitarii in the cat. Circ Res 40: 72– 81, 1977.
    1. Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR: A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 49: 1373– 1379, 1996.
    1. Schobel HP, Frank H, Naraghi R, Geiger H, Titz E, Heusser K: Hypertension in patients with neurovascular compression is associated with increased central sympathetic outflow. J Am Soc Nephrol 13: 35– 41, 2002.
    1. Schreihofer AM, Guyenet PG: The baroreflex and beyond: control of sympathetic vasomotor tone by GABAergic neurons in the ventrolateral medulla. Clin Exp Pharmacol Physiol 29: 514– 521, 2002.
    1. Shirao S, Yoneda H, Ishihara H, Harada K, Ueda K, Sano Y, Kudomi S, Hayashi Y, Shigeeda T, Nakano K, Nomura S, Fujii M, Kato S, Suzuki M: Fate of clots in patients with subarachnoid hemorrhage following different surgical treatment modality: a comparison between surgical clipping and GDC embolization. Neurosurgery 68: 966– 973, 2011.
    1. Sun MK, Guyenet PG: GABA-mediated baroreceptor inhibition of reticulospinal neurons. Am J Physiol 249: R672– R680, 1985.
    1. Sved AF, Ito S, Madden CJ: Baroreflex dependent and independent roles of the caudal ventrolateral medulla in cardiovascular regulation. Brain Res Bull 51: 129– 133, 2000.
    1. Yagil Y, Futterweit W, Krakoff LR, Rubin H, Weinrauch H: Cerebellar tumor causing hypertensive crisis and simulating pheochromocytoma and Cushing's syndrome. Mt Sinai J Med 56: 56– 58, 1989.

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