Neuroanesthesia for the Pregnant Woman

Unique Challenge of Saving Two Lives in Pregnancy with Severe Traumatic Brain Injury: A Narrative Review

A pregnant patient is a body with two lives. Saving the mother and baby after severe head injuries during pregnancy requires intensive monitoring and multidisciplinary team based management. There are many neurosurgical challenges in cases of pregnancy with severe traumatic brain injury (TBI) during pregnancy and the postpartum period due to changes in physiological and anatomical changes due to pregnancy. The strategy to treat post traumatic hydrocephalus using a ventriculoperitoneal shunt is also risky as it tends to malfunction due to a gravid uterus. The challenges and issues faced by the multidisciplinary team of the level I apex trauma center while managing pregnancy complicated by severe TBI and its consequences, like a threat to continue of pregnancy, post traumatic hydrocephalus, anesthesia management if there is requirement of surgery, and perioperative management, are discussed in this review based on available literature. A "one size fits all" approach is slowly being replaced by individualized approaches in children and pregnant women. This is affected by novel diagnostics, advanced monitoring, and multispeciality teams in dedicated trauma centers.

Awake craniotomy during pregnancy: A systematic review of the published literature

Neurosurgical pathologies in pregnancy pose significant complications for the patient and fetus, and physiological stressors during anesthesia and surgery may lead to maternal and fetal complications. Awake craniotomy (AC) can preserve neurological functions while reducing exposure to anesthetic medications. We reviewed the literature investigating AC during pregnancy. PubMed, Scopus, and Web of Science databases were searched from the inception to February 7th, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Studies in English investigating AC in pregnant patients were included in the final analysis. Nine studies composed of nine pregnant patients and ten fetuses (one twin-gestating patient) were included. Glioma was the most common pathology reported in six (66.7%) patients. The frontal lobe was the most involved region (4 cases, 44.4%), followed by the frontoparietal region (2 cases, 22.2%). The awake-awake-awake approach was the most common protocol in seven (77.8%) studies. The shortest operation time was two hours, whereas the longest one was eight hours and 29 min. The mean gestational age at diagnosis was 13.6 ± 6.5 (2-22) and 19.6 ± 6.9 (9-30) weeks at craniotomy. Seven (77.8%) studies employed intraoperative fetal heart rate monitoring. None of the AC procedures was converted to general anesthesia. Ten healthy babies were delivered from patients who underwent AC. In experienced hands, AC for resection of cranial lesions of eloquent areas in pregnant patients is safe and feasible and does not alter the pregnancy outcome.

Anaesthetic management of cerebral arteriovenous malformation hemorrhage during pregnancy: A case series

RATIONALE

There is no clear consensus guidance for anesthesiologists on how to manage patients with cerebral arteriovenous malformation (cAVM) rupture and hemorrhage during pregnancy who need craniotomy. Our objective was to review the anesthesia management of pregnant women who underwent resection of cAVM at our institution and to provide opinions and suggestions.

PATIENT CONCERNS

Herein, we report of 3 patients with cAVM rupture and hemorrhage during pregnancy who underwent neurosurgery at the 22nd, 28th, and 20th weeks of pregnancy.

DIAGNOSES

All 3 patients were admitted to the emergency department of our hospital due to sudden symptoms. Subsequently, their head imaging results confirmed the rupture and hemorrhage of cAVM. The rupture and hemorrhage of cAVM during pregnancy has a low incidence and high mortality, which seriously endangers the safety of the mother and fetus. For this emergency condition, craniotomy for removing intracranial lesions and clear hematoma can result in a chance of a successful delivery. Especially in the second and third trimesters of pregnancy, the management goal of anesthesia is to ensure the maternofetal safety and to maintain continuous pregnancy.

INTERVENTIONS

This article describes the process of intraoperative anesthesia management and maternal-fetal outcomes and discusses the key issues for the anesthesia management of cAVM rupture during pregnancy, including considerations of physiological changes during pregnancy and anesthesia medication, intraoperative monitoring, the maintenance of hemodynamic stability, and the control of intracranial pressure, among other considerations. Resection of intracranial lesions should be performed whenever possible while maintaining the pregnancy for better maternal and infant outcomes.

OUTCOMES

The operations of the 3 pregnant women were successfully completed under our detailed anesthesia planning and careful anesthesia management. All the patients recovered well after the operation, and underwent cesarean section to give birth smoothly.

