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Neuraxial Anesthesia Use in Parturients with Intracranial Lesions
Abstract Number: 109
Abstract Type: Original Research
Introduction: While intracranial lesions complicating pregnancy are uncommon(1,2), they can have an enormous impact on anesthetic and obstetric management. Some women with intracranial lesions may not be candidates for neuraxial anesthesia, yet there appears to be a subset in whom neuraxial anesthesia is safe.
Methods: We performed an IRB-approved, retrospective search of the medical records of patients with coexisting pregnancy and intracranial lesions (1994-2009) to identify patients in whom neuraxial anesthesia was used at two major teaching institutions. Patient characteristics and clinical details were abstracted from the medical records.
Results: Out of a total of 25 patients, there were 20 deliveries in 15 parturients with intracranial lesions where neuraxial anesthesia was used (see Table); the remaining patients had general anesthesia. The most common documented reasons for choosing general anesthesia were due to signs of increased intracranial pressure (ICP), altered mental status, or emergent nature of the procedure. The majority of lesions were supratentorial (73%, or 11/15). 53% were vascular lesions, 27% were tumors, and 20% were cysts. None of the parturients had radiographic signs of increased ICP. There were no instances of neurologic or anesthetic complications. There were 3 neonatal ICU admissions for respiratory distress (patients 1 & 2) and for sepsis workup (patient 5), and one intrauterine fetal demise discovered prior to admission (patient 7). There were no cases of maternal or neonatal mortality.
Conclusions: Among parturients with intracranial lesions, neuraxial anesthesia appears to be safe in some patients. Rather than lesion tissue type, the potential to cause increased intracranial pressure due to mass effect or obstructive hydrocephalus seems to be a key determinant of safety. Selection of neuraxial anesthesia, either spinal or epidural, in these patients should focus on the potential consequences of dural puncture, both purposeful (as in a spinal) and inadvertent (as in an epidural). In addition, identifying patient features such as lack of altered mental status compromising airway protective reflexes and absence of increased intracranial pressure or obstructive hydrocephalus may allow neuraxial anesthesia to be used without an increased incidence of maternal or neonatal morbidity or mortality.
References: 1. Isla A, et al. Obstet Gynecol 1997;89:19-23. 2. Tewari KS, et al. Am J Obstet Gynecol 2000;182:1215-1221.