DIAGNOSTIC TESTING

• Sequential MRI studies, with and without contrast, demonstrated tumor presence and enlargement (1996-97).
• Intraoperative ultrasonography with biopsies, documenting diffusely infiltrative tumor in posterior temporal lobe, directly within the speech area (4/97).
• Neuropsychological evaluation (8/97).
• WADA testing showed left lobe dominance for speech (9/97).
• Speech and sensory cortex mapping facilitated by subdural grid (9/97).

PERTINENT FAMILY / SOCIAL HISTORY
     Father (+) neurofibromatosis; stable family; sixth-grade student

MEDICATIONS / SUPPLEMENTS
     Carbamazepine 300 mg BID; Acupuncture augmentation for craniotomy

ALLERGIES
     Phenytoin, Carboplatin

PERTINENT REVIEW OF SYSTEMS
     ROS was (+) for average intelligence with normal information-processing and language skills; right hand dominance, significant memory deficits; right optic pallor but, otherwise, intact cranial nerves and neurological examination. Prior surgical scars were present.

PERTINENT PHYSICAL EXAMINATION FOR TECHNIQUE USED
     Cognitively intact with positive response to perioperative support directed towards acceptance of "awake" craniotomy. Pulses and appearance consistent with sufficient Qi for therapeutic manipulation with acupuncture.

DIAGNOSIS
     Low grade, expanding astrocytoma of the left temporal lobe, extending into the dominant speech area.

TREATMENT
     TCM: single session

POINTS
     Yin Tang # 1 (0. 16 x 15mm needle), retained 45 minutes prior to arterial, venous lines, and urinary catheter placement. Taichong (LR 3), Xiangu (ST 43) bilaterally; Zulinqi (G13 4 1) right foot only, as access denied on left. #30 gauge 1 " stainless steel needles were inserted with strong technique to obtain the Qi.

TECHNIQUE
    An ITO-173 electroacupuncture unit, with lead wires to all foot needles was used to provide continuous stimulation, progres- sively increasing in intensity, and adjusted to patient comfort. Needles with electrical stimulation were retained for 4.25 hours.

ASSOCIATED MODALITIES
     Monitored anesthesia care with invasive monitoring of arterial blood pressure; intravenous sedation and analgesia titrated to surgical stimulation and patient response; local anesthetic infiltration of the scalp prior to incision and with wound closure; contin- uous patient support and guidance by child life specialist remaining at patient's side throughout the procedure.

OUTCOME / SUBJECTIVE
     Patient remained calm and fully cooperative throughout the entire 5.5 hour procedure; communicated verbally and denied sig- nificant discomfort. At the end of the case, she moved herself from the OR table into her bed, and was fully alert and verbal upon arrival into the ICU.

OUTCOME / OBJECTIVE
     Sequential postoperative MRI studies, with and without contrast, demonstrated complete tumor removal. Postoperative phys- ical examination and neuropsychological testing revealed minor to modest short-term memory deficits with some difficulty in find- ing words and quadrantanopsia. She had no difficulties in reading or returning to her previous classroom and school activities. Overall, her change from preoperative baseline was minimal, consistent with previous deficits and excision of tumor-infiltrated brain tissue.

COMPLICATIONS
     None

FOR ADDITIONAL READING
1. Section IV, Chapter 2; Acupuncture anesthesia. O'Connor, J, Bensky, D. (eds): Acupuncture a comprehensive text. Chicago, Eastland Press, 1981; 562-563.
2. National Cooperative Group of Acupuncture Anesthesia for Neurosurgery: Acupuncture anesthesia in neurosurgery. Zhang XiangtoDg (H.T. Chang) (eds): Research on acupuncture, moxibustion, and acupuncture anesthesia: Beijing (Science Press) and Berlin (Springer-Verlag), 1986; 961-972.

AUTHORS' INFORMATION
Dr. Lynnae Schwartz is a Pediatrician/Anesthesiologist; her subspecialities include Pediatric Anesthesia and Critical Care. Her affiliations include Department of Critical Care Medicine, Children's National Medical Center, Washington, DC, and George Washington University School of Medicine, Washington, DC. Dr. Schwartz has a master's degree from the New England School of Acupuncture, 1996.

Lynnae Schwartz, M.D.
Department of Critical Care Medicine,
Children's National Medical Center
111 Michigan Avenue, NW,
Washington, DC 20010
Phone: 202-884-3596 - Fax: 202-884-5724 -
Email: Ischwar@erols.com; also, Ischwartz@cnmc.org

Dr. Joanne Shay is an attending Anesthesiologist, Children's National Medical Center in Washington, DC., and Assistant Professor, Department of Anesthesiology and Pediatrics at George Washington University, Washington, DC.

Joanne Shay, M.D.
Children's National Medical Center
I I I Michigan Avenue, NW,
Washington, DC 20010
Phone: 202-884-2025
Email: jshay@cnmc.org

NEXT ABSTRACT >