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A primigravid parturient with an expanding internal carotid artery (ICA) aneurysm and neurologic symptoms
Abstract Number: T 52
Abstract Type: Case Report/Case Series
Introduction: The incidence of intracranial aneurysms in pregnancy is similar to that in the general population, however, the risk of rupture is much higher due to physiologic changes associated with pregnancy. Intracranial aneurysm rupture during pregnancy carries a poor prognosis, with maternal and fetal mortality approaching 35% and 25%, respectively (1).
Case Report: A 33 yo G1PO with an expanding ICA aneurysm was sent for obstetric anesthesia evaluation. The patient had a spontaneous SAH from a ruptured ICA aneurysm 18 months prior, with three coilings before becoming pregnant. At 26 weeks gestational age (wga) the patient developed transient left sided headaches, visual scintillations, and numbness on the right side of her body. A MRI/MRA of the head and neck at 30 wga showed a 7 mm flow-enhancing area at the base of the left ICA, consistent with aneurysm regrowth. After collaboration with the maternal fetal medicine and neurosurgical team, the decision was made to schedule a primary cesarean section at 38 wga. Preoperatively, an arterial line was placed; phenylephrine and nicardipine drips were available and the patient was bolused with 1500 mL of lactated ringers. A spinal anesthetic with 2 mL of 0.75% hyperbaric bupivacaine, 15 mcg of fentanyl, and 150 mcg of morphine was administered. The systolic blood pressure was maintained between 100- 130 mm Hg, a level deemed safe by the neurosurgical team. A baby boy was delivered with vacuum assistance. The neurosurgical attending was present from uterine incision to placental delivery to perform an abbreviated neurologic exam. Hemodynamic and neurologic status remained stable. The patient was transported to the post anesthesia care unit and had an uneventful post-operative course.
Discussion: Although the patient had previous coiling, the aneurysm was not definitively treated. With new neurologic symptoms and imaging that demonstrated aneurysm regrowth, the neurosurgical team was concerned that the stress of labor and vaginal delivery could potentially cause the aneurysm to rupture. A cesarean section with vacuum assistance was chosen to minimize pushing on the uterine fundus, which could increase intracranial vasculature pressure. To monitor hemodynamic status continually and maintain tight blood pressure parameters, a pre-spinal arterial line was used. A neuraxial technique was preferred for the ability to check neurologic status throughout the case. Epidural anesthesia was avoided due to body habitus and likely difficult placement. Accidental dural puncture with an 18 gauge Tuohy needle could have been catastrophic, causing a sudden drop in ICP and risk of aneurysm rupture. With the risk of rupture higher in pregnancy, every precaution in management must be taken. This case illustrates the importance of interdepartmental collaboration and preparation for high-risk obstetric patients.
1. Wang L, Paech MJ- Neuroanesthesia for the pregnant woman. Anesth Analg; 2008; 107: 193-200