Perioperative Management of a Parturient with Refractory Idiopathic Intracranial Hypertension requiring Optic Nerve Fenestration
Abstract Number: SA-62
Abstract Type: Case Report/Case Series
Idiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure in the absence of hydrocephalus or mass lesion with an increase in CSF pressure. This rare disorder is often seen in obese women of reproductive age and can present during pregnancy.
32 year old, G3P1A1, African American female presented at 38 weeks gestational age with a history of previous cesarean delivery. She was diagnosed with IIH 6 months prior with symptoms of nausea, vomiting, tinnitus, dizziness and acute vision loss in the right eye. Following diagnosis she underwent urgent right optic nerve fenestration that was complicated by central retinal artery occlusion resulting in complete and permanent vision loss in the right eye. The patient declined placement of a shunt and left optic nerve fenestration due to her previous intraoperative complication and was managed conservatively. She received serial lumbar punctures with opening pressures up to 40 cmH2O and at times had symptoms of post-dural puncture headaches that were resistant to conservative management. She was also managed with titrated doses of acetazolamide up to 1500mg BID. On presentation, she described a 1 month history of intermittent paresthesias of the fingers, ankles and toes, and worsening vision in her left eye. With her worsening neurological symptoms, the plan for an urgent cesarean delivery was deemed necessary to salvage the vision in her left eye. Her cesarean delivery was done under general anesthesia with controlled induction and she delivered a healthy male baby with apgars of 6,8. She did well postoperatively and was discharged on post operative day 4.
The optimal anesthetic management of IIH during cesarean delivery still remains controversial1; this case highlights the utility of general anesthesia in a parturient with IIH. Regional anesthesia has been performed safely in pregnant patients with IIH as they have no specific contraindications to neuraxial techniques2; however, in this parturient it was avoided due to her worsening neurologic symptoms.
1. Karmaniolou I, Petropoulos G, Theodoraki K. (2011) Can J Anaesth. Jul;58(7):650-7. doi: 10.1007/s12630-011-9508-4. Epub 2011 Apr 26. Review
2. Kim K, Orbegozo M (2000). J Clin Anesth. May;12(3):213-5.