Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study

Anaesthetic management of obstetric patients with Chiari type I malformation: a retrospective case series and literature review

The peripartum management of obstetric patients with Chiari type I malformation remains a challenge due to the degree of cerebellar tonsillar herniation and a paucity of published evidence. There is concern about neuraxial anaesthetic blocks and uncertainty regarding the optimum mode of delivery. We systematically searched the literature for the obstetric management of patients with Chiari type I malformation, independent of publication date and language. We also searched our local hospital database from December 2009 to December 2022 for all deliveries to patients with this condition. We identified 137 cases comprising 103 deliveries described in 40 publications that met our inclusion criteria; 34 deliveries were identified in our local database. There were 84 spontaneous vaginal deliveries, 52 caesarean deliveries, and one delivery by unknown modality. Sixty neuraxial blocks were performed; approximately half of these were epidural procedures for labour analgesia. Six patients had new or worsened symptoms following delivery, but it is unclear whether these were related to their Chiari malformation. We identified no cases with brainstem herniation or severe symptoms. We discuss our findings in relation to other published literature and address the concerns described. Our review reveals the use of a variety of modes of delivery and anaesthetic techniques and that most patients suffered no neurological complication. We conclude there is no of evidence to avoid any one approach to labour analgesia, delivery and anaesthesia. We propose a holistic, individualised and patient-centred approach with an appraisal of the risks and benefits to support shared-decision making.

Chiari I malformation: Case report of a postnatal diagnosis and literature review

Mode of delivery and intrapartum analgesia for women with Chiari I malformation pose a challenge to the obstetrician and anaesthetist. Clinicians often advocate caesarean section delivery under general anaesthetic to prevent an uncontrolled rise in intracranial pressure or a fall in cerebrospinal fluid pressure during labour that may result in neurological complications, or rarely, brainstem herniation. This case report discusses a woman with hitherto undiagnosed Chiari I malformation who delivered by CS due to obstetric concerns, but remained asymptomatic throughout the preceding labour and in spite of multiple epidural insertion attempts. We discuss considerations for future pregnancies, and review the literature to challenge the view that women with Chiari I need planned caesarean or must avoid epidural/spinal analgesia; instead presenting evidence to support the safety and suitability of vaginal delivery and neuroaxial block in labouring parturients with this condition.

Pregnancy complicated by neurological and neurosurgical conditions - The evidence regarding mode of delivery

Neurological and neurosurgical conditions complicating pregnancy may precipitate considerable concern regarding the risk of complications, and uncertainty regarding the preferred mode of delivery and anaesthesia. Caesarean section is known to be associated with significantly increased risk of adverse maternal outcomes compared with vaginal delivery in healthy pregnancy. Nevertheless, a common perception exists among the general population and some health professionals that caesarean section is safer for the mother and baby in high-risk pregnancies. This manuscript examines the literature regarding the risks and outcomes related to mode of delivery in pregnancy complicated by disorders of the central nervous system. With the exception of women with raised intracranial pressure, and some women with Von Hippel-Lindau syndrome, the available evidence suggests that the mode of delivery should be based upon obstetric indications.

Complex Pathology and Management in the Obstetric Patient: A Narrative Review for the Anesthesiologist

Pregnant patients may present with multiple complex comorbidities that can affect peripartum management and anesthetic care. The preanesthesia clinic is the ideal setting for early evaluation of high-risk pregnant patients. Comorbidities may include cardiovascular pathology such as valvular abnormalities, septal defects, aortopathies, arrythmias and cardiomyopathies. Additional comorbidities include pulmonary conditions such as obstructive sleep apnea as well as preexisting neuromuscular and skeletal disorders that may impact anesthetic management. Hematologic conditions involving both bleeding diathesis and thrombophilias may present unique challenges for the anesthesiologist. Patients may also present with endocrinopathies including diabetes and obesity. While not as common, high-risk patients may also have preexisting gastrointestinal conditions such as liver dysfunction, renal failure, and even post-transplant status. Ongoing and prior substance abuse, obstetric conditions such as placenta accreta spectrum disorders, and fetal conditions needing ex utero Intrapartum treatment also require advanced planning. Preanesthesia evaluations also help address important ethical and cultural considerations. Counseling patients regarding anesthetic considerations as well as addressing concerns will play a role in reducing racial and ethnic disparities. Anticipatory guidance by means of pre-anesthetic planning can facilitate multidisciplinary communication and planning. This can allow for an impactful and meaningful role in the care provided, allowing for safe maternal care and optimal outcomes.

Anesthetic management for cesarean delivery in a woman with congenital atlantoaxial dislocation and Chiari type I anomaly: a case report and literature review

Background

The preferable choice of anesthesia for the patients with congenital atlantoaxial dislocation (CAAD) and type I Arnold Chiari malformations (ACM-I) has been a very confusing issue in clinical practice. We describe the successful administration of combined spinal-epidural anesthesia for a woman with CAAD and ACM-1 accompanied by syringomyelia.

Case presentation

Our case report presents the successful management of a challenging obstetric patient with CAAD and ACM-1 accompanied by syringomyelia. She had high risks of difficult airway and aspiration. The injection of bolus drugs through the spinal or epidural needle may worsen the previous neurological complications. The patient was well evaluated with a multidisciplinary technique before surgery and the anesthesia was provided by a skilled anesthesiologist with slow spinal injection.

Conclusions

An interdisciplinary team approach is needed to weigh risks and benefits for patients with CAAD and ACM-1 undergoing cesarean delivery. Therefore, an individual anesthetic plan should be made basing on the available anesthetic equipments and physicians’ clinical experience on anesthetic techniques.