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Segherlou ZH, Shakeri-Darzekonani M, Khavandegar A, Stephenson S, Ciccone K, Masheghati F, Hosseini Siyanaki MR, Lyerly M, Lucke-Wold B. Hormonal influences on cerebral aneurysms: unraveling the complex connections. Expert Rev Endocrinol Metab 2024; 19:207-215. [PMID: 38712738 DOI: 10.1080/17446651.2024.2347275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Intracranial aneurysms (IAs) occur in 3-5% of the general population and are characterized by localized structural deterioration of the arterial wall with loss of internal elastic lamina and disruption of the media. The risk of incidence and rupture of aneurysms depends on age, sex, ethnicity, and other different factors, indicating the influence of genetic and environmental factors. When an aneurysm ruptures, there is an estimated 20% mortality rate, along with an added 30-40% morbidity in survivors. The alterations in hormonal levels can influence IAs, while the rupture of an aneurysm can have various impacts on endocrine pathways and affect their outcome. AREA COVERED This review explores the reciprocal relationship between endocrinological changes (estrogen, growth hormone, and thyroid hormones) and IAs, as well as the effects of aneurysm ruptures on endocrine fluctuations. EXPERT OPINION Based on the data presented in this paper, we recommend further exploration into the influence of hormones on aneurysm formation and rupture. Additionally, we propose conducting endocrine assessments for patients who have experienced a rupture of IAs. Monitoring hormonal changes in patients with IAs could serve as a potential risk factor for rupture, leading to interventions in the approach to managing IAs.
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Affiliation(s)
| | | | - Armin Khavandegar
- College of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Stephenson
- Biotechnology Department, Krieger School of Arts and Sciences, John Hopkins University, Baltimore, MD, USA
| | - Kimberly Ciccone
- Department of Behavioral Neuroscience, College of Arts and Sciences, University of North Florida, Jacksonville, FL, USA
| | - Forough Masheghati
- College of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mac Lyerly
- School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
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2
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Garg A, Elmashala A, Roeder H, Ortega-Gutierrez S. Endovascular coiling versus neurosurgical clipping for treatment of ruptured and unruptured intracranial aneurysms during pregnancy and postpartum period. J Neurointerv Surg 2023; 15:310-314. [PMID: 35508381 DOI: 10.1136/neurintsurg-2022-018705] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/19/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Selection of appropriate surgical strategy for the treatment of intracranial aneurysms (IA) during pregnancy requires careful consideration of the potential risks to the mother and fetus. However, limited data guide treatment decisions in these patients. We compared the safety profiles of endovascular coiling (EC) and neurosurgical clipping (NC) performed for the treatment of ruptured and unruptured IA during pregnancy and the postpartum period. METHODS Pregnancy-related or postpartum hospitalizations undergoing surgical intervention for IA were identified from the Nationwide Readmissions Database 2016-2018. Safety outcomes included periprocedural complications, in-hospital mortality, discharge disposition, and 30-day non-elective readmissions. RESULTS There were 348 pregnancy-related or postpartum hospitalizations that met the study inclusion criteria (mean±SD age 31.8±5.9 years). Among 168 patients treated for ruptured aneurysms, 115 (68.5%) underwent EC and 53 (31.5%) underwent NC; whereas among 180 patients treated for unruptured aneurysms, 140 (77.8%) underwent EC and 40 (22.2%) underwent NC. There were no statistically significant differences in the baseline characteristics between patients undergoing EC versus NC for either ruptured or unruptured aneurysm groups. The outcomes were statistically comparable between EC and NC for both ruptured and unruptured IA, except for a lower incidence of ischemic stroke in patients undergoing EC for ruptured aneurysms (OR 0.12, 95% CI 0.02 to 0.84). CONCLUSIONS Most pregnant and postpartum patients are treated with EC for both ruptured and unruptured IA. For treatment of ruptured IA, EC is independently associated with a lower risk of perioperative ischemic stroke, but other in-hospital complications and mortality are comparable between EC and NC.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Amjad Elmashala
