Skip to main content Skip to main navigation menu Skip to site footer

Anaesthetic management in the patient with thoracic–lumbar intradural tumor accompanied by heart failure and atrial fibrillation: a case report

  • Satrio Adi Wicaksono ,
  • Taufik Eko Nugroho ,
  • Sulistiyati Bayu Utami ,


Background: Spinal cystic intradural Schwannoma is a type of tumor that is rarely found, with an incidence of 0.3–0.5/100,000 person per year. The operative procedure for this tumor was simple. However, some patients showed other comorbidities, such as heart failure with low ejection fraction (EF) and atrial fibrillation. Such cases are a challenge to the anaesthesiologist as they are most commonly complicated by progressive cardiac failure.

Case Presentation: A 68-year-old woman was consulted by the Anaesthesiology Department in dr. Kariadi General Hospital Semarang in April 2019. She had been experiencing right lower extremity and lower back pain since April 2018, and they have been getting worse since two weeks ago. She also complained of shortness of breath two weeks before, accompanied by typical symptoms and signs of heart failure. Her electrocardiogram showed atrial fibrillation, and her echocardiogram showed an LVEF of 33.7%. Magnetic resonance imaging (MRI) showed two lobulated intradural-extramedular cystic lesions at thoracal vertebrae 12 until lumbar vertebrae 1 (VTh12–L1) that were a high suspicious of Schwannoma on the anterior aspect and the lateral aspect accompanied by spinal cord compression at that level. The drugs used for premedication were metoclopramide 10 mg and ranitidine 50 mg, for induction was fentanyl 100 μg, and for maintenance were dobutamine 10 μg/kgBW/minute, rocuronium bromide 30 mg/hour via syringe pump, opioid fentanyl 100 μg and muscle relaxant using rocuronium bromide 40 mg. The patient was hemodynamically stable throughout the surgery, and blood loss was minimal.

Conclusion: In patients with heart problems, a moderate reduction in contractility and heart rate often occurs and may induce mild to severe bradyarrhythmia or tachyarrhythmia related to induction agents. It is important to maintain adequate cardiac output that requires inotropic agents to augment contractility and improve circulation. As an inotropic choice, a β-agonist (e.g., dobutamine) causes less vasodilation, increased contractility, and adjuncts to augment contractility in the setting of significant hypotension.


