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Anesthesia For Cesarean Section in a Patient with a Hemorrhagic Cerebral Cavernous Malformation
Abstract Number: S-73
Abstract Type: Case Report/Case Series
Case Report: A 14 y.o. P1G0 presented at 30 wks. gestation with generalized weakness. MRI revealed a right pontine hemorrhage from a cerebral cavernous malformation(CCM). She was discharged after serial MRI's showed no worsening of the bleed but was re-admitted at 32 wks. with left-sided weakness, inability to walk and left facial droop. MRI showed increased hemorrhage with mass effect on the fourth ventricle. The decision was made to perform cesarean delivery due to worsening neurologic status. Epidural anesthesia was conducted with slow incremental titration of lidocaine 2% with epinephrine to achieve a T4 level. Cesarean delivery of a healthy infant was uneventful. Neurologic symptoms worsened on POD1 with MRI evidence of extension of the bleed and hydrocephalus. A ventriculostomy was done to relieve the pressure, but after further expansion of the hemorrhage,a craniotomy for resection of the CCM was required.
Discussion: CCM's are berry-like,tiny clusters of abnormal,sinusoidal-type blood vessels found in the brain or spinal cord. The walls of the capillaries are thin, less elastic than normal, and prone to leaking. CCM is present in 0.1-0.5% of the population and account for 8-15% of all CNS vascular malformations. Most of these remain asymptomatic and are incidental radiologic findings.
Unlike AV malformations, CCM's have no large feeding arteries and are low-flow lesions. They can occur sporadically or have a familial component. Symptomatic CCM may manifest with seizures, neurologic impairment, hydrocephalus or raised ICP. Because they are low-flow, it is uncommon to have sudden catastrophic neurologic injury, but repeated bouts of hemorrhage can be severely disabling.
It is controversial whether the risk of hemorrhage increases during pregnancy. Some are of the opinion that the hemodynamic changes of pregnancy (increased blood volume, cardiac output) and hormonal changes(relaxin,progesterone) which affect connective tissue and the vasculature may predispose to hemorrhage. However, large case studies suggest the risk of CCM rupture(3%/pregnancy) is no greater in pregnant patients with CCM than non-pregnant. Furthermore vaginal delivery was not contraindicated in patients with CCM.
Our patient fell into the rare category of severe CCM hemorrhage in pregnancy. Early delivery was chosen to avoid additional risk to the fetus and mother should neurosurgical intervention be required. Our anesthetic goals were extrapolated from the management of ruptured AVM- avoidance of wide swings in hemodynamics and ICP. We chose to avoid GA and the stresses of laryngoscopy, intubation and extubation. Regional also allowed monitoring the neurologic status during the procedure. A slow, titrated epidural was preferred to avoid the sudden hypotension seen with spinal anesthesia. Re-bleeding is more common with ruptured AVM in pregnancy and our patient worsened post-op despite a stable intra-op course.
References: J Neurosurg 118:50-55,2013