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Hannah Roeder
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery, and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Xie F, Hao J, Richard SA, Yang Y, Zou W, Liu HB, Deng M, Zhang C. Awake endovascular coiling of a dissected intracranial aneurysm in a third-trimester twin pregnancy: A case report. Medicine (Baltimore) 2021; 100:e24239. [PMID: 33429826 PMCID: PMC7793342 DOI: 10.1097/md.0000000000024239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/17/2020] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Subarachnoid hemorrhages (SAHs) from ruptured intracranial aneurysms are very rare during pregnancy. Management of ruptured intracranial aneurysms with SAH in pregnancy is often challenging because of the risks to the fetus and the mother. We present the first successful awake endovascular coiling of a dissected intracranial aneurysm in a third trimester twin pregnancy. PATIENT CONCERNS A 28 years' old pregnant woman was admitted at the obstetric department of our hospital on account of very severe headaches associated with nausea and vomiting. DIAGNOSIS Emergency obstetric ultrasound scan done confirmed 32 weeks' twin gestation, whereas magnetic resonance imaging established hemorrhage in the suprasellar cistern and the subarachnoid space. Magnetic resonance angiography revealed a dissected aneurysm in the ophthalmic segment of the left internal carotid artery. INTERVENTIONS Awake cerebral angiography as well as embolization of the aneurysm with coils was done via the transarterial route and the twins were delivered via caesarean section at 37 weeks' gestation. OUTCOMES Two years' follow-up indicated no complications and children as well as their mother are healthy. LESIONS Awake endovascular coiling was very beneficial in our case because we avoided general anesthesia and the use of osmotic diuretics which are potentially hazardous during pregnancy.
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Affiliation(s)
| | | | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
- Department of Medicine, Princefield University, Ho-Volta Region, Ghana West Africa
| | - Yuanli Yang
- Department of Obstetrics and Gynecology, Ziyang First People's Hospital, Ziyang
| | - Wuchun Zou
- Department of Obstetrics and Gynecology, Ziyang First People's Hospital, Ziyang
| | | | - Min Deng
- Department of Obstetrics and Gynecology, Ziyang First People's Hospital, Ziyang
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
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Beighley A, Glynn R, Scullen T, Mathkour M, Werner C, Berry JF, Carr C, Abou-Al-Shaar H, Aysenne A, Nerva JD, Dumont AS. Aneurysmal subarachnoid hemorrhage during pregnancy: a comprehensive and systematic review of the literature. Neurosurg Rev 2021; 44:2511-2522. [PMID: 33409763 DOI: 10.1007/s10143-020-01457-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/10/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent condition requiring rapid intervention and prolonged monitoring. There are few recommendations regarding the management of aSAH in pregnancy. We identified all available literature and compiled management decisions as well as reported outcomes through a systematic literature review without meta-analysis to provide recommendations for management of aSAH during pregnancy. We included a total of 23 articles containing 54 cases of pregnancy-related aSAH in our review. From these reports and other literature, we evaluated information on aSAH pathophysiology, diagnosis, and management with respect to pregnancy. Early transfer to an appropriate facility with neurocritical care, a high-risk obstetric service, and a neurosurgery team available is crucial for the management of aSAH in pregnancy. Intensive monitoring and a multidisciplinary approach remain fundamental to ensure maternal and fetal health.
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Affiliation(s)
- Adam Beighley
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Ryan Glynn
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Tyler Scullen
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA. .,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA. .,Neurosurgery Division, Surgery Department, Jazan University, Jazan, Kingdom of Saudi Arabia.
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - John F Berry
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Christopher Carr
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aimee Aysenne
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurocritical Care, Tulane Medical Center, New Orleans, LA, USA
| | - John D Nerva
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA. .,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA.
