///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Neuraxial Anesthesia for Cesarean Delivery in a Parturient With a Cerebral Cavernous Malformation

Abstract Number: FCD-183
Abstract Type: Case Report Case Series

Kelly L Au MD FRCPC1 ; Simon Massey MBBCh MRCP FRCA FRCPC2; Roanne Preston MD FRCPC3; Vit Gunka MD FRCPC4; Anthony Chau MD FRCPC MMSc5

Introduction: Cerebral cavernous malformations (CCMs) are slow-flow, low-pressure vascular lesions devoid of smooth muscle and elastin that rupture at a rate of 1%/lesion/yr.[1] The paucity of literature on the anesthetic management of CCMs in pregnancy presents a dilemma for neuraxial anesthesia (NA) due to concerns for potential for spinal CMs and the poorly understood mechanism for hemorrhage.[2] We report the management of a parturient with CCM who underwent successful cesarean delivery (CD) under NA.

Case: A 31 yo G1P0 presented at 5 weeks gestation with sudden onset L-sided photopsia and hemianopsia. Imaging showed a R-occipital lobe intracranial bleed from a large CCM with additional small (<1cm) CCMs.(Fig) She was managed conservatively and was left with small residual visual deficits.

Given the low-pressure nature of CCMs, Neurosurgery felt route of delivery was the patient’s choice; she opted for elective CD. We recommended a single-shot spinal (SSS) over general anesthesia (GA) in consultation with Neurosurgery given the benefits of NA and likely greater changes in ICP during laryngoscopy and extubation. Neuroradiology did not feel further neuraxial imaging would be useful as without contrast, small extramedullary CCMs would not be located, and the woman was clinically asymptomatic. Furthermore, Neurosurgery indicated that direct needle entry into an extradural CM would be expected to behave like an epidural venous bleed.

At 38 weeks gestation, ultrasound-guided SSS was performed with a 25G Whitacre needle at L3-4 level. Bilateral T5 block was achieved and BP was maintained with a phenylephrine infusion. She had an uneventful operation and healthy neonate. She had good post-operative analgesia with PO acetaminophen and hydromorphone. While not contraindicated, NSAIDs were avoided. Her thrombosis risk was low so prophylactic LMWH was not required.

Discussion: This case highlights the challenge in devising an anesthetic plan for a parturient with familial CCM. The risks of ICP changes and spinal involvement have led some reports to recommend neuraxial MRI and GA for patients with CCMs undergoing CD[2, 3]. We illustrate the importance to collaborate with Neurosurgery for risk stratification and that a small-gauge, SSS can be successfully performed and may better balance the risk-benefit profile over GA in a parturient with CCMs.

1. Gross BA et al. J Neurosurg 2017

2. Hayashi M et al. A A Case Rep 2017

3. De Jong A et al. Ann Fr Anesth Reanim 2012

SOAP 2019