The anaesthetic management of a patient with a phaeochromocytoma and acute stroke

Seizures in patients with a phaeochromocytoma/paraganglioma (PPGL): A review of clinical cases and postulated pathological mechanisms

The purpose of this work was to expound on the postulated pathological mechanisms through which pheochromocytoma/paraganglioma (PPGL) can cause seizures by conducting a comprehensive review of ten cases and several pathogenic mechanisms. The goal was to enhance awareness amongst doctors and researchers about patients with PPGL presenting with seizures. This would help decrease the risk of misdiagnosis and mismanagement in future clinics. Additionally, this review was written with the purpose to attract more attention to etiological explorations, particularly concerning rare causes of seizures, which is consistent with the idea that League Against Epilepsy (ILAE) has emphasized in the new version of the ILAE position paper published in 2017. It is of great importance to keep in mind the fact that seizures can constitute an atypical presentation of PPGL and to establish early diagnosis and accurate cure for these patients, especially in the presence of paroxysmal hypertension or other suggestive symptoms of PPGL.

Management of hypertension in intrapericardial paraganglioma

Functioning paraganglioma is extra-adrenal catecholamine-secreting tumours that may cause secondary hypertension. Primary intrapericardial paragangliomas are very rare and are located adjacent to the great vessels or heart, typically near the left atrium. These tumours are an exceptionally uncommon finding during the investigation of refractory hypertension. However, in recent years, intrapericardial paragangliomas have been diagnosed incidentally with increased frequency, due to the extensive use of radiologic chest imaging. The mainstay of treatment of functioning intrapericardial paraganglioma is surgical removal, which usually achieves blood pressure normalization. Due to the locations of these tumours, the surgical approach is through a median sternotomy or posterolateral thoracotomy, and manipulation-induced catecholamine release may cause paroxysmal hypertension. Typically in these patients, blood pressure fluctuates dramatically intra- and post-operatively, increasing the risk of cardiovascular complications. We review here the current modalities of perioperative fluid and hypotensive drug administration in the setting of surgery for functioning intrapericardial paraganglioma and discuss the recently proposed paradigm shift that omits preoperative preparation.

Cardiovascular manifestations of phaeochromocytoma

Clinical expression of phaeochromocytoma may involve numerous cardiovascular manifestations, but usually presents as sustained or paroxysmal hypertension associated with other signs and symptoms of catecholamine excess. Most of the life-threatening cardiovascular manifestations of phaeochromocytoma, such as hypertensive emergencies, result from a rapid and massive release of catecholamines from the tumour. More rarely, patients with phaeochromocytoma present with low blood pressure or even shock that may then precede multisystem crisis. Sinus tachycardia, with palpitations as the presenting symptom, is the most prevalent abnormality of cardiac rhythm in phaeochromocytoma, but tumours can also be associated with more serious ventricular arrhythmias or conduction disturbances. Reversible dilated or hypertrophic cardiomyopathy are well established cardiac manifestations of phaeochromocytoma, with more recent attention to an increasing number of cases with Takotsubo cardiomyopathy. This review provides an update on the cause, clinical presentation and treatment of the cardiovascular manifestations of phaeochromocytoma. As the cardiovascular complications of phaeochromocytoma can be life-threatening, all patients who present with manifestations that even remotely suggest excessive catecholamine secretion should be screened for the disease.

Emergencies caused by pheochromocytoma, neuroblastoma, or ganglioneuroma

Pheochromocytoma may lead to important emergency situations, ranging from cardiovascular emergencies to acute abdomen and multiorgan failure. It is vital to think about this disease in any emergency situation when conventional therapy fails to achieve control or symptoms occur that do not fit the initial diagnosis. The importance of keeping this diagnosis in minds is underscored by the fact that, in 50% of pheochromocytoma patients, the diagnosis is initially overlooked. Two other tumors of the sympathetic nervous system, neuroblastoma and ganglioneuroma, are less commonly associated with emergency conditions. If they occur, they are often linked to catecholamine excess, paraneoplastic phenomena, or local tumor mass effect.