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Nussbaum ES, Goddard JK, Davis AR. A Systematic Review of Intracranial Aneurysms in the Pregnant Patient - A Clinical Conundrum. Eur J Obstet Gynecol Reprod Biol 2020; 254:79-86. [PMID: 32942080 DOI: 10.1016/j.ejogrb.2020.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/22/2020] [Accepted: 08/27/2020] [Indexed: 01/12/2023]
Abstract
Hemodynamic and hormonal changes during pregnancy can increase rates of formation, growth, and rupture of intracranial aneurysms (IA), and the increased incidence of subarachnoid hemorrhage (SA) in pregnant patients represents a risk to both mother and fetus. Despite this, management and treatment guidelines have not been defined for this patient population. In most instances, treatment decisions are made on a case-by-case basis with varying degrees of input from subspecialists. Important considerations, such as aneurysm location, morphology, size, growth pattern, and patient characteristics have not been presented in a management algorithm in the context of the pregnant patient. Given limited and controversial literature describing management of IAs in pregnant patients, we performed a systematic literature review. We then describe our multidisciplinary team approach and provide analysis of existing literature to provide guidelines for the management of the pregnant patient with an IA. A systematic review was undertaken to identify studies describing the management of IAs in the pregnant patient using the PubMed database. Overall maternal and fetal morbidity and mortality rates were determined. Data was analyzed for 1537 patients, including 1115 (73%) pregnant with ruptured intracranial aneurysms. In most cases, these aneurysms were managed conservatively (77%; 781/1013); however, when treatment was provided, surgical clipping was the most common modality (15%; 149/1013). Overall maternal outcomes were reported for 934 cases with morbidity and mortality rates of 5% (42/934) and 21% (194/934), respectively. Overall fetal outcomes were reported for 114 cases with morbidity and mortality rates of 10% (12/119) and 8% (9/119), respectively. Pregnancy-associated physiological changes likely elevate the risk of intracranial aneurysm formation, growth, and rupture. Treatment for aneurysms and SAs is safe and effective during pregnancy when risks are properly mitigated. Due to the complexity of care, such patients should be treated using a collaborative, interdisciplinary approach by a multidisciplinary team.
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Affiliation(s)
- Eric S Nussbaum
- National Brain Aneurysm & Tumor Center, Department of Neurosurgery, United Hospital, St. Paul, MN, United States.
| | | | - Amber R Davis
- Superior Medical Experts, St. Paul, MN, United States
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Karabuk E, Kadirogullari P, Kutlu Dilek TU, Ozluk E, Ozturk G. A Pregnant Woman with Cranial Aneurysm Rupture in the Second Trimester of Pregnancy. World Neurosurg 2020; 140:229-232. [PMID: 32438000 DOI: 10.1016/j.wneu.2020.04.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reports of cerebral aneurysm and aneurysm rupture during pregnancy are rare in the literature. Aneurysms might rupture and cause intracranial hemorrhage during or after pregnancy. Aneurysmal subarachnoid hemorrhage during pregnancy presents a challenge regarding treatment and management. No institution has reported a large patient population or experience in managing this condition during pregnancy in the literature. Owing to the limited number of cases, there are no available treatment guidelines, and treatment is usually based on a case-by-case approach. CASE DESCRIPTION A 31-year-old woman presented in the 27th week of pregnancy with sudden-onset headache, which was diagnosed as subarachnoid hemorrhage. The diagnosis of subarachnoid hemorrhage with an aneurysm located on the anterior communicating artery was made with magnetic resonance imaging and digital subtraction angiography. The aneurysm was treated by surgical clipping. The pregnancy continued successfully until the 35th gestational week, when the infant was successfully delivered by planned cesarean section owing to preeclampsia and fetal growth retardation. Postoperative follow-up was uneventful. CONCLUSIONS We present our experience in the management of aneurysmal subarachnoid hemorrhage during pregnancy and maternal and fetal outcomes of this rare disease. More cases and multicenter studies are needed to develop standardized management of this disease.
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Affiliation(s)
- Emine Karabuk
- Department of Obstetrics and Gynecology, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Pinar Kadirogullari
- Department of Obstetrics and Gynecology, Acıbadem University Atakent Hospital, Istanbul, Turkey.
| | - Talat Umut Kutlu Dilek
- Department of Obstetrics and Gynecology, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Enes Ozluk
- Department of Radiology, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Gulsah Ozturk
- Department of Neurosurgery, Acıbadem University Atakent Hospital, Istanbul, Turkey
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Mehrotra M, Mehrotra A, Nair A, Srivastava A, Sahu RN, Pradhan M, Kumar R. Intracranial hemorrhage from giant aneurysm in pregnancy: A rare association. Asian J Neurosurg 2017; 12:142-144. [PMID: 28413559 PMCID: PMC5379791 DOI: 10.4103/1793-5482.145553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We report a case of giant aneurysm causing subarachnoid hemorrhage in a pregnant female. A 25-year-old female presented with sudden onset of severe headache and vomiting with altered sensorium and right hemiplegia. On investigation, she had a giant supraclinoid segment internal carotid artery (ICA) aneurysm. She was planned for digital substraction angiography, but during the procedure she deteriorated neurologically and went into spontaneous labor. The baby was a male child with weight of 1.1 kg. She was taken up for surgery and aneurysm was clipped. We discuss the rare occurrence of intracranial hemorrhage in pregnancy due to a giant ICA aneurysm.
