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Anesthetic Management of a Parturient with Reversible Cerebral Vasoconstriction Syndrome
Abstract Number: RF4AD-469
Abstract Type: Case Report Case Series
Introduction: Reversible cerebral vasoconstriction syndrome (RCVS) is a rare group of vascular disorders characterized by severe headache with or without other neurological symptoms.(1) Little is known about the clinical course or management of RCVS in the peripartum period. We describe the anesthetic management of a patient with RCVS admitted for induction of labor.
Case: A 29-year-old, G2P1 female with a past medical history notable for migraines and preeclampsia with her first pregnancy developed new onset headache, right sided vision loss, right hand numbness, and word finding difficulty at 26w gestation. MRA study demonstrated possible focal stenosis of the left posterior cerebral artery without evidence of ischemia. After spontaneous resolution of her symptoms, subsequent imaging demonstrated vascular recovery and prompted discharge with nimodipine maintenance therapy.
Patient was admitted at 37w3d for induction of labor for preeclampsia in the setting of recurrent neurological complaints. Magnesium sulfate therapy was initiated given concerns that nimodipine might mask the blood pressure manifestations of preeclampsia. In line with neurology consult recommendations for close hemodynamic control and maintenance of systolic blood pressure between 100-140mmHg, a radial arterial line was placed under ultrasound guidance. An early combined spinal-epidural procedure was performed with intrathecal dosing of bupivacaine 2.5mg and fentanyl 15mcg. Nicardipine infusion was started during the late first stage of labor in response to worsening hypertension with headache, and additional 200-400mcg nicardipine boluses were administered prior to each valsalva during the second stage of labor. A healthy 3150g fetus was delivered vaginally. The patient’s post-partum course was notable for a 10-minute episode of monocular visual changes on PPD#1 that resolved spontaneously. Follow-up MRA was stable and transcranial dopplers demonstrated improvement in cerebral blood flow. The patient was discharged on PPD#2 with close follow up.
Discussion: While the pathophysiology of RCVS remains unclear, the relationship between intermittent dysregulated vasoconstriction on symptomatology mirrors that seen with vasospasm after subarachnoid hemorrhage and guided our strategy for intrapartum management. Patients with RCVS are at risk for sudden deterioration, especially in response to hemodynamic swings. In addition to pharmacologic vasodilation and early neuraxial analgesia, our strategy for preventing worsening symptoms included strict hemodynamic stability and euvolemia. Anesthesia presence at bedside throughout the second stage of labor facilitated timely administration of nicardipine boluses and quick response to changing symptomatology. A multidisciplinary approach to patients with RCVS is recommended to characterize the severity of neurological involvement and implications on both mode of delivery and intrapartum care.
1. Miller. 2015 Am Jour Neurorad 36(8):1392