Primary Cesarean Delivery Complicated by the Incidental Finding of a Cerebral Aneurysm: Selecting a Safe Anesthesia Technique

The presence of a cerebral aneurysm in an obstetric patient raises a special anesthetic concern for cesarean delivery. General anesthesia poses the inherently increased risk of a difficult airway as well as an adverse impact of hypertension during induction and emergence. Epidural anesthesia may facilitate gradual hemodynamic changes and allows intraoperative neurologic monitoring. However, potential dural puncture headache may lender it difficult to recognize an intracranial hemorrhage. In the end, spinal anesthesia was chosen for the advantage of avoiding hypertensive responses from either airway stimulation or inadequate analgesia. *Corresponding author: Won Chee, M.D, Assistant Professor, Department of Anesthesiology, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, NY, 10467 USA; Tel: 718 920 4316; Fax: 718 881 2245; E-mail: wchee@montefiore.org Citation: Won Chee. Primary Cesarean Delivery Complicated by the Incidental Finding of a Cerebral Aneurysm: Selecting a Safe Anesthesia Technique (2015) J Anesth Surg 2(1) : 1-2. J Anesth Surg | volume 2: issue 1 www.ommegaonline. com Introduction Possible diagnoses for headache during pregnancy include subarachnoid hemorrhage (SAH) from cerebral aneurysm rupture. The incidence of SAH is 5-7 per 100,000 person-years for women between the ages of 15-44 years[1]. The incidental finding of a cerebral aneurysm in pregnancy raises a serious concern with possible rupture and an intracranial hemorrhage during vaginal or cesarean delivery. The case report considers the available anesthesia techniques in managing the patient safely. The written patient consent was obtained for publication. Case Presentation A 39 year-old obese female at 31 weeks gestation was scheduled for primary cesarean delivery. Her past medical history was significant for hypertension and chronic pain and weakness of her right arm and leg from a motor vehicle accident (MVA) 2 years ago. In addition, she developed wheezing at 24 weeks gestation and was newly diagnosed with asthma. Her past surgical history included appendectomy under general anesthesia. The patient was allergic to latex manifested by skin rash. Her current medications included acetaminophen, clindamycin, famotidine and subcutaneous heparin for DVT prophylaxis. Physical exam findings included: Height: 160cm, Weight: 94kg, BMI 36.7, BP 108/62, PR 103, RR 18, RA SpO2 100%. Her airway classification was Mallampati 3. The lungs were clear to auscultation but with decreased breath sounds at the base bilaterally. The heart rhythm was regular without murmur or gallop. Since the MVA the patient had required multiple radiologic studies for chronic pain in her head, abdomen, right arm and right knee. All studies had yielded negative findings. As the patient complained of headache during this admission, an MRI of head was performed which revealed a 4-mm cerebral aneurysm arising from the supraclinoid segment of the left internal carotid artery. Neurology consultation and the radiologic evaluation did not find any intracerebral hemorrhage or rupture. The obstetrician decided to proceed with cesarean delivery mainly to avoid hypertensive responses from prolonged labor and straining. The patient was brought to the operating room and placed in a sitting position. The ASA standard monitors were placed; no invasive arterial line monitor was placed as the patient’s blood pressure had been stable throughout the course of pregnancy. After prehydration (>2 liters of Ringer’s Lactate) spinal anesthesia was performed using a 25-gage Sprotte needle. T8 level block was achieved from the mixture of 1.5ml of 0.75% bupivacaine in 8.25% dextrose and 20mcg of fentanyl. The cesarean section proceeded uneventfully with the estimated blood loss of 800ml. The Apgar score was 9/9. In short, the patient did not experience any anesthetic sequelae including spinal headache or intracranial hemorrhage. Nor did the patient develop any signs and symptoms of SAH postoperatively.