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DELIVERY IN A PARTURIENT WITH COEXISTING IDIOPATHIC INTRACRANIAL HYPERTENSION AND CHIARI MALFORMATION TYPE 1- A CASE REPORT AND REVIEW OF LITERATURE
Abstract Number: F-85
Abstract Type: Case Report/Case Series
INTRODUCTION Idiopathic Intracranial hypertension (IIH)is a syndrome of elevated ICP without ventricular enlargement or mass lesions. Chiari malformation type 1 (CM)is a congenital or acquired condition characterized by herniation of cerebellar tonsils > 5 mm below the foramen magnum. We describe a case where these two conditions coexisted and review relevant literature regarding mode of delivery and anesthesia.
CASE A 20 year old parturient G1P0 presented to our preanesthetic clinic at 32 weeks gestation. She gave history of IIH diagnosed 4 years ago. The condition had been refractory to medical therapy, with improvement in her headaches after receiving serial lumbar punctures. She had also been diagnosed with CM based on MRI. Currently she reported no other symptoms. MRI brain now done showed the extent of herniation to be about 10mm with no hydrocephalus. An ophthalmology consult done ruled out papilledema. She subsequently had an uneventful vaginal delivery with epidural analgesia.
DISCUSSION Both IIH and CM have similar symptomatology. Both have been found to coexist, though a cause- and- effect has yet to be proven. IIH occurs more in obese females and symptoms such as headache and blurring of vision are said to worsen during pregnancy. The aim of therapy is to preserve vision and improve symptoms. Labor may be allowed, however the uterine contractions and bearing down efforts can increase CSF pressure worsening any papilledema, c section has been preferred in such cases.(1) Neuraxial anesthesia has been used effectively and elevated ICP does not imply herniation risk after dural puncture.(2) Lumbar puncture in these patients is beneficial and safe as it allows CSF drainage reducing CSF pressure. The presence of a lumbo-peritoneal shunt placed for treatment of IIH may be an exception.
Patients with congenital CM can be asymptomatic as our patient, or have symptoms and signs due to increased ICP. The uterine contractions and bearing down efforts of labor can worsen herniation, optimal pain relief (small, slow, epidural boluses preferred) and a short 2nd stage of labor can prevent worsening of symptoms.(3) C-section is often done if high ICP exists. In this scenario, the reduction in lumbar CSF volume that occurs with an intentional spinal anesthetic, inadvertent dural puncture during epidural placement or epidural catheter dosing, can cause brain shifts, placing parturients at risk for neurological deterioration.
To safely perform dural puncture, there should be preserved continuous CSF flow and absence of a large pressure differential between intracranial and intraspinal compartments. Both factors are preserved in IIH, but may be compromised in CM contraindicating neuraxial anesthesia. Our patient had IIH, and significant CM with both factors preserved, allowing for safe neuraxial anesthesia.(2)
1.Bagga R et al Med Gen Med 2005.
2.Leffert L et al Anesthesiology 2013
3.Choi CK et al Case reports in Anesthesiology 2013