Labetalol Pretreatment Reduces Blood Pressure Instability During Surgical Resection of Pheochromocytoma

BACKGROUND

To evaluate the effect of pretreatment with the mixed alpha- and beta-adrenergic blocker, labetalol, on blood pressure instability during surgical resection of pheochromocytoma.

METHODS

Blood pressure stability and surgical results were compared between patients in the saline (n = 11) and labetalol (n = 15) groups. Anesthesia was induced with fentanyl, sodium thiopental and atracurium, and maintained with isoflurane in a 50% oxygen/nitrous oxide mixture. Intravenous labetalol was administered in the labetalol group before surgical incision, with the maximal dose being 1.2 mg/kg, while normal saline was administered to patients in the control, saline, group. Supplemental intravenous sodium nitroprusside (SNP) infusion was administered whenever systolic blood pressure exceeded 180 mmHg. The number of patients with intraoperative hypertension or hypotension, dosage of SNP administered, number of intraoperative hypertension episodes, use of fluid and blood transfusion, and heart rate (defined as the mean of heart rate every 5 minutes throughout the operation) were compared between these two groups.

RESULTS

The number of patients with intraoperative hypertension, number of patients receiving SNP, dose of SNP administered, and number of hypertension episodes were significantly lower in patients who received labetalol pretreatment than in control patients.

CONCLUSION

This study has demonstrated that labetalol pretreatment (1.2 mg/kg) with supplemental SNP provides more favorable blood pressure control during surgical resection of pheochromocytoma than with SNP alone.

[Pheochromocytoma. Severe and uncommon presentations]

We report five cases of phaeochromocytoma in patients admitted for myocardial infarction, severe cardiac failure, with shock, stroke and ischaemic gangrene of a lower limb respectively. The pathophysiology of these events is discussed. Early surgery prevents visceral damage from massive release of catecholamines.

Reversible cerebral ischemia in patients with pheochromocytoma

Cerebral ischemia and symptoms of stroke can occur as a rare manifestation in patients with pheochromocytoma. We describe a 45-year-old woman who was admitted because of a right-sided hemiparesis due to an ischemic lesion in the left hypothalamus. The clinical diagnosis of a pheochromocytoma was proven by highly elevated urinary catecholamines and confirmed histologically after operation. The successful removal of the tumor led to the almost complete recovery of the neurological deficiencies. It is of vital importance to know this atypical presentation of pheochromocytoma. The diagnosis of pheochromocytoma should be suspected in patients with focal cerebral symptoms, particularly in the presence of intermittent hypertension or other paroxysmal symptoms suggestive of pheochromocytoma.

Haemodynamic heterogeneity and treatment with the calcium channel blocker nicardipine during phaeochromocytoma surgery

BACKGROUND

Favourable outcome of phaeochromocytoma surgery requires that paroxysmal hypertension and arrhythmia be controlled, and that hypotension be prevented. Is nicardipine, a calcium channel blocking drug, always adequate?

METHODS

Nineteen consecutive patients underwent surgery for phaeochromocytoma. Management was standardised with regards to anaesthesia and antihypertensive treatment. Nicardipine was used as a vasodilator and was given in order to maintain systemic vascular resistance lower than 1600 dyn.s.cm-5.

RESULTS

Hypertension did not occur at any time during surgery in 6/19 patients. Blood pressure rose acutely in 3/19 patients at the time of tracheal intubation or surgical approach to the tumour, and was controlled by increased depth of anaesthesia. Hypertensive episodes occurred in 11/19 patients during tumour manipulation. Nicardipine always succeeded in maintaining low systemic vascular resistance but its dosage varied widely between patients (0.5 to 70 mg), a fact that may be accounted for by the striking intersubject variability of haemodynamic behaviour during surgery. In 7/11 patients, despite nicardipine treatment, sustained increase in blood pressure persisted with increased cardiac index, but low systemic vascular resistance. Following tumour removal, transient serious hypotension (MAP < 60 mmHg) occurred in 4 patients, and was corrected by fluid volume expansion. Perioperative incidence of hypertension or hypotension was not related to preoperative clinical status.

