A0041 Pineal Region Space-Occupying Lesion Surgery in Sitting Position in a 2.5- Year-Old Patient: A Case Report

Background: The sitting position for neurosurgery was first introduced by De Martel in 1931, and it provides ideal access to the surgeon for suboccipital craniotomy. Sitting position in pediatric population presents unique physiological challenges for the anesthesiologist with potential for serious complications like venous air embolism, postural hypotension, and serious cardiac arrhythmias due to surgical stimulation of cranial nerves and brainstem. The present case is one of the youngest cases reported so far.

Case Description: A 2.5- year-old girl presented with complaints of intermittent fever and vomiting for 30 days, weakness of left upper limb and lower limb for 3 days and two episodes of generalized seizure. On evaluation, a pineal space-occupying lesion (SOL) was diagnosed. A ventriculoperitoneal shunt was placed to relieve the mass effect and a suboccipital craniotomy with excision of SOL in sitting position under general anesthesia was decided. After detailed evaluation by the neuroanesthesiologist, the patient was accepted for surgery in ASA III. The patient underwent the procedure with invasive monitoring, in addition to standard ASA monitoring. Modified sitting position was achieved with elevation of lower limbs, and lower limbs were wrapped with elastic bandage to prevent venous pooling. Intraoperative period was uneventful. Patient was not extubated and shifted to PICU for elective postoperative mechanical ventilation and monitoring. The patient was extubated next day without any complication. The patient recovered with some residual weakness.

Conclusions: The sitting position still has a role in modern neurosurgical practice but should be considered following consideration of its potential complications. Proper vigilance and monitoring with appropriate precautions can prevent complications both during and after the surgery.