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Anesthetic Management of Cesarean Delivery for a Parturient with Moyamoya Disease, Acute Exacerbation of Chronic Headaches, and Preeclampsia with Severe Features
Abstract Number: F-82
Abstract Type: Case Report/Case Series
A 37-year-old G4P2012 woman at 37 weeks gestation with a history of moyamoya disease (MMD) presented for repeat cesarean delivery due to preeclampsia with severe features. She was diagnosed with MMD after a stroke during her first pregnancy, which resulted in a residual left sided hemiparesis. She subsequently underwent bilateral superficial temporal artery-middle cerebral artery bypass, but continued to have chronic, intractable headaches that had worsened during pregnancy. Multidisciplinary planning was coordinated among obstetrics, neurology, and anesthesiology.
A neuraxial technique was preferred to general anesthesia in order to monitor her neurological status and to avoid hypertension associated with direct laryngoscopy and extubation in the setting of MMD and elevated blood pressures. Conventional epidural was chosen as opposed to a combined spinal epidural or spinal neuraxial technique so as to minimize any dural puncture that may lead to post dural puncture headache (PDPH) in this patient with intractable headache. It also allowed for incremental anesthetic dosing to maintain hemodynamic stability. She remained stable during epidural dosing and surgery; the peripartum course was uneventful. Her headaches returned to baseline shortly after delivery and she was discharged home on postoperative day 3.
MMD is a rare, chronic progressive cerebrovascular disease distinguished by stenosis or occlusion of the distal internal carotid arteries and proximal Circle of Willis vessels, resulting in the development of fragile collateral blood vessels and often microaneurysms (1). Headache and neurological deficits due to cerebral hemorrhage or ischemia are the most common presenting symptoms. There is no evidence for an increased risk of cerebral hemorrhage or ischemia during pregnancy or delivery, however physiologic changes (increased circulating volume, hypercoagulability) and stressors during labor (sympathetic response to pain, hyperventilation, valsalva) can exacerbate clinical symptoms (3).
Optimal peripartum management begins with multidisciplinary planning. Recommendations for anesthetic management during cesarean delivery are based on case reports and small reviews. Goals include avoiding hypotension (decreased cerebral blood flow) and hypertension (increased stroke risk), as well as maintaining normocapnia (2). Pain and anxiety leading to hyperventilation causes hypocapnia and decreased cerebral blood flow. Excessive sedation leading to hypercapnia causes decreased perfusion to affected areas of brain via cerebrovascular steal phenomenon. For our patient with intractable headaches as a persistent symptom, we also forewent dural puncture to avoid PDPH.
1. Scott RM, et al. N Engl J Med. 2009;360:1226-37
2. Kato R, et al. Int J Obstet Anesth. 2006;15:152–8
3. Yun J Yung, et al. Yonsei Med J 2015;56(3):793–797