Successful use of epidural anesthesia for a parturient with an intracranial hemorrhage.
Abstract Number: 237
Abstract Type: Case Report/Case Series
The incidence of Intracranial Hemorrhage (ICH) is 10-50 in 100,000 deliveries. Anesthetic management of parturients with ICH is particularly challenging due to the paucity of published literature to guide the best management. Our case involves a 39 year old female at 38 weeks estimated gestational age transferred from a community hospital. The patient presented with a diagnosis of subarachnoid hemorrhage (SAH). Upon admission to our institution an MRI of the brain was performed which revealed two anterior communicating artery aneurysms with evidence of SAH, intraventricular hemorrhage and signs of central herniation. The patient was agitated and complained of a headache, but was alert and oriented. Following consultation with neurosurgery, we planned to proceed first with cesarean section under epidural anesthesia, to be followed the next day by repair of the aneurysm. The patient was delivered under epidural anesthesia without complication. The following day the patient was taken for endovascular coiling of the anterior communicating artery aneurysms; however, secondary to the anatomy of the aneurysms endovascular repair was not possible and the procedure was aborted. The patient was taken immediately to the operating room where she underwent craniotomy with clipping of the aneurysms. Surgical repair was successful and the initial post-op course was unremarkable. On post-bleed day 6, the patient suffered acute neurological deterioration requiring intubation. Cerebral angiogram demonstrated severe vasospasm of the entire cerebrovasculature. Emergent angioplasty and intra-arterial nicardipine were unsuccessful and the patient infarcted both cerebral hemispheres and subsequently expired. Interdisciplinary communication is essential for management of complicated parturients. We plan to discuss the interdisciplinary team based approach and rationale of our management.