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Cesarean Delivery in a Patient with Headache and Neurological Deficits with Cerebrospinal fluid Lymphocytosis (HaNDL)
Abstract Number: RF5BH-67
Abstract Type: Case Report Case Series
Obstetric anesthesia requires an understanding of neurologic diseases due to the potential impact on neuraxial anesthesia. One such condition is headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL). HaNDL presents with severe headaches and symptoms of aphasia, sensory loss, and/or motor weakness (1). Neurologic workup in these patient is unrevealing except for elevated white blood count on lumbar puncture (LP) (1). It is extremely rare with an incidence of 0.2 per 100,000 (1). There are a paucity of case reports describing HaNDL in the general or pregnant patient populations, with no reports on the use of neuraxial anesthesia for labor and delivery (2,3). The following case discusses the safe and effective use of epidural anesthesia for Cesarean delivery in a patient with HaNDL.
A 39 y.o. female with a history of prior Cesarean delivery, HaNDL, colitis, and anxiety presented for repeat Cesarean at 41 weeks gestation. The patient was diagnosed with HaNDL following her first pregnancy after experiencing severe headaches, left arm numbness, blurred vision, and slurred speech. Workup including MRI, CT, LP, and EEG showed no abnormalities except for an elevated WBC on LP. On presentation for delivery, the patient was asymptomatic. She underwent lumbar epidural placement without complication. A total of 15 mL of lidocaine 2% with 1:200,000 epinephrine was administered to achieve a T4 anesthetic level. Delivery was uncomplicated and the patient recovered well. She experienced no neurologic sequelae or relapse of her symptoms in the immediate post-partum period.
Our case provides an example of safe and effective use of epidural analgesia in the rare neurologic disorder of HaNDL. This report is of importance since there have been few cases in the literature of HaNDL in pregnancy, and none to our knowledge that describe the safety of neuraxial anesthesia in this patient population. Future questions of importance are the safety of spinal anesthesia, as well as the use of neuraxial anesthesia in a symptomatic patient. We decided to avoid spinal anesthesia due to the theoretical risk associated with intrathecal local anesthetic administration and potential for neurotoxicity or exacerbation of HaNDL symptoms. No literature exists, however, that contraindicates spinal anesthesia in patients with HaNDL.
1. Cifelli A, Vaitianathar L. Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL). BMJ Case Rep 2011;2011:pii: bcr0320102862. PMID 22700346
2. Dooling EC, Sweeney VP. Migrainous hemiplegia during breast-feeding. Am J Obstet Gynecol 1974;118:568-70. PMID 4812579
3. Kaplan, Y., et al. “HaNDL Syndrome Presenting during Pregnancy.” Journal of the Neurological Sciences, vol. 333, 2013, doi:10.1016/j.jns.2013.07.1827.