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Affiliation(s)
- Manasi Mehrotra
- Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anup Nair
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mandakini Pradhan
- Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Raj Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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8
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Mehrotra M, Mehrotra A, Nair A, Srivastava A, Sahu RN, Pradhan M, Kumar R. Dissecting intracranial aneurysm in pregnancy: A rare association. Asian J Neurosurg 2017; 12:127-130. [PMID: 28413555 PMCID: PMC5379786 DOI: 10.4103/1793-5482.150224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of dissecting aneurysm of the right posterior cerebral artery presenting with sudden onset headache and altered behavior during labor. A 26-year-old P1001 with uncomplicated antenatal period, except history of headache off and on since 32 weeks of pregnancy, developed sudden onset headache and altered behavior during 3rd stage of labor. She had vaginal delivery and a live born male baby was delivered with good Apgar score. The CT was suggestive of subarachnoid hemorrhage and DSA was suggestive of dissecting aneurysm of the right P2 segment with hypoplasia of right P1 segment and A1 segment of posterior and anterior cerebral artery, respectively. The patient was managed conservatively. At 4-month follow-up, the patient was doing well. We discuss about the rare association of a dissecting aneurysm and pregnancy, especially dissection of the posterior cerebral artery.
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Affiliation(s)
- Manasi Mehrotra
- Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Anup Nair
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Mandakini Pradhan
- Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Raj Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
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Edlow AG, Edlow BL, Edlow JA. Diagnosis of Acute Neurologic Emergencies in Pregnant and Postpartum Women. Emerg Med Clin North Am 2016; 34:943-965. [PMID: 27741996 DOI: 10.1016/j.emc.2016.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute neurologic symptoms in pregnant and postpartum women may be caused by exacerbation of a preexisting neurologic condition, the initial presentation of a non-pregnancy-related problem, or a new neurologic problem. Pregnant and postpartum patients with headache and neurologic symptoms are often diagnosed with preeclampsia or eclampsia; however, other etiologies must also be considered. A team approach with close communication between emergency physicians, neurologists, maternal-fetal medicine specialists, and radiologists is the key to obtaining best outcomes. This article reviews the clinical features and differential diagnosis of acute serious neurologic conditions in pregnancy and the puerperium, focusing on diagnosis.
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Affiliation(s)
- Andrea G Edlow
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mother Infant Research Institute, Tufts Medical Center, 800 Washington Street, Box 394, Boston, MA 02111, USA
| | - Brian L Edlow
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Place, West Clinical Center, 2nd Floor, Boston, MA 02215, USA.
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11
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Robba C, Bacigaluppi S, Bragazzi NL, Bilotta F, Sekhon MS, Bertuetti R, Ercole A, Bertuccio A, Czosnyka M, Matta B. Aneurysmal Subarachnoid Hemorrhage in Pregnancy-Case Series, Review, and Pooled Data Analysis. World Neurosurg 2015; 88:383-398. [PMID: 26724616 DOI: 10.1016/j.wneu.2015.12.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy represents an important cause of maternal and fetal morbidity and mortality. Approaches to diagnostics and treatment are still controversial, and there are only a limited number of cases described in the literature. Our study examines the management of aSAH in pregnant patients, creating a case series by combining patients from our hospital records with those from the limited available literature. METHODS Data collected from Addenbrooke's Hospital records and cases published between January 1995 and January 2015 were studied. Chi-square test, exact Fisher's test, and chi-square test for trend were used for analyzing categorical data, while the t-test and Mann-Whitney-Wilcoxon test were used for continuous data. RESULTS Fifty-two patients were included. The mean age was 31.47 ± 5.80, and most patients were in their third trimester. A univariate pooled data analysis suggested that the maternal outcome may depend on the mother's age, mother's Hunt and Hess scale score, Glasgow Coma Scale at arrival, treatment modality for the aneurysm, mode, and timing of delivery. However, at the multivariate analysis only the presence of general complications resulted in a significant impact on maternal outcome. CONCLUSIONS Ruptured aneurysms in pregnant patients with aSAH may be safely secured in a timely manner. The diagnostic and treatment strategy for each of these patients should consider peculiar maternal and obstetric factors and requires a multidisciplinary assessment involving obstetrics, neurosurgeons, and intensivists. Considering the observed statistical power of our series, our findings should be taken with caution and should be supported by further systematic data collection.
