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Intracranial Injury in a Woman Presenting for Cesarean Delivery
Abstract Number: F5C-2
Abstract Type: Case Report/Case Series
Intracranial pathology in the parturient poses a challenge when determining the most appropriate anesthetic technique for cesarean delivery. Increased intracranial pressure (ICP) is a concern due to the risk for herniation. General anesthesia poses a significant risk as well, with the potential to increase the intracranial pressure with laryngoscopy and a potentially difficult intubation. Neuraxial anesthesia increases the risk of herniation in this patient population if they have elevated ICP. There is little data about anesthetic management for cesarean delivery of parturients with intracranial trauma. We describe a case of cesarean delivery in a parturient following intracranial injury at the beginning of pregnancy with cerebral edema and neurologic deficits.
A 19-year-old, 52 kg G1P0 (BMI 20) woman underwent right sided hemicraniectomy after a gunshot to the head at 16 weeks gestation. Her postoperative course was complicated by a dural leak, left sided hemiparesis and she was wheelchair bound. She presented for scheduled cesarean delivery at 37 weeks due to cholestasis. Upon presentation, she had evidence of cerebral edema and her bone flap had not been replaced, with the plan being to wait until postpartum. The decision was made to perform a neuraxial anesthetic as opposed to a general anesthetic for a few reasons. Being pregnant, she was at increased risk for aspiration and difficult airway. She was also at increased risk for a significant rise in intracranial pressure with laryngoscopy. A single shot spinal was uneventfully performed with 12 mg of 0.75% hyperbaric Bupivacaine, 15 mcg of Fentanyl and 150 mcg of Morphine. As per standard practice, a phenylephrine infusion was started and titrated to maintain blood pressure within 20% of her baseline.
There are rare cases reported of obstetric patients undergoing cesarean delivery after intracranial injury with residual deficits and an open skull. Despite her continued cerebral edema, neuraxial anesthesia was chosen given that she was at decreased risk for herniation without the bone flap in place.
In summary, we present a patient with intracranial trauma during pregnancy and the successful management of cesarean delivery via spinal anesthesia. Close hemodynamic monitoring and titration of vasopressors is prudent in this particular situation to maintain perfusion while minimizing worsening cerebral edema and further neurologic injury.