  1. Van Goethem JW, van den Hauwe L, Ozsarlak O, De Schepper AM, Parizel PM. Spinal tumors. Eur J Radiol. 2004;50(2):159-176. doi:10.1016/j.ejrad.2003.10.021.
  2. Baek SW, Kim C, Chang H. Intradural schwannoma complicated by lumbar disc herniation at the same level: A case report and review of the literature. Oncol Lett. 2014;8(2):936-938. doi:10.3892/ol.2014.2181.
  3. Pan J, Wang Y, Huang Y. Coexistence of intervertebral disc herniation with intradural schwannoma in a lumbar segment: a case report. World J Surg Oncol. 2016;14:113. Published 2016 Apr 18. doi:10.1186/s12957-016-0864-y.
  4. Arnautovic K, Arnautovic A. Extramedullary intradural spinal tumors: a review of modern diagnostic and treatment options and a report of a series. Bosn J Basic Med Sci. 2009;9 Suppl 1:40-45. doi:10.17305/bjbms.2009.2755.
  5. Lenzi J, Anichini G, Landi A, et al. Spinal Nerves Schwannomas: Experience on 367 Cases-Historic Overview on How Clinical, Radiological, and Surgical Practices Have Changed over a Course of 60 Years. Neurol Res Int. 2017;2017:3568359. doi:10.1155/2017/3568359.
  6. Bhargah A, Jayantika IGABK, Prabawa IPY, and Manuaba IBP. Spontaneous conversion to sinus rhythm in atrial fibrillation after dual antiplatelet and anticoagulant therapy in patients with unstable angina. Bali Medical Journal. 2020;9(3). p664–667.
  7. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC [published correction appears in Eur Heart J. 2016 Dec 30;:]. Eur Heart J. 2016;37(27):2129-2200. doi:10.1093/eurheartj/ehw128.
  8. Chua JH, Nguyen R. Anesthetic management of the patient with low ejection fraction. Am J Ther. 2015;22(1):73-79. doi:10.1097/MJT.0b013e31826fc458.
  9. Shaheen MSA, Sardar K, Chowdhury AKMN, Rahman MM, Alam MNA, Ahmed R, et al. Ejection Fraction <35% - Anaesthetic Experience of 236 Cases: A Retrospective Study. Anwer Khan Modern Med Coll J. 2018;9(2):114-20. DOI:
  10. Mittal AK, Chowdhury I, Arora M, Jain CR. Anesthetic management of a patient with heart failure and reduced ejection fraction for radical cholecystectomy with liver resection surgery. Indian Anaesth Forum. 2017;18(1):19-22. DOI:10.4103/TheIAForum.TheIAForum_5_17.
  11. Magner JJ, Royston D. Heart failure. Br J Anaesth. 2004;93(1):74-85.
  12. Larsen JR, Torp P, Norrild K, Sloth E. Propofol reduces tissue-Doppler markers of left ventricle function: a transthoracic echocardiographic study. Br J Anaesth. 2007;98(2):183-188. doi:10.1093/bja/ael345.
  13. Ryu T, Song SY. Perioperative management of left ventricular diastolic dysfunction and heart failure: an anesthesiologist's perspective. Korean J Anesthesiol. 2017;70(1):3-12. doi:10.4097/kjae.2017.70.1.3.
  14. Caputo LA, Cusimano MD. Schwannoma of the cauda equina. J Manipulative Physiol Ther. 1997;20(2):124-129..
  15. Kagaya H, Abe E, Sato K, Shimada Y, Kimura A. Giant cauda equina schwannoma. A case report. Spine (Phila Pa 1976). 2000;25(2):268-272. doi:10.1097/00007632-200001150-00021.
  16. Hwang SK, Jung SH. Schwannoma of the heart. Korean J Thorac Cardiovasc Surg. 2014;47(2):141-144. doi:10.5090/kjtcs.2014.47.2.141.
  17. Almobarak AA, AlShammari A, Alhomoudi RI, et al. Benign Pericardial Schwannoma: Case Report and Summary of Previously Reported Cases. Am J Case Rep. 2018;19:90-94. Published 2018 Jan 24. doi:10.12659/ajcr.907408.
  18. Koujanian S, Pawlowicz B, Landry D, Alexopoulou I, Nair V. Benign cardiac schwannoma: A case report. Human Pathology: Case Reports. 2017;8:24-6.
  19. D'Amato N, Correale M, Ireva R, Di Biase M. A rare cause of acute heart failure: malignant schwannoma of the pericardium. Congest Heart Fail. 2010;16(2):82-84. doi:10.1111/j.1751-7133.2009.00124.x.
  20. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944.
  21. Vermeyen KM, Erpels FA, Janssen LA, Beeckman CP, Hanegreefs GH. Propofol-fentanyl anaesthesia for coronary bypass surgery in patients with good left ventricular function. Br J Anaesth. 1987;59(9):1115-1120. doi:10.1093/bja/59.9.1115.
  22. Searle NR, Sahab P. Propofol in patients with cardiac disease. Can J Anaesth. 1993;40(8):730-747. doi:10.1007/BF03009770.

How to Cite

Wicaksono, S. A., Nugroho, T. E., & Utami, S. B. (2022). Anaesthetic management in the patient with thoracic–lumbar intradural tumor accompanied by heart failure and atrial fibrillation: a case report. Bali Medical Journal, 11(3), 1282–1288.




Search Panel

Satrio Adi Wicaksono
Google Scholar
BMJ Journal

Taufik Eko Nugroho
Google Scholar
BMJ Journal

Sulistiyati Bayu Utami
Google Scholar
BMJ Journal