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Affiliation(s)
- Chiara Robba
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Susanna Bacigaluppi
- Department of Neurosurgery, Galliera Hospital, University of Genova, Genova, Italy
| | | | - Federico Bilotta
- Department of Anaesthesiology, University of Rome "La Sapienza", Rome, Italy
| | - Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Rita Bertuetti
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Ari Ercole
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Alessandro Bertuccio
- Department of Neurosurgery, St. George's Hospital, University of London, London, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Basil Matta
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Grant EN, Wang J, Gelpi B, Wortman A, Tao W. Diagnosing and managing peripartum headache. Proc (Bayl Univ Med Cent) 2015; 28:463-5. [PMID: 26424942 DOI: 10.1080/08998280.2015.11929309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A 38-year-old gravida 7 para 5 Hispanic woman at 36 weeks and 4 days gestation presented with a postpartum headache following vaginal delivery complicated by an unintentional dural puncture for epidural analgesia. Due to the positional nature of the headache and its frontal and occipital origin, a postdural puncture headache was diagnosed. After failure of conservative treatment, an epidural blood patch was used, which offered immediate relief. However, shortly following the procedure, the parturient's neurological condition deteriorated due to an unrecognized intraparenchymal and subarachnoid hemorrhage requiring an emergent craniectomy. This case highlights the importance of diligence when evaluating and treating postpartum headache despite a classic presentation.
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Affiliation(s)
- Erica N Grant
- Department of Anesthesiology and Pain Management (Grant, Wang, Gelpi, Tao) and the Department of Obstetrics and Gynecology (Wortman), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jia Wang
- Department of Anesthesiology and Pain Management (Grant, Wang, Gelpi, Tao) and the Department of Obstetrics and Gynecology (Wortman), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brian Gelpi
- Department of Anesthesiology and Pain Management (Grant, Wang, Gelpi, Tao) and the Department of Obstetrics and Gynecology (Wortman), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alison Wortman
- Department of Anesthesiology and Pain Management (Grant, Wang, Gelpi, Tao) and the Department of Obstetrics and Gynecology (Wortman), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Weike Tao
- Department of Anesthesiology and Pain Management (Grant, Wang, Gelpi, Tao) and the Department of Obstetrics and Gynecology (Wortman), University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Monsalve-Mejía G, Palacio W, Rodríguez C. [Emergency cesarean section and craniectomy in a patient with rupture of a cerebral arteriovenous malformation]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:209-213. [PMID: 23664062 DOI: 10.1016/j.redar.2013.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 03/12/2013] [Accepted: 03/19/2013] [Indexed: 06/02/2023]
Abstract
The intracerebral hemorrhage in pregnancy is a rare event, but can have catastrophic consequences for both mother and fetus. The management of non-ruptured arteriovenous malformations in pregnancy is not free of controversy in the current literature, as there is the possibility of spontaneous bleeding and becoming a true emergency. We report the case of a pregnant patient of 35 weeks with a diagnosis of a cerebral arteriovenous malformation, who developed a sudden onset of headache, generalized tonic-clonic seizures, loss of consciousness, and hemiparesis with radiological images of an intracranial hematoma with a mass effect, and signs of herniation. The multidisciplinary management is discussed, emphasizing perioperative cesarean approach plus craniotomy and drainage of the hematoma, and subsequent management in intensive care, and definitive management by neuroradiology, with a successful outcome.
