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ANESTHETIC MANAGEMENT OF A PREGNANT PATIENT WITH ARNOLD CHIARI TYPE I MALFORMATION
Abstract Number: T 42
Abstract Type: Case Report/Case Series
Arnold-Chiari type I malformation (ACM-I) is a congenital neurological anomaly that involves the cerebellar tonsils prolapsing into the magnum foramen. Approximately 30-50% of ACM-I patients have syringomyelia. Incidence ranged between 0.56 and 0.77% on MRI studies, of which 15-30% are asymptomatic. Symptoms, including headaches, neck and shoulder pain, paresthesia and loss of pain and temperature sensation in upper limbs, and ataxia are the usual manifestations. It is mostly predisposed to women, in a F:M ratio of 3:1. Severity of symptoms is related to the degree of herniation as seen on the sagittal MRI view.
A 17 year-old female, G1P0, with history of hypothyroidism and ACM-I presented with symptoms of headache and neck pain. She denied of any other neurological manifestations. A multidisciplinary team consulted her for planned induction with instrument-assisted vaginal delivery. MRI of the brain showed a 7-mm cerebellar tonsil herniation into the foramen magnum without syringomyelia (Fig 1).
Vital signs were: BP=134/89, P=62, RR=12, and SpO2=99%. Labs were: Hg=11.9 and PLT=206. CSE analgesia was obtained with fentanyl 15 µg and and bupivacaine 1.5 mg intrathecally. A continuous epidural of bupivacaine 0.1% and fentanyl 0.0002% was infused at the rate of 10 mL/h. A 5-mL bolus of bupivacaine 0.25% was injected epidurally 90 min before the onset of fetal expulsion and subsequently augmented with another bolus to provide further analgesia and to minimize the urge of pushing. Labor lasted for 9 h. A healthy girl was born with Apgar scores of 9/9.
Attempt to demonstrate which neuraxial technique is safer (epidural vs spinal) in ACM-I parturients has been the subject of controversy. Accidental subarachnoid puncture with the epidural needle can lead to a greater risk of tentorial herniation, decreased CPP, and brain shifts than a spinal puncture. Risk vs benefit analysis and individualized care must be taken into consideration while planning the choice of anesthesia (neuraxial vs general) and the mode of delivery (vaginal vs Cesarean). Key points in the anesthetic management include: early CSE analgesia to decrease painful uterine contractions to dampen elevated CSF pressure, vacuum-assisted vaginal delivery to minimize increase in ICP during maternal valsalva maneuvers, slow titration of bolus through the epidural to prevent undue extradural pressure, and minimization of wide variations in maternal hemodynamics.