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A Rare Neurological case in pregnancy
Abstract Number: S-47
Abstract Type: Case Report/Case Series
A 25 year-old primipara with a long-standing history of Migraine, headache, aphasia and numbness of the left arm two years ago with no history of trauma or infection. Initial CT Scan of the Brain had revealed cerebellar tonsillar herniation through foramen magnum. MRI Scan of the brain confirmed Arnold Chiari Type 1 malformation with tonsillar descent by 4 mm with no hydrocephalus and syringomyelia. Tertiary Hospital referral with Neurological review and repeat CT scan had been done. Final diagnosis was low-lying cerebellar Tonsils. She was discharged from Neurological follow up.
She was now admitted to labour ward with spontaneous rupture of membrane without prior anaesthetic review in pregnancy. Patient was asymptomatic during labour. Labour epidural was requested as patient was induced for prolong rupture of membrane. Epidural catheter had to be re-sited after the first placement, due to analgesic solution leaking from the site of insertion. Maternal and fetal hemodynamics was stable with effective analgesia. The patient had an uneventful normal vaginal delivery.
Low-lying cerebellar tonsils has some association with Arnold Chiari malformation. Arnold Chiari Type 0 malformation is characterized by an alteration in Cerebro Spinal Fluid (CSF) hydrodynamics at the level of the Foramen Magnum. Patients with this subtype have syringomyelia either without tonsil herniation or with only mild tonsil herniation-associated findings (1). Neuroaxial anaesthesia is contraindicated in presence of raised intracranial pressure in view of herniation of cerebellar tonsils compressing lower brainstem and upper spinal cord causing life-threatening consequences more so with inadvertent dural puncture. Risk of intracranial haemmorrhage is also high. Spinal anesthesia can present with similar manifestation but the magnitude of the effect and incidence is less compared to epidural induced dural puncture (2). Our decision to perform the epidural was based on the patient having no history or signs of new/severe onset of neurological symptoms in which case we can safely say that regional technique would be contra-indicated. There are no firm guidelines to suggest GA over regional technique as similar risks exist. There are 2 cases of cerebellar tonsils herniation in the UK registry of high-risk obstetric cases. Both cases had Elective LSCS under general anaesthesia (3). Neurological disease does not preclude regional anaesthesia, however multidisciplinary approach and individualized care plan must be made.
1. Alfredo Avellaneda Fernández et al. Chiari type I and syringomyelia: classification, diagnosis and treatment: BMC Musculoskelet Disord. 2009;0(Suppl 1): S1
2. Clark K et al. Combined spinal-epidural analgesia for laboring parturient with Arnold –Chiari Type1 Malformation: A Case Report in Anaesthesiology 2013
3. May A et al. UK registry of high risk obstetric anaesthesia: report on neurological disease. Int J Obstetric Anesthesia 2008;17:31-6