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Regional Anesthesia for Cesarean Delivery in a Parturient with an Intracranial Aneurysm
Abstract Number: T 48
Abstract Type: Case Report/Case Series
Cerebral aneurysms are thought to be at increased risk of rupture during pregnancy and delivery. Data to support or refute the use of regional anesthesia in these patients is lacking (1). We describe the anesthetic management of a parturient with an intracranial aneurysm.
A 34-year-old (P 2-1-5-3) parturient with asthma, obesity, chronic hypertension, hepatitis C, multiple previous abdominal surgeries and a 36-week breech pregnancy presented for elective repeat cesarean delivery. The patient had right-sided blindness and left-sided weakness due to a previously ruptured right para-ophthalmic artery aneurysm. She was treated with endovascular coil embolization, but had aneurysm recurrence with multiple subsequent failed endovascular interventions. A tentative plan was made for off-label pipeline embolization of her aneurysm after delivery.
An epidural was placed in the sitting position (resident preference) despite a theorized potentially greater drop in intracranial pressure should a wet tap occur. Cesarean delivery of a healthy infant followed with arterial line blood pressure readings in the 120-160/60-80 range. Postoperatively, pain was controlled with epidural analgesia and the patient exhibited no new deficits. Two months later a cerebral angiogram showed interval occlusion of her right ophthalmic artery aneurysm (likely due to the hypercoagulable state of pregnancy) and a new left cavernous carotid artery aneurysm. Endovascular embolization of this new aneurysm is planned.
The management of a parturient with an unruptured intracranial aneurysm balances the risks of pulmonary aspiration, difficult intubation, and fetal exposure to systemic drugs against the risk of aneurysmal rupture. General anesthesia allows for greater control over transmural pressure (avoiding systemic hypertension and intracranial hypotension—which can occur after a wet tap) while avoiding the compensatory cerebral vasodilation that occurs after a wet tap (which can theoretically increase risk of rupture). Regional anesthesia allows for excellent neurologic monitoring while avoiding airway manipulation and side effects from systemic medications such as opioids (vomiting and associated hypertension, fetal depression, and sedation) (2). While historically these patients were treated with general anesthesia this case shows that regional anesthesia can be performed safely (2).
1. Carvalho LS, Vilas Boas WW. Anesthetic conduct in cesarean section in a parturient with unruptured intracranial aneurysm. Rev Bras Anestesiol. 2009; 59(6): 746-50.
2. Gupta A, Hesselvik F, Eriksson L, Wyon N. Epidural anaesthesia for caesarean section in a patient with a cerebral artery aneurysm. Int J Obstet Anesth. 1993; 2(1): 49-52.