Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment

Awake craniotomy during pregnancy: A systematic review of the published literature

Neurosurgical pathologies in pregnancy pose significant complications for the patient and fetus, and physiological stressors during anesthesia and surgery may lead to maternal and fetal complications. Awake craniotomy (AC) can preserve neurological functions while reducing exposure to anesthetic medications. We reviewed the literature investigating AC during pregnancy. PubMed, Scopus, and Web of Science databases were searched from the inception to February 7th, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Studies in English investigating AC in pregnant patients were included in the final analysis. Nine studies composed of nine pregnant patients and ten fetuses (one twin-gestating patient) were included. Glioma was the most common pathology reported in six (66.7%) patients. The frontal lobe was the most involved region (4 cases, 44.4%), followed by the frontoparietal region (2 cases, 22.2%). The awake-awake-awake approach was the most common protocol in seven (77.8%) studies. The shortest operation time was two hours, whereas the longest one was eight hours and 29 min. The mean gestational age at diagnosis was 13.6 ± 6.5 (2-22) and 19.6 ± 6.9 (9-30) weeks at craniotomy. Seven (77.8%) studies employed intraoperative fetal heart rate monitoring. None of the AC procedures was converted to general anesthesia. Ten healthy babies were delivered from patients who underwent AC. In experienced hands, AC for resection of cranial lesions of eloquent areas in pregnant patients is safe and feasible and does not alter the pregnancy outcome.

Neurosurgery for intractable epilepsy in pregnancy: A case report

We describe the management of a 39-year-old woman with intractable focal epilepsy whose condition deteriorated during pregnancy and who required emergency neurosurgery. A literature search did not identify any previous reports of epilepsy surgery in pregnancy. To our knowledge, this is the first time surgery was planned and executed in rapid order with a successful outcome, without obstetrical or surgical complications and seizure freedom achieved. The value of rapid communication between established women's health advanced nurse practitioner clinics, the multidisciplinary Epilepsy Surgery Group and specialist Obstetrical Epilepsy service is highlighted. A care cycle for pregnant women with refractory epilepsy is proposed.

Management and treatment of brain tumors during pregnancy: an Italian survey

PURPOSE

The management of brain tumors during pregnancy is challenging. The clinical rarity and prognostic heterogeneity of such condition makes it difficult to develop standardized guidelines of treatment. The aim of this study was to assess the treatment options used in pregnant women with brain tumors that are currently used in Italy, considering the management of these patients reported in current literature in this field.

METHODS

A survey addressing the treatments options and management of brain tumors during pregnancy was designed on behalf of an ad-hoc task-force Neuro-Oncology committee of the Società Italiana di Neurochirurgia (SINch) to analyze the management of pregnant patients with brain tumors. We conducted a search of the literature published between January 2011 and September 2021, using MEDLINE (PubMed) in accordance to PRISMA guidelines. Data were discussed to obtain recommendations after evaluation of the selected articles and discussion among the experts.

RESULTS

A total of 18 Neurosurgical centers participated in the survey. A total of 31 pregnant women were included in this retrospective study. Meningiomas and gliomas were the two most common types of brain tumors diagnosed during pregnancy. An emergency surgical procedure was required in 12.9% of cases.

CONCLUSION

A multidisciplinary and tailored approach is fundamental. In women showing clinical stability, neurosurgical options should preferably be delayed if possible, and considered during the second trimester or after delivery. In patients with acute neurological symptoms or tumor progression, medical abortion in the first trimester or a C-section in the second and third trimester need to be considered.

Neurosurgical emergencies during pregnancy - Management dilemmas

Background

Neurosurgical emergencies in the obstetric setting pose considerable challenges. Decision-making involves deliberations on the gestational age, critical nature of the illness, timing of surgery, maternal positioning during neurosurgery, anesthesiologic strategies, monitoring of the pregnancy during surgery, and the mode of delivery. The present study discusses the management and ethical dilemmas encountered during the management of six obstetric patients with neurosurgical emergencies.

Methods

A retrospective review of all neurosurgical operations performed between January 2016 and December 2022 were included in the study.

Results

This study includes a series of six pregnant women who presented with neurosurgical emergencies, secondary to freshly diagnosed pathologies in the period 2016-2022. The mean maternal age was 31.33 years. Four of the six patients were in the third semester and two were in the second trimester. The underlying etiologies were as follows: spontaneous intracerebral hypertensive hemorrhage (1), obstructive hydrocephalus due to shunt malfunction (1), brain tumor (02), and compressive spinal cord myelopathy due to tumors (02). Three patients who were near term underwent lower cesarean section followed by emergency neurosurgical procedure in the same sitting. Two second trimester patients continued their pregnancy after the emergency neurosurgical operation. In one patient, in whom a brain tumor was diagnosed near term, underwent neurosurgery 1 week after successful cesarean section. All the six mothers and fetus recovered well, ex3cept two patients who have persisting residual deficits.

Conclusion

Treatment of neurosurgical emergencies during pregnancy needs to be customized depending on the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. With careful planning, timely intervention, consultative decision making and it is possible to achieve the ultimate goal - which is to protect and safeguard the mother and preserve and deliver a viable fetus.

Not All Subarachnoid Hemorrhages in Pregnancy Are Intracranial in Origin: A Case Report

Subarachnoid hemorrhage is uncommon in pregnancy and may be caused by intracranial aneurysms, arteriovenous malformations, venous thrombosis, or preeclampsia. We present an unusual case of subarachnoid hemorrhage in a term parturient where the bleeding originated from an extracranial source, namely a cervicothoracic arteriovenous malformation. This case highlights the challenge of diagnosing this condition when the initial presentation may be nonspecific, lacking in neurologic deficits, and confounded by the simultaneous presence of preeclampsia.