LESSONS

The preservation of pregnancy under cAVM resection is a complex challenge for anesthesiologists, and these 3 cases provide an extensive amount of experience for anesthesia management in similar situations. Detailed anesthesia planning and careful anesthesia management by anesthesiologists are important guarantees for good maternal and fetal outcomes.

Neurosurgical emergencies during pregnancy - Management dilemmas

Background

Neurosurgical emergencies in the obstetric setting pose considerable challenges. Decision-making involves deliberations on the gestational age, critical nature of the illness, timing of surgery, maternal positioning during neurosurgery, anesthesiologic strategies, monitoring of the pregnancy during surgery, and the mode of delivery. The present study discusses the management and ethical dilemmas encountered during the management of six obstetric patients with neurosurgical emergencies.

Methods

A retrospective review of all neurosurgical operations performed between January 2016 and December 2022 were included in the study.

Results

This study includes a series of six pregnant women who presented with neurosurgical emergencies, secondary to freshly diagnosed pathologies in the period 2016-2022. The mean maternal age was 31.33 years. Four of the six patients were in the third semester and two were in the second trimester. The underlying etiologies were as follows: spontaneous intracerebral hypertensive hemorrhage (1), obstructive hydrocephalus due to shunt malfunction (1), brain tumor (02), and compressive spinal cord myelopathy due to tumors (02). Three patients who were near term underwent lower cesarean section followed by emergency neurosurgical procedure in the same sitting. Two second trimester patients continued their pregnancy after the emergency neurosurgical operation. In one patient, in whom a brain tumor was diagnosed near term, underwent neurosurgery 1 week after successful cesarean section. All the six mothers and fetus recovered well, ex3cept two patients who have persisting residual deficits.

Conclusion

Treatment of neurosurgical emergencies during pregnancy needs to be customized depending on the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. With careful planning, timely intervention, consultative decision making and it is possible to achieve the ultimate goal - which is to protect and safeguard the mother and preserve and deliver a viable fetus.

Ten Rules for the Management of Moderate and Severe Traumatic Brain Injury During Pregnancy: An Expert Viewpoint

Moderate and severe traumatic brain injury (TBI) are major causes of disability and death. In addition, when TBI occurs during pregnancy, it can lead to miscarriage, premature birth, and maternal/fetal death, engendering clinical and ethical issues. Several recommendations have been proposed for the management of TBI patients; however, none of these have been specifically applied to pregnant women, which often have been excluded from major trials. Therefore, at present, evidence on TBI management in pregnant women is limited and mostly based on clinical experience. The aim of this manuscript is to provide the clinicians with practical suggestions, based on 10 rules, for the management of moderate to severe TBI during pregnancy. In particular, we firstly describe the pathophysiological changes occurring during pregnancy; then we explore the main strategies for the diagnosis of TBI taking in consideration the risks related to mother and fetus, and finally we discuss the most appropriate approaches for the management in this particular condition. Based on the available evidence, we suggest a stepwise approach consisting of different tiers of treatment and we describe the specific risks according to the severity of the neurological and systemic conditions of both fetus and mother in relation to each trimester of pregnancy. The innovative feature of this approach is the fact that it focuses on the vulnerability and specificity of this population, without forgetting the current knowledge on adult non-pregnant patients, which has to be applied to improve the quality of the care process.

Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Neuro-anesthesiology in pregnancy

Management of the pregnant patient requiring neurosurgery poses multiple challenges, juxtaposing pregnancy-specific considerations with that accompanying the safe provision of intracranial or spine surgery. There are no specific evidence-based recommendations, and case-by-case interdisciplinary discussions will guide informed decision-making about the timing of delivery vis-à-vis neurosurgery, the performance of cesarean delivery immediately before neurosurgery, consequences of neurosurgery on subsequent delivery, or even the optimal anesthetic modality for neurosurgery and/or cesarean delivery. In general, identifying whether increased intracranial pressure poses a risk for herniation is crucial before allowing neuraxial procedures. Modified rapid sequence induction with advanced airway approaches (videolaryngoscopic or fiberoptic) allows improved airway manipulation with reduced risks associated with endotracheal intubation of the obstetric airway. Currently, very few anesthetic drugs are avoided in the neurosurgical pregnant patient; however, ensuring access to critical care units for prolonged monitoring and assistance of the respiratory-compromised patient is necessary to ensure safe outcomes.