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MESH Headings
- Adult
- Anesthesia, Obstetrical/methods
- Aneurysm, Ruptured/etiology
- Aneurysm, Ruptured/surgery
- Cesarean Section
- Combined Modality Therapy
- Decompressive Craniectomy
- Drainage
- Embolization, Therapeutic
- Emergencies
- Female
- Hematoma, Subdural, Intracranial/etiology
- Hematoma, Subdural, Intracranial/surgery
- Humans
- Infant, Newborn
- Intracranial Aneurysm/etiology
- Intracranial Aneurysm/surgery
- Intracranial Arteriovenous Malformations/complications
- Intracranial Arteriovenous Malformations/surgery
- Intracranial Arteriovenous Malformations/therapy
- Intracranial Hypertension/drug therapy
- Intracranial Hypertension/etiology
- Intracranial Hypertension/surgery
- Pregnancy
- Pregnancy Complications, Cardiovascular/drug therapy
- Pregnancy Complications, Cardiovascular/surgery
- Rupture, Spontaneous
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Affiliation(s)
- G Monsalve-Mejía
- Departamento de Anestesiología y Reanimación, Clínica El Rosario, Medellín, Colombia.
| | - W Palacio
- Departamento de Anestesiología y Reanimación, sección Anestesia Cardiovascular, Clínica El Rosario, Medellín, Colombia
| | - C Rodríguez
- Servicio Anestesiología y Reanimación, Universidad de Antioquia, Medellín, Colombia
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14
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Tang SC, Jeng JS. Management of stroke in pregnancy and the puerperium. Expert Rev Neurother 2014; 10:205-15. [DOI: 10.1586/ern.09.126] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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16
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17
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18
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Mavromatidis G, Dinas K, Mamopoulos A, Delkos D, Vosnakis C, Michailidis K, Rousso D. Uneventful delivery with caesarean section in a woman with a history of endovascular management of an intracranial aneurysm. J OBSTET GYNAECOL 2011; 31:664. [DOI: 10.3109/01443615.2011.603770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. J Emerg Nurs 2009; 35:e43-71. [DOI: 10.1016/j.jen.2008.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Tiel Groenestege AT, Rinkel GJ, van der Bom JG, Algra A, Klijn CJ. The Risk of Aneurysmal Subarachnoid Hemorrhage During Pregnancy, Delivery, and the Puerperium in the Utrecht Population. Stroke 2009; 40:1148-51. [DOI: 10.1161/strokeaha.108.539700] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
It is unclear whether the risk of aneurysmal subarachnoid hemorrhage (aSAH) is increased during pregnancy, labor, and the puerperium. We compared the risk of aSAH during this period with the risk outside this period.
Methods—
We included women with aSAH between 18 and 42 years of age (n=244) from our prospectively collected database of patients with subarachnoid hemorrhage treated in the University Medical Center Utrecht, the provincial referral center, between January 1987 and April 2006. We estimated the relative risk of aSAH during pregnancy, delivery, or the puerperium by a case-crossover design and calculated a standardized incidence ratio, dividing the observed number of patients with aSAH during pregnancy, delivery, or puerperium by the expected number based on the incidence in the general population of women of the same age during the study period.
Results—
Of the 244 women, 4 were pregnant, 3 in the puerperium and none in labor. The relative risk of aSAH during pregnancy, delivery, or the puerperium was 0.4 (95% CI, 0.2 to 0.9). Based on the number of women aged 18 to 42 years within the catchment area of our hospital and the number of pregnancies within the study period, the expected number of patients with aSAH during pregnancy, delivery, or the puerperium was 12, resulting in a standardized incidence ratio of 0.6 (95% CI, 0.2 to 1.1).
Conclusions—
The risk of aSAH is not increased during pregnancy, labor, and the puerperium. There is no need to advise against pregnancy in women with an increased risk of subarachnoid hemorrhage and no evidence to advise against vaginal delivery in such women.