CONCLUSION

Adequate management of patients operated upon for phaeochromocytoma requires invasive monitoring, since the mechanisms underlying hypertensive crises are heterogeneous with regards to systemic vascular resistance and not predictable from preoperative data. Nicardipine provides a good control of vasoconstriction during phaeochromocytoma surgery with limited risk of serious hypotension after tumour removal.

[Use of urapidil during surgery for pheochromocytoma]

OBJECTIVE

To investigate the efficacy of urapidil, administered either by boluses or a continuous infusion, to control hypertension during resection of phaeochromocytoma.

STUDY DESIGN

Prospective open study.

PATIENTS

Seven consecutive patients aged between 23 and 60 years, with a hypersecretant phaeochromocytoma.

METHODS

Standard anaesthetic technique including thiopentone, opioid, muscle relaxant, nitrous oxide and isoflurane. Invasive haemodynamic monitoring with a Swan-Ganz catheter and radial arterial catheterization. Infusion of cristalloids and colloids (20 mL.kg-1.h-1). Evaluation of two regimens of urapidil administration following the initial injection of a bolus of 25 mg in case of severe hypertension i.e. SAP > 180 mmHg > 1 min: a) boluses of 25 or 50 mg of urapidil injected according to the response obtained after the first bolus or in case of resurgence of a new hypertensive event; b) continuous infusion of 150-200 mg.h-1.

RESULTS

Three patients developed hypertension between the induction of anaesthesia and the beginning of the tumor dissection. One bolus of 25 or 50 mg of urapidil was efficient to control this event. During the dissection of the phaechromocytoma, higher doses (75-100 mg) were required to significantly decrease SAP and DAP values (P < 0.001). Heart rate did not change significantly in patients not receiving esmolol. A continuous infusion, used in three patients, did not prevent the occurrence of peaks in two patients, requiring additional doses. After the removal of the tumor, three patients experienced severe hypotension with decreased systemic vascular resistances and high cardiac output. Vasoactive drugs were injected to restore better haemodynamic conditions.

CONCLUSION

Urapidil is useful for the management of hypertension during the resection of phaechromocytoma. However further investigations are needed to determine its role in the occurrence of prolonged collapse after the tumor removal.

Case report: bilateral adrenal pheochromocytoma

Pheochromocytoma remains a clinical challenge to diagnose and manage. In addition, the association of multiple endocrine neoplasia syndromes with pheochromocytoma require the clinician's awareness to evaluate patients with pheochromocytoma (especially when bilateral) for abnormalities in thyroidal C-cell function with serum calcitonin determinations. The authors present a case of a 42-year-old woman initially diagnosed with, and treated for, cranial artery vasculitis because she had a stroke and a history of rheumatoid arthritis and asthma. Subsequent evaluation of episodic blood pressure increases, headache, and tachycardia revealed biochemical evidence of catecholamine overproduction. Bilateral adrenal masses were found on computed tomography scanning, and the functional nature of the adrenal masses was confirmed by a meta-Iodobenzylguanidine scan. Upon further evaluation, an elevated serum calcitonin concentration was demonstrated, which increased greatly with pentagastrin stimulation. C-cell hyperplasia was demonstrated by subsequent thyroidectomy, confirming the diagnosis of multiple endocrine neoplasia 2A. The difficulty in arriving at a correct diagnosis, the subsequent management, including bilateral adrenalectomy and thyroidectomy, and newer insight into the genetic abnormalities of multiple endocrine neoplasia 2A are discussed.