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HELLP! Delivery Complicated by Chiari Malformation and Stroke
Abstract Number: T3D-5
Abstract Type: Case Report/Case Series
Introduction: Chiari Malformation Type I (CM-1) is described as abnormal shaped cerebellar tonsils that have been displaced below the level of the foramen magnum. Though the true cause has yet to be described, the symptom does not generally occur until adolescence or adulthood. CM-1 can manifest either symptomatically or can be asymptomatic with patients being diagnosed incidentally. 
HPI: A 37 year-old G2P0202 with a past medical history concerning for CM-1, HELLP and cesarean delivery with her previous pregnancy, asthma, anxiety and depression presented at 25.5 weeks gestation with concerns for evolving HELLP. The patient was found to have proteinuria, thrombocytopenia and slightly elevated aminotransferases; her vital signs remained stable. She received betamethasone and magnesium sulfate for seizure prophylaxis and neuroprotection before delivery. Prior to induction of labor, neurology was consulted for recommendations with regards to the patient’s ability to Valsalva during delivery as well as the possibility for neuraxial anesthesia. MRI of the brain without contrast incidentally showed restricted diffusion consistent with acute ischemia identified in the right superior cerebellar hemisphere as well as borderline CM-1 without syringomyelia. CT head without contrast was completed which showed subacute to chronic right cerebellar infarction without mass effect or hemorrhage. These findings were discussed with neurology and felt to be secondary to the patient’s preeclampsia. The decision was made to proceed with urgent Cesarean delivery under general anesthesia. The patient tolerated the procedure and had no complications with anesthesia. The patient was transferred to the intensive care unit for further management.
Discussion: It is known that patients found to have stroke due to preeclampsia should undergo emergent delivery, however whether to undergo general anesthesia or neuraxial is still up for debate and should be decided on a clinical basis. [2,3] Our case remains unique with the patient having CM-1 and inadvertently being diagnosed with an ischemic stroke. With this in mind, it was decided that general anesthesia was the best option. Whether neuraxial anesthesia would have worsened the risk of incurring a larger stroke is still up for debate. We can conclude that based on current evidence, the type of anesthesia required should be decided on a case-by-case basis and should be a multidisciplinary decision that looks out for the patient’s best interest.
1. Barton JJ, Sharpe JA. Oscillopsia and horizontal nystagmus with accelerating slow phases following lumbar puncture in the Arnold-Chiari malformation. Ann Neurol. 1993;33(4):418-21.
2. Ray A, Ray S. Epidural therapy for the treatment of severe pre-eclampsia in non labouring women. Cochrane Database Syst Rev. 2017;11:CD009540.
3. Yoshitani K, Inatomi Y, Kuwajima K, Ohnishi Y. Anesthetic management of pregnant women with stroke. Neurol Med Chir (Tokyo). 2013;53(8):537-4