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Affiliation(s)
- Andreas T. Tiel Groenestege
- From the Department of Neurology (A.T.T.G., G.J.E.R., A.A., C.J.M.K.), Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands; the Department of Clinical Epidemiology (A.A.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; and the Department of Clinical Epidemiology (J.G.v.d.B., A.A.), Leiden University Medical Center, Leiden, The Netherlands
| | - Gabriel J.E. Rinkel
- From the Department of Neurology (A.T.T.G., G.J.E.R., A.A., C.J.M.K.), Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands; the Department of Clinical Epidemiology (A.A.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; and the Department of Clinical Epidemiology (J.G.v.d.B., A.A.), Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G. van der Bom
- From the Department of Neurology (A.T.T.G., G.J.E.R., A.A., C.J.M.K.), Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands; the Department of Clinical Epidemiology (A.A.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; and the Department of Clinical Epidemiology (J.G.v.d.B., A.A.), Leiden University Medical Center, Leiden, The Netherlands
| | - Ale Algra
- From the Department of Neurology (A.T.T.G., G.J.E.R., A.A., C.J.M.K.), Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands; the Department of Clinical Epidemiology (A.A.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; and the Department of Clinical Epidemiology (J.G.v.d.B., A.A.), Leiden University Medical Center, Leiden, The Netherlands
| | - Catharina J.M. Klijn
- From the Department of Neurology (A.T.T.G., G.J.E.R., A.A., C.J.M.K.), Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands; the Department of Clinical Epidemiology (A.A.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; and the Department of Clinical Epidemiology (J.G.v.d.B., A.A.), Leiden University Medical Center, Leiden, The Netherlands
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21
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Le LT, Wendling A. Anesthetic management for cesarean section in a patient with rupture of a cerebellar arteriovenous malformation. J Clin Anesth 2009; 21:143-8. [DOI: 10.1016/j.jclinane.2008.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 02/19/2008] [Accepted: 07/06/2008] [Indexed: 10/21/2022]
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22
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Hirsch KG, Froehler MT, Huang J, Ziai WC. Occurrence of perimesencephalic subarachnoid hemorrhage during pregnancy. Neurocrit Care 2009; 10:339-43. [PMID: 19184552 DOI: 10.1007/s12028-009-9189-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 01/12/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Perimesencephalic subarachnoid hemorrhage (P-SAH) is a benign subset of subarachnoid hemorrhage with a favorable prognosis and low rate of re-bleeding. Risk factors may include hypertension and tobacco use, but it has not previously been reported during pregnancy. METHODS We report two cases of P-SAH in pregnant women, a 40-year-old female, 8-weeks pregnant and a 37-year-old female at 35 weeks gestational age. RESULTS CT scan confirmed P-SAH in both cases. CT angiography in one case and cerebral angiogram in the other did not reveal aneurysm or other potential bleeding source. The patients underwent transcranial Doppler ultrasound monitoring without evidence of vasospasm. CONCLUSION P-SAH hemorrhage may occur during early or late pregnancy. We do not propose an increased risk of P-SAH during pregnancy. The clinical course appears favorable and CT angiography alone may be considered the preferred diagnostic test to assess for aneurysm in first trimester pregnancy.
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Affiliation(s)
- Karen G Hirsch
- Department of Neurology, Johns Hopkins University School of Medicine, Meyer 8-140, 600 N. Wolfe St., Baltimore, MD, USA
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Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008; 52:407-36. [PMID: 18809105 DOI: 10.1016/j.annemergmed.2008.07.001] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
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24
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Pregnancy and coma. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18631830 DOI: 10.1016/s0072-9752(07)01717-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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25
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26
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Ferro JM, Canhão P, Peralta R. Update on subarachnoid haemorrhage. J Neurol 2008; 255:465-79. [DOI: 10.1007/s00415-008-0606-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Revised: 02/12/2007] [Accepted: 03/06/2007] [Indexed: 11/29/2022]
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27
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Vega-Basulto S, Lafontaine-Terry E, Gutiérrez-Muñoz F, Roura-Carrasco J, Pardo-Camacho G. Hemorragia intracraneal por aneurismas y malformaciones arteriovenosas durante el embarazo y el puerperio. Neurocirugia (Astur) 2008. [DOI: 10.1016/s1130-1473(08)70245-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Avitsian R, Schubert A. Anesthetic considerations for intraoperative management of cerebrovascular disease in neurovascular surgical procedures. Anesthesiol Clin 2007; 25:441-63, viii. [PMID: 17884703 DOI: 10.1016/j.anclin.2007.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite new surgical methods and interventions a considerable number of patients who undergo neurovascular procedures emergently or electively have substantial mortality, morbidity, and disability. Sound knowledge of pathophysiology of cerebral hypoperfusion, reliable and timely information from monitoring devices, and appropriate choice of therapeutic intervention is essential for successful anesthetic management of these patients. The management of perioperative vasospasm and temporary ischemia during aneurysm clipping require an understanding of cerebral vascular pathophysiology and neuroprotective measures.
