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Management of a Parturient with Arnold-Chiari Malformation during Cesarean Section
Abstract Number: SA-70
Abstract Type: Case Report/Case Series
Arnold Chiari malformations are caused by structural defects in the cerebellum and may present with a vast array of neurological sequelae. The classification system used to diagnose Arnold Chiari malformation (types I-IV) is based on the parts of the cerebellum that herniate through the spinal cord and the severity of the symptoms. Arnold-Chiari type I is due to the downward displacement of the cerebellar tonsils and vermis through the foramen magnum, which compresses local nerve fibers, and can cause neck pain, cervical kyphosis, headache, ataxia, and sensory or motor deficits. Although surgical treatment can relieve these symptoms, symptomatic improvement ranges from only 60-90%. Parturients are under a considerable amount of physiological stress that may contribute to increased ICP, and anesthetic management of these patients is controversial.
We present a 32 year-old female who presented with Arnold-Chiari malformation type I with C1-2 laminectomy and surgical decompression, now with occipital headaches, who presented to UHB in active labor. She had a past medical history of asthma, anxiety, type II diabetes, and obesity. After multi-disciplinary discussion, we decided to electively c-section the patient for concern for ICP changes during active labor. Her airway exam was likewise concerning: Mallampati class III, obese, limited neck extension. We therefore elected to perform an awake fiberoptic intubation followed by general anesthesia. Her supraglottic airwaywas topicalized with 4% lidocaine with suppression of the gag reflex. After visualization of her glottis, an epidural catheter was placed via the fiberoptic side port between the vocal cords, and the trachea was topicalized with 4% lidocaine. The endotracheal tube was passed on the second attempt. General anesthesia was subsequently administered with propofol and sevoflurane.
Due to its rarity, anesthetic management for parturients with symptomatic Arnold-Chiari malformations must be carefully considered, as there is an increased risk for both labor analgesia and anesthesia for c-sections. Combined spinal-epidurals have been given successfully to a patients with this condition, and while a spinal can theoretically decrease ICP through dural puncture, the increased extradural pressure from the epidural aspect can lead to increased ICP and progression of symptoms, and the risks and benefits of this technique must be considered and discussed with the patient. We present a method of anesthesia that sidesteps both the ICP concerns of the neuraxial technique, and also the concern of a difficult airway present in pregnant patients.