The Successful Resection of an Acoustic Neurinoma in a Patient on Maintenance Hemodialysis, with Special Reference to Perioperative Management

Abstract

Reported is the case of a 73-year-old male patient on maintenance hemodialysis for the past 8 years. He was admitted to hospital on May 10, 1994 because of a headache and a gait disturbance that had gradually grown more severe over a 2-week period. On examination, MRI revealed a large mass (4 x4 cm) in the brain stem that was severely compressing the brain stem at the left cerebellopontine angle. This finding suggested an acoustic neurinoma and decompression surgery became mandatory since the neurological symptoms progressively worsened. Thus, on May 25 a resection of the tumor was performed. Prior to the operation, however, frequent hemodialysis was initiated using nafamostat mesilate instead of heparin. Fruther, cerebellar edema was kept well controlled by external ventricular drainage and hyperventilation. As for the surgery, except for 2 part of the internal auditory canal, the tumor was resected totally. The postoperative course was uneventful, and the patient resumed his daily life on maintenance hemodialysis. Although reports of successful neurosurgery for patients on maintenance hemodialysis have appeared in the recent literatrure, the operative results do not seem to be entirely satisfactory. Important and difficult problems have yet to be solved in the perioperative management, specifically the tendency of bleeding in patients with chronic renal failure, fluid balances with respect to cerebral edema, hyperpotassemia, and similar manifestations during and after the surgery. These problems often neccesitate repeated hemodialysis by staff with technical skill. In this reported case, nafamostat mesilate was used in the hemodialysis and hemodynamic control was maintained with Swan-Ganz catheterization. In addition to these technical problems, the perioperative management of brain surgery for patients on maintenance hemodialysis is discussed.