Intravenous Magnesium Sulfate as an Adjuvant to Propofol-Based TIVA in Pediatric Glioma Resection: A Case Report with Real-Time ONSD and TCD Monitoring

Background: Pediatric glioma surgery poses significant anesthetic challenges due to raised intracranial pressure (ICP), neurodevelopmental vulnerability, and the need to achieve optimal brain relaxation without delaying postoperative recovery. Intravenous magnesium sulfate (MgSO₄), through NMDA receptor antagonism and analgesic- and hemodynamic-sparing effects, may support propofol-based total intravenous anesthesia (TIVA) within pediatric ERAS pathways. Case Presentation: A 10-year-old girl with a left temporoparietal glioma presented with seizures, progressive right hemiparesis, and papilledema. She underwent craniotomy under propofol-based TIVA augmented with MgSO₄ (loading 30 mg/kg; maintenance 10–15 mg/kg/h). Individualized cerebral physiology was guided using real-time optic nerve sheath diameter (ONSD) and transcranial Doppler (TCD) measurements. After induction and MgSO₄ infusion, ONSD values and middle cerebral artery pulsatility indices decreased toward more favorable ranges, consistent with improved intracranial compliance. Intraoperatively, brain relaxation was excellent, hemodynamics were stable, and only minimal rescue opioids and neuromuscular blockers were required. The patient was extubated within 24 hours, demonstrated low postoperative pain scores without agitation or PONV, and had no magnesium-related toxicity. A transient episode of diabetes insipidus occurred postoperatively, attributed to tumor-related hypothalamic–pituitary involvement, and resolved with vasopressin therapy. Discussion: This case highlights the feasibility of MgSO₄ as an adjunct to propofol-based TIVA in pediatric neuro-oncologic surgery. Real-time ONSD and TCD monitoring provided a practical, non-invasive method to tailor ICP and cerebral perfusion management. Conclusion: MgSO₄ may be a safe and effective adjuvant during pediatric glioma resection when combined with vigilant monitoring and ultrasound-guided cerebral physiology assessment. Prospective studies are needed to validate standardized dosing and ultrasound-guided ICP management protocols.