Anesthetic Considerations for Woman in a Barrel Syndrome
Abstract Number: S4C-9
Abstract Type: Case Report/Case Series
Introduction: Man-in-a-barrel syndrome is characterized by bilateral proximal brachial muscular weakness, most commonly caused by vascular disorders, arterial hypotension leading to watershed cerebral infarct, cerebral metastases, lesions in the pons, spinal cord involvement of the anterior horns, and demyelinating or infectious etiologies (Orsini et al. Rev Neurocienc. 2009;17(2):138-40). This is a case of a 27 year old pregnant woman who experienced acute onset “woman-in-a-barrel” syndrome during her pregnancy.
Case Report: A 27 year old previously healthy G2P0010 presented at 25 weeks gestation after preterm premature rupture of membranes with an antepartum history notable for sudden onset bilateral upper extremity weakness in the 5th week of pregnancy that occurred after waking up with sharp pain in her upper back. Subsequent inpatient workup, including MR brain, MR c-spine, and lumbar puncture, were all unrevealing.
Upon admission, the patient was found to have brachial diplegia with right flail arm, vibration and light touch sensory loss, and hyperreflexia in upper extremities. Mild lower extremity quadriparesis was also noted. Repeat MRI demonstrated a signal abnormality in the ventral cord from C3 to C7-T1. Neurology coined her “woman-in-a-barrel” and suspected a possible undetected dural arteriovenous fistula that would ultimately require an angiogram postpartum for diagnosis. They recommended against neuraxial procedures or a spontaneous vaginal delivery. She had a Mallampati I airway.
At 30 weeks she was emergently taken to the operating room for non-reassuring fetal heart tones for a cesarean delivery under general endotracheal anesthesia. A pre-induction arterial catheter was placed for strict blood pressure control. High-dose rocuronium was used in lieu of succinylcholine. Her blood pressure was kept within 20% of her baseline throughout the case. Her neurological exam remained stable during her postpartum inpatient stay as well as during her follow-up with neurology. She has subsequently declined further workup.
Discussion: The differential diagnosis for man-in-a-barrel syndrome is broad and has significant anesthetic implications. In our case, a vascular etiology was deemed to be the most likely cause given the sudden onset and lack of associated visual symptoms that would likely accompany a demyelinating disorder, as well as lack of evidence of infection on lumbar puncture. This precluded the patient from having a vaginal trial-of-labor due to concern regarding venous engorgement from increased intraabdominal pressure causing rupture. The safety of a neuraxial procedure was also up for debate given similar concerns about the risk of engorgement or rupture from pressure changes during volume loading of the epidural space or a dural puncture. In a patient at high risk for a devastating neurological complication, cesarean delivery under general anesthesia was determined to be the safest method of delivery.