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Anesthetic Management for a Cesarean Delivery in Patients with Cavernous Malformations
Abstract Number: F-46
Abstract Type: Case Report/Case Series
A 32 year old female G3P2 noticed progressive left sided weakness over a four week course at 20 weeks gestation. Her cardiac work-up was negative. The MRI demonstrated a 3cm left thalamic hemorrhage [Fig 1], most likely a cavernous malformation (CVM). Neurosurgery was consulted; an angiogram was negative for associated bleeds. Repeat MRI [Figure 2] at 26 weeks gestation exhibited no change in size, with decreased edema and mass effect. After discussion with her obstetrician, anesthesiologist and neurosurgeon, an elective cesarean delivery was planned with a spinal anesthetic. She remained hemodynamically stable during the Cesarean delivery; there were no reported incidents of postdural puncture headache postoperatively. She was discharged on the third post-operative day with no neurological sequelae on follow-up post-partum visits.
Because the majority of CVM are asymptomatic in nature, their true prevalence is unknown. These malformations have been found in 0.5% of the population, on autopsy and MRI imaging series . Cerebral cavernous malformations account for 5%-15% of vascular malformations in the CNS .
The clinical presentation of these lesions is variable, ranging from incidental findings on neuroimaging to intracerebral bleeds with subsequent neurological deficits. Acute or progressive in nature, neurological sequelae are the third most common clinical manifestation of cavernous malformation; their frequency in clinical series ranges from 15.4% to 46.6%[1,2].
The overall risk of CVM hemorrhage during pregnancy is controversial. Overall, the frequency of hemorrhage among those who present either with incidental diagnosis or seizures is 0.4% to 2% per year . The peak danger periods of hemorrhage from CVM in pregnancy occur at the times of greatest rate of change of cardiac output, typically, between the 30th and 40th weeks of gestation, or between the second day of the sixth postpartum week . Patients with known arteriovenous malformations who have had an earlier bleed during their pregnancy, have a reported 25% chance of a recurrent bleed during the same pregnancy .
Data regarding obstetrical management of patients with untreated cavernous angiomas is limited. A definite advantage of a cesarean delivery over vaginal delivery has not been demonstrated .In either scenario, hemodynamic stability must be maintained in the parturient.While neuraxial techniques are preferred, neither analgesic has been shown to be superior to the other .
In summary, a decision regarding the anesthetic technique in the parturient with an unresected CVM should be individualized using a multidisciplinary approach to optimize fetal and maternal outcomes.
1.) J Neurosurg 75:702-708, 1991.
2.) Acta Neurochir (Wein) 40:61-82, 1978
3.) J Neurosurg. 1991; 75:709-714.
4.) Brit Med J 24: 19–24, 1968
5.) Surg Neurol 1990; 33:305-13.
6.) Clin Obstet Gynecol 1990; 33467
7.) Int J Obstet Anesth 1996