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Affiliation(s)
- Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Affiliation(s)
- Cary Ward
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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30
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Inoue T, Nishimura S, Hayashi N, Numagami Y, Takazawa H, Nishijima M. Postpartum dissecting aneurysm of the posterior cerebral artery. J Clin Neurosci 2007; 14:576-81. [PMID: 17430781 DOI: 10.1016/j.jocn.2006.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Revised: 04/13/2006] [Accepted: 04/22/2006] [Indexed: 11/15/2022]
Abstract
Intracranial dissecting aneurysm may cause subarachnoid hemorrhage (SAH) or infarction, and postpartum dissecting aneurysm is rare. A 30-year-old 6 days postpartum woman presented with posterior cerebral artery (PCA) dissection evolving dramatically over a short period. She had been well until 6 days after delivery when she suffered sudden onset of headache, vomiting, and unconsciousness. CT scan demonstrated SAH and digital subtraction angiography (DSA) revealed a fusiform dilatation of the left PCA (P3/P4 segment). The initial diagnosis was ruptured dissecting aneurysm, and conservative management was recommended in the acute period. DSA showed smoothening of the vascular wall 6 days after onset, and obliteration of the left P3/P4 segment was observed 13 days after onset. She was discharged without neurological deficits 26 days after onset. Postpartum SAH due to dissecting aneurysm of the PCA is rare, but should be considered in the differential diagnosis of postpartum headache.
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Affiliation(s)
- Tomoo Inoue
- Department of Neurosurgery, Aomori Prefectural Central Hospital, 2-1-1 Higashitsukurimichi, Aomori, Aomori 030-8553, Japan.
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Marshman LAG, Aspoas AR, Rai MS, Chawda SJ. The implications of ISAT and ISUIA for the management of cerebral aneurysms during pregnancy. Neurosurg Rev 2007; 30:177-80; discussion 180. [PMID: 17508225 DOI: 10.1007/s10143-007-0074-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Revised: 02/26/2007] [Accepted: 03/04/2007] [Indexed: 11/28/2022]
Abstract
Both the International Subarachnoid Aneurysm Trial (ISAT) and the International Study on Unruptured Intracranial Aneurysms (ISUIA) have been widely extrapolated to influence the management of actual or anticipated aneurysmal subarachnoid hemorrhage (SAH). However, it remains possible that sub-groups exist for which such extrapolation might subsequently prove premature. In this review, we discuss the implications that such extrapolation may potentially have for one such SAH sub-group: the clinically rare scenario of SAH in pregnancy.
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Affiliation(s)
- Laurence A G Marshman
- Departments of Neurosurgery, Oldchurch Hospital, Waterloo Rd Romford, Essex, RM7 0BE, UK.
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Bhatia R, Hughes D, Crocker M, Strong AJ. Aneurysmal subarachnoid haemorrhage in a patient with thyrotoxicosis. Br J Neurosurg 2006; 20:165-8. [PMID: 16801052 DOI: 10.1080/02688690600777133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A case of subarachnoid haemorrhage secondary to rupture of an intracranial aneurysm occurring in a patient with new-onset, frank thyrotoxicosis is described. This unusual case highlights the dilemma of whether to continue beta-blockers such as propanolol for frank thyrotoxicosis, or whether to assign higher priority to maintaining adequate cerebral perfusion pressure in established ischaemic deficit due to vasospasm. In a complicated case such as this, the Maudsley Mentation Test score and perfusion CT scanning are two useful adjuncts for the early detection and evaluation of the course of ischaemic deficit.
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Affiliation(s)
- R Bhatia
- Department of Clinical neurosciences (Neurosurgery), Kings College Hospital, Denmark Hill, London, UK.
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Kuczkowski KM. Labor analgesia for the parturient with neurological disease: what does an obstetrician need to know? Arch Gynecol Obstet 2006; 274:41-6. [PMID: 16463165 DOI: 10.1007/s00404-006-0125-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Accepted: 12/28/2005] [Indexed: 10/25/2022]
Abstract
Several neurological disorders including multiple sclerosