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Multidisciplinary Approach: NEURAXIAL ANESTHESIA IN THE SETTING OF CVST
Abstract Number: RF7A10-437
Abstract Type: Case Report Case Series
Introduction: Cerebral venous sinus thrombosis is a rare, but serious condition occurring more commonly in females, with increased incidence during the peripartum period owing to inherent physiologic changes during pregnancy. Patients are managed with anticoagulation and may require other symptomatic treatments for complications such as seizure and headache. Peripartum anesthetic options often raise concern with regards to safety, given potential complications caused by intracranial pressure gradients resulting in potentially life-threatening complications .
Case: 25 year old female with no significant past medical history, G6P2214 @ 8 weeks by LMP presented with a 5-day history of right-sided headache, nausea/vomiting, and new-onset tonic-clonic seizure. MRI/MRV of the brain revealed revealed superior sinus venous thrombosis extending distal to the coronal suture into the proximal transverse sinuses bilaterally, with small right parietal hemorrhage. She was treated with a unfractionated heparin drip, loaded with levetiracetam 2g, and discharged on enoxaparin 1 mg/kg BID and levetiracetam 500 mg BID. Hypercoagulability/autoimmune workup notable for decreased protein S (24, range 50-144), normal protein C, positive ANA (1:320, homogenous pattern), negative antiphospholipid antibodies, and normal antithrombin III activity. MRV brain performed three months after initial diagnosis revealed partial resolution of superior sagittal sinus thrombus, retained thrombus in portion of right transverse sinus, and dominant/patent left transverse sinus. Our patient was offered labor epidural, but ultimately delivered successfully without anesthesia.
Discussion: Perioperative management for patients with recent CVST often revolves around mitigating potential complications related to elevated intracranial pressure. This is a topic of discussion in similar situations where there is elevated ICP, such as IIH, neoplasm, or other space-occupying lesion, as well as in situations where subtle shifts in intracranial structures risks harm, such as with an AVM. Data are limited in these cases, complicating the decision-making process. Future studies may investigate risks of similar patients who have incomplete resolution of CVST or other factors influencing ICP at the time of delivery to determine the safest means of peripartum anesthetic management . In these cases, the choice of using epidural/spinal or general anesthesia would each infer a unique risks and benefits, understanding of which would undoubtedly influence decision making.
1. Month, RC and Vaida, SJ. Spinal anesthesia for cesarean delivery in a patient with cerebral venous sinus thrombosis. Can J Anaesth. 2008; 55(9): 658-659.
2. El-Refai, NE. Anesthetic management for parturients with neurological disorders. Anest Essay Res. 2013; 7(2): 147-154.