Anesthesia for Nonobstetric Surgery in Pregnancy

Nonobstetric surgery during pregnancy occurs in 1% to 2% of pregnant women. Physiologic changes during pregnancy may have an impact when anesthesia is needed. Anesthetic agents commonly used during pregnancy are not associated with teratogenic effects in clinical doses. Surgery-related risks of miscarriage and prematurity need to be elucidated with well-designed studies. Recommended practices include individualized use of intraoperative fetal monitoring and multidisciplinary planning to address the timing and type of surgery, anesthetic technique, pain management, and thromboprophylaxis. Emergency procedures should be performed immediately and elective surgery should be deferred during pregnancy.

Extradural Anesthesia in a Case of Mild Head Injury

We experienced a case posted for bilateral lower limb surgery in a patient having mild traumatic brain injury (TBI), where administration of graded epidural anesthesia led to agitation, probably resulting from the transient elevation of intracranial pressure (ICP). Due to the wide range of benefits provided by regional anesthesia, an anesthetist should be aware of the possible options for perioperative management to best handle such polytrauma cases. In this case, agitation was managed with a bolus of benzodiazepine and maintenance infusion of dexmedetomidine while the six-hour-long surgery continued with epidural anesthesia. This patient was a smoker who had bronchospasm and underlying pneumonia precluding a high risk for postoperative ventilatory support if only general anesthesia was administered. Post-surgery the patient was conscious, oriented, and pain-free leading to early mobilization and discharge from the hospital. The patient did not report any neurological deterioration in a follow-up period of one month.

Algorithm of Traumatic Brain Injury in Pregnancy (Perspective on Neurosurgery)

BACKGROUND

The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources.

CASE SERIES

A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E1V1M4, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E1V1M3, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition.

DISCUSSION

We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment.

CONCLUSION

The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.

Management of brain tumors presenting in pregnancy: a case series and systematic review

Patients who present with brain tumors during pregnancy require unique imaging and neurosurgical, obstetrical, and anesthetic considerations. Here, we review the literature and discuss the management of patients who present with brain tumors during pregnancy. Between 2009 and 2019, 9 patients were diagnosed at our institution with brain tumors during pregnancy. Clinical information was extracted from the electronic medical records. The median age at presentation was 29 years (range, 25-38 years). The most common symptoms at presentation included headache (n=5), visual changes (n=4), hemiparesis (n=3), and seizures (n=3). The median gestational age at presentation was 20.5 weeks (range, 11-37 weeks). Of note, 8 patients (89%) delivered healthy newborns, and 1 patient terminated her pregnancy. In addition, 5 patients (56%) required neurosurgical procedures during pregnancy (gestational ages, 14-37 weeks) because of disease progression (n=2) or neurologic instability (n=3). There was 1 episode of postneurosurgery morbidity (pulmonary embolism [PE]) and no surgical maternal mortality. The median length of follow-up was 15 months (range, 6-45 months). In cases demonstrating unstable or progressive neurosurgical status past the point of fetal viability, neurosurgical intervention should be considered. The physiological and pharmacodynamic changes of pregnancy substantially affect anesthetic management. Pregnancy termination should be discussed and offered to the patient when aggressive disease necessitates immediate treatment and the fetal gestational age remains previable, although neurologically stable patients may be able to continue the pregnancy to term. Ultimately, pregnant patients with brain tumors require an individualized approach to their care under the guidance of a multidisciplinary team.

[Pregnant patients wirsth major trauma in the resuscitation room : Special (patho)physiological and therapeutic aspects]

BACKGROUND

Severely injured pregnant women are rarely encountered even in major trauma centers; at the same time high expectations are set for the best possible outcome of mother and child.

OBJECTIVE

Summary of the main pathophysiological aspects of pregnancy and essential therapeutic implications for emergency room treatment from the perspective of anesthetists.

METHODOLOGY

Selective literature analysis with a focus on primary physiological literature and the synthesis of pregnancy-adapted recommendations of related guidelines.

RESULTS

The essential physiological adaptations to pregnancy and their implications for acute care are presented.

CONCLUSION

Teamwork, structured decision making as well as airway management and goal-oriented hemodynamic treatment are the foundations for a good outcome of mother and child.

Tuberculum Sellae Meningiomas in Pregnancy: 3 Cases Treated in the Second Trimester and Literature Review

BACKGROUND

Tuberculum sella meningiomas typically present with progressive visual loss. It is also known that meningiomas can become symptomatic during pregnancy. Herein we report on 3 patients who presented with progressive visual decline during pregnancy, prompting urgent surgical removal of their meningiomas.

CASE DESCRIPTIONS

From our prospectively collected brain tumor database, all women surgically treated for tuberculum sella meningioma since 2006 were retrospectively reviewed. Clinical presentation, surgical approach, perioperative management, and pathology of pregnant patients were reviewed and compared with those of the nonpregnant cohort. Of 43 women with newly diagnosed tuberculum sella meningioma, 3 (7%) presented in pregnancy with progressive visual loss, 1 in the late first trimester and 2 in the early second trimester. One woman pregnant with twins had a broad-based meningioma and underwent a supraorbital craniotomy and gross total tumor removal in her second trimester. Two women with singleton pregnancies both underwent endoscopic endonasal gross total tumor removal during their second trimesters. All 3 patients had visual recovery, 2 of which were complete, and all went on to have successful uncomplicated deliveries of their children and maintain normal pituitary gland function.

CONCLUSIONS

Presentation of tuberculum sella meningioma during pregnancy is uncommon but not rare, accounting for 7% of women in our series. Ideally, surgery is performed in the second trimester, ensuring fetal safety while restoring maternal vision and maintaining pituitary gland function are essential. Depending on tumor size and sellar anatomy, endoscopic endonasal or supraorbital keyhole craniotomy approaches are both viable options.

Traumatic brain injury in pregnancy

Trauma is the leading cause of nonobstetric maternal mortality and affects up to 8% of all pregnancies. Pregnant patients with traumatic brain injury (TBI) are an especially vulnerable population, and their management is complex, with multiple special considerations that must be taken into account. These include but are not limited to alterations in maternal physiology that occur with pregnancy, potential teratogenicity of pharmacologic therapies and diagnostic studies using ionizing radiation, need for fetal monitoring, Rh immunization status, placental abruption, and preterm labor. Despite these challenges, evidence regarding management of the pregnant patient with a TBI is lacking, limited to only case reports/series and retrospective analyses. Despite this uncertainty, expert opinion on management of these patients seems to be that, overall, the standard therapies for management of TBI are safe and effective in pregnancy, with a few notable exceptions described in this chapter. Significant work is needed to continue to develop best-practice and evidence-based guidelines for the management of TBI pregnancy.

Neurosurgical Interventions for Neurotrauma in the Obstetric Population: A Systematic Review

Trauma requiring neurosurgical intervention in the obstetric population is rare. Provision of care must include consideration for both maternal and fetal well-being, and conflicts may arise. Management strategies to reduce elevated maternal intracranial pressure (ICP) and provide adequate surgical exposure, for example, may compromise uteroplacental perfusion. There is scarce literature to guide anesthetic care and few resources summarizing management of these uncommon cases. We conducted a systematic literature search for English publications of neurosurgical interventions on obstetric patients following trauma. We searched MEDLINE, EMBASE, and Google Scholar from inception to May 1, 2019. We identified 18 cases from 13 publications including 9 case reports and 4 case series. Median Glasgow coma scale on presentation was 6, good maternal outcome occurred in 39% of cases, and good fetal outcome occurred in 67% of cases. Qualitative review of the articles suggests an initially low Glasgow coma scale on admission commonly resulted in worse maternal and fetal outcomes. Delivery occurred postneurosurgical intervention in the majority of viable fetuses. Few details were available regarding anesthetic management, and ICP management strategies varied widely. Our review identified only a small number of case reports and case series. Maternal outcomes were generally poor, although the majority of fetal outcomes were good. Although there seems to be a relationship between outcomes and severity of maternal injury on presentation, it is difficult to draw conclusions or make recommendations because of limited data on perioperative anesthetic and ICP management strategies. Regardless of gestational age, maternal supremacy must be upheld. Our results are limited by the quality of the available research and potential selection bias.

Nonobstetric Surgery During Pregnancy

One percent to 2% of pregnant women undergo nonobstetric surgery during pregnancy. Historically, there has been a reluctance to operate on pregnant women based on concerns for teratogenesis, pregnancy loss, or preterm birth. However, a careful review of published data suggests four major flaws affecting much of the available literature. Many studies contain outcomes data from past years in which diagnostic testing, surgical technique, and perioperative maternal-fetal care were so different from current experience as to make these data of limited utility today. This issue is further compounded by a tendency to combine experience from vastly disparate types of surgery into a single report. In addition, reports in nonobstetric journals often focus on maternal outcomes and contain insufficient detail regarding perinatal outcomes to allow distinction between complications associated with surgical disease and those attributable to surgery itself. Finally, most series are either uncontrolled or use the general population of pregnant women as controls rather than women with surgical disease who are managed nonsurgically. Consideration of these factors as well as our own extensive experience suggests that when the risks of maternal hypotension or hypoxia are minimal, or can be adequately mitigated, indicated surgery during any trimester does not appear to subject either the mother or fetus to risks significantly beyond those associated with the disease itself or the complications of surgery in nonpregnant individuals. In some cases, reluctance to operate during pregnancy becomes a self-fulfilling prophecy in which delay in surgery contributes to adverse perinatal outcomes traditionally attributed to surgery itself.

Newly Diagnosed Optic Pathway Glioma During Pregnancy

BACKGROUND

Optic pathway gliomas (OPGs) are relatively rare, and their presentation after the first decade of life is even less common. Although many treatment options exist, surgery is typically reserved for tumors significantly compressing surrounding structures. Pregnancy can complicate the management of these tumors, as fetal developmental considerations limit the ways in which they are imaged and treated.

CASE DESCRIPTION

In this report we detail the case of a 27-year-old pregnant woman who was found to have an OPG during her third trimester. After a decline in this patient's vision and clinical status, a decision was made to induce labor at 31 weeks so that her disease could be more thoroughly addressed.

CONCLUSIONS

While OPGs are typically benign tumors, pregnancy complicates their management significantly. Contrast media and anesthesia pose significant risks to the fetus, while pregnancy may contribute to increased rates of tumor growth and clinical deterioration. Managing OPGs in pregnant patients thus requires balancing the risks to the fetus and patient.

Postoperative management with dexmedetomidine in a pregnant patient who underwent AVM nidus removal: a case report

Background

Following cerebral arteriovenous malformation (AVM) surgery, severe brain edema and hemorrhage may be caused by postoperative normal perfusion pressure breakthrough (NPPB). Sedation is necessary for this population. It is a challenge for the anesthesiologist to maintain hemodynamic stability without interfering with the neurological assessment. In Japan, propofol is contraindicated for pregnant patients. Dexmedetomidine is a versatile drug in anesthesia practice and may be useful for this situation. There is no report using dexmedetomidine for the purpose of NPPB control in pregnant patients. We describe the postoperative management with dexmedetomidine for a pregnant patient who underwent cerebral AVM nidus removal.

Case presentation

A 32-year-old patient presented with headache at the 16th week of gestation. Neuroimaging revealed an intraventricular hemorrhage and an AVM at the right anterior horn of the lateral ventricle which caused bleeding. A multidisciplinary team discussion was done, and then a craniotomy for AVM nidus removal was performed under general anesthesia. Preanesthetic aspiration prophylaxis and rapid sequence induction were added to our conventional anesthetic management. Hypotension occurred after anesthetic induction but the patient recovered by volume resuscitation and vasopressors. Anesthesia was maintained with 50% O₂ in air and sevoflurane. The AVM was completely removed, and no perioperative complications occurred. Postoperative sedation with dexmedetomidine was used to prevent breakthrough hyperperfusion and cerebral edema.

Conclusions

Dexmedetomidine infusion was used for postoperative sedation without causing any side effects, and it can be an alternative for sedation, especially when propofol is contraindicated.

Anesthetic considerations for labor and delivery in women with cerebrospinal fluid shunts

BACKGROUND

The anesthetic management of labor and delivery in pregnant women with cerebrospinal fluid shunts can be challenging. We conducted a literature review to understand the anesthetic implications in pregnant women with cerebrospinal fluid shunts.

METHODS

We searched PubMed, EMBASE, and Medline databases to identify reports of pregnant women with cerebrospinal fluid shunts during the 30-year period from 1985 to 2015. Twenty-four studies reporting anesthetic techniques for labor and delivery were included in the analyses.

RESULTS

A total of 97 women with 130 pregnancies were included. Ventriculo-peritoneal shunts (77%) were the most common type of shunt. Twenty-eight (29%) women had shunt malfunction during pregnancy, with 20 (71%) requiring shunt revision. Overall, 73 women (56%) delivered vaginally and 23 (40%) received epidural analgesia. Fifty-seven women (44%) underwent cesarean delivery and general anesthesia was used in 45% of cases.

CONCLUSION

This review suggests that shunt malfunctions occurred commonly during pregnancy. The presence of neurological symptoms warrants careful evaluation of shunt function. Anesthetic management for labor and delivery varied and was dependent on shunt function. Epidural analgesia appears to be safe in women with functional shunts.

Aneurysmal hemorrhage in a pregnant patient with coarctation of aorta: An anesthetic challenge

A 25years old female patient with pregnancy of 16weeks (G₂ P₁), diagnosed to have distal anterior cerebral artery aneurysm (DACA) with Hunt & Hess grade I, subarachnoid hemorrhage (SAH) and coexisting atretic type of aortic coarctation posted for aneurysmal clipping under general anesthesia is a challenge to anesthesiologists in perioperative period. Hypertensive surges in a pregnant patient may result in rupture of aneurysms. Mortality in the mothers with CoA has been reported to be in the range of 0 to 9%. Anesthetic management of a pregnancy with CoA and SAH has never been reported.

Foramen Magnum Meningioma with Brainstem Compression During Pregnancy

BACKGROUND

Meningiomas can present during pregnancy as the result of hormonal as well as fluid changes. Foramen magnum meningiomas are particularly rare. We present the first reported case successfully treated during pregnancy.

CASE DESCRIPTION

A 34-year-old female patient in her second trimester of pregnancy presented with a several-week history of neck pain, clonus, and right-sided upper extremity weakness. Magnetic resonance imaging of the brain demonstrated a 3.5-cm foramen magnum meningioma causing severe compression of the cervicomedullary junction. The patient underwent a far lateral craniotomy with successful decompression of the brainstem, resection of the tumor, and no permanent postoperative neurologic deficits. She made an excellent recovery and delivered a normal baby at 38 weeks with no complications. A small residual tumor engulfing the vertebral artery was treated with stereotactic radiosurgery 3 months postpartum. Diagnostic and treatment challenges unique to this case are discussed.

CONCLUSIONS

Large skull base tumors symptomatic in pregnancy can be safely treated with careful planning and close monitoring.

Case Report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery

Trauma is estimated to complicate approximately one in twelve pregnancies, and is currently a leading non-obstetric cause of maternal death. Pregnant trauma patients requiring non-obstetric surgery pose a number of challenges for anesthesiologists. Here we present the successful perioperative management of a pregnant trauma patient with multiple injuries including occult pneumothorax who underwent T9 to L1 fusion in prone position, and address the pertinent perioperative anesthetic considerations and management.

[Anaesthetic management of excision of a cervical intraspinal tumor with intraoperative neurophysiologic monitoring in a pregnant woman at 29 weeks]

The intraoperative neurophysiological monitoring is a technique used to test and monitor nervous function. This technique has become essential in some neurosurgery interventions, since it avoids neurological injuries during surgery and reduces morbidity. The experience of intraoperative neurophysiological monitoring is limited in some clinical cases due to the low incidence of pregnant women undergoing a surgical procedure. A case is presented of a 29-weeks pregnant woman suffering from a cervical intraspinal tumour with intense pain, which required surgery. The collaboration of a multidisciplinary team composed of anaesthesiologists, neurosurgeons, neurophysiologists and obstetricians, the continuous monitoring of the foetus, the intraoperative neurophysiological monitoring, and maintaining the neurophysiological and utero-placental variables were crucial for the proper development of the surgery. According to our experience and the limited publications in the literature, no damaging effects of this technique were detected at maternal-foetal level. On the contrary, it brings important benefits during the surgery and for the final result.

Safety and efficacy of combined epidural/general anesthesia during major abdominal surgery in patients with increased intracranial pressure: a cohort study

Background

The increased intracranial pressure can significantly complicate the perioperative period in major abdominal surgery, increasing the risk of complications, the length of recovery from the surgery, worsening the outcome. Epidural anesthesia has become a routine component of abdominal surgery, but its use in patients with increased intracranial pressure remains controversial. The goal of the study was to evaluate the safety and efficacy of epidural anesthesia, according to monitoring of intracranial pressure in patients with increased intracranial pressure.

Methods

The study includes 65 surgical patients who were routinely undergone the major abdominal surgery under combined epidural/general anesthesia. Depending on the initial ICP all patients were divided into 2 groups: 1 (N group) - patients with the normal intracranial pressure (≤12 mm Hg, n = 35) and 2 (E group) – patients with the elevated intracranial pressure (ICP > 12 mm Hg, n = 30). During the surgery we evaluated ICP, blood pressure, cerebral perfusion pressure (CPP). The parameters of recovery from anesthesia and the effectiveness of postoperative analgesia were also assessed.

Results

In N group ICP remained stable. In E group ICP decreased during anesthesia, the overall decline was 40 % at the end of the operation (from 15 to 9 mm Hg (P <0.05)). The correction of MAP with vasopressors to maintain normal CPP was required mainly in patients with increased ICP (70 % vs. 45 %, p <0.05). CPP declined by 19 % in N group. In E group the CPP reduction was 23 %, and then it remained stable at 60 mm Hg. No significant differences in time of the recovery of consciousness, effectiveness of postoperative analgesia and complications between patients with initially normal levels of ICP and patients with ICH were noted.

Conclusions

The combination of general and epidural anesthesia is safe and effective in patients with increased intracranial pressure undergoing elective abdominal surgery under the condition of maintaining the arterial pressure. Its use is not associated with the increase in intracranial pressure during the anesthesia, but it needs an intraoperative monitoring of ICP in order to prevent CPP reduction.

Anesthetic management for parturients with neurological disorders

Anesthesia care for the pregnant and the parturient presenting with a neurological disease requires (1) expertise with neuroanesthesia and obstetric anesthesia care, (2) accurate physical examination of the neurological system preoperatively, (3) safe choice and conductance of the anesthesia technique (mostly regional anesthesia), (4) avoidance of unfavorable drug effects for the fetus and the nervous system of the mother, and (5) intraoperative neuromonitoring together with the control of the fetal heart rate. The most important message is that in the ideal case, any woman with a known, preexisting neurological disorder should discuss her plans to become pregnant with her physician before she becomes pregnant. Neurological diseases in pregnancy can be classified into three categories: (a) Pre-existent chronic neurological diseases such as epilepsy and multiple sclerosis (MS). (b) Diseases with onset predominantly in pregnancy such as some brain tumors or cerebrovascular events. (c) Pregnancy-induced conditions such as eclampsia and Hemolysis elevated liver enzymes and low platelets syndrome. This article addresses specific issues surrounding neurologic disease in pregnant women including MS parturient, spinal cord injury, parturient with increased intracranial pressure and shunts, parturient with brain tumors, Guillain-Barré syndrome and epilepsy.

Pregnancy with co-morbidities: Anesthetic aspects during operative intervention

The presence of co-morbidities during pregnancy can pose numerous challenges to the attending anesthesiologists during operative deliveries or during the provision of labor analgesia services. The presence of cardiac diseases, endocrinological disorders, respiratory diseases, renal pathologies, hepatic dysfunction, anemia, neurological and musculoskeletal disorders, connective tissue diseases and many others not only influence the obstetric outcome, but can significantly impact the anesthetic technique. The choice of anesthesia during the pregnancy depends upon the type of surgery, the period of gestation, the site of surgery, general condition of patient and so on. Whatever, the anesthetic technique is chosen the methodology should be based on evidentially supported literature and the clinical judgment of the attending anesthesiologist. The list of co-morbid diseases is unending. However, the present review describes the common co-morbidities encountered during pregnancy and their anesthetic management during operative deliveries.

Simultaneous cesarean delivery and craniotomy in a term pregnant patient with traumatic brain injury

The management of pregnant patients with traumatic brain injury is challenging. A multidisciplinary team approach is mandatory, and management should be individualized according to the type and extent of injury, maternal status, gestational age, and fetal status. We report a 27-year-old term primigravida presenting after head injury with Glasgow coma scale score 11 and anisocoria. Depressed temporal bone fracture and acute epidural hematoma were diagnosed, necessitating an urgent neurosurgery. Her fetus was viable with no signs of distress and no detected placental abnormalities. Cesarean delivery was performed followed by craniotomy in the same setting under general anesthesia with good outcome of the patient and her baby.

Anaesthetic management of a pregnant patient with intracranial space occupying lesion for craniotomy

Intracranial space occupying lesion [SOL] during pregnancy presents several challenges to the neurosurgeons, obstetricians and anaesthesiologists in not only establishing the diagnosis, but also in the perioperative management as it requires a careful plan to balance both maternal and foetal well-being. It requires modification of neuroanaesthetic and obstetric practices which often have competing clinical goals to achieve the optimal safety of both mother and foetus. Intracranial tuberculoma should be considered in the differential diagnosis of intracranial SOL in pregnant women with signs and symptoms of raised intracranial pressure with or without neurological deficits, especially when they are from high incidence areas. We report a 28-week pregnant patient with intracranial SOL who underwent craniotomy and excision of the lesion, subsequently diagnosed as cranial tuberculoma.

Anesthetic management of labor and delivery in patients with elevated intracranial pressure

The anesthetic management of labor and delivery in patients with elevated intracranial pressure is complex. This review discusses the etiologies of diffuse and focal pathologies which lead to elevated intracranial pressure in pregnancy. The role of neuraxial and general anesthesia in the management of labor and delivery is also examined. Finally, a comprehensive review of strategies to minimize increases in intracranial pressure during general anesthesia for cesarean delivery is presented.

Intracranial Meningioma Diagnosed during Pregnancy Caused Maternal Death

Brain tumors are rarely diagnosed during pregnancy. Accelerated growth of intracranial meningiomas during pregnancy sometimes requires urgent surgical intervention. We describe a 41-year-old pregnant woman with severe neurological decompensation requiring immediate neurosurgery. Cesarean section resulted in maternal death. Meningioma diagnosed during a viable pregnancy should be managed according to the severity of maternal neurological symptoms and gestational age of pregnancy. Early intervention for intracranial tumors during pregnancy may save maternal and fetal lives.

Anesthetic management of a parturient with glioma brain for cesarean section immediately followed by craniotomy

The anesthetic management of a parturient with an intracranial tumor can be quite challenging for the anesthetist as it requires a fine balance of both maternal and fetal safety. The literature pertaining to anesthetic management of such cases is limited. We describe the anesthetic management and peri-operative concerns of this unusual case of a parturient aged 25 years with 8 months amenorrhea and a high grade glioma in the left temporo-parietal region who underwent cesarean section under general anesthesia immediately followed by craniotomy. Anesthetic management was tailored keeping in mind maternal safety and fetal considerations.

Anesthetic management of pregnant women with stroke

Stroke during pregnancy is rare, but after occurring, most patients develop serious neurological conditions. Hemorrhagic stroke, including intracerebral hemorrhage and subarachnoid hemorrhage, often requires emergency surgical intervention. In addition to significant maternal physiological changes, the potential for fetal harm should be considered during anesthetic management of these patients. Whether cesarean section or neurosurgical intervention should be prioritized or performed simultaneously in pregnant women with stroke is an important issue. Whether the patients receive general or spinal and epidural anesthesia is another clinically significant issue. Finally neurosurgeons, anesthesiologists, and obstetricians should cooperate to manage pregnant women with stroke.

[Emergency cesarean section and craniectomy in a patient with rupture of a cerebral arteriovenous malformation]

The intracerebral hemorrhage in pregnancy is a rare event, but can have catastrophic consequences for both mother and fetus. The management of non-ruptured arteriovenous malformations in pregnancy is not free of controversy in the current literature, as there is the possibility of spontaneous bleeding and becoming a true emergency. We report the case of a pregnant patient of 35 weeks with a diagnosis of a cerebral arteriovenous malformation, who developed a sudden onset of headache, generalized tonic-clonic seizures, loss of consciousness, and hemiparesis with radiological images of an intracranial hematoma with a mass effect, and signs of herniation. The multidisciplinary management is discussed, emphasizing perioperative cesarean approach plus craniotomy and drainage of the hematoma, and subsequent management in intensive care, and definitive management by neuroradiology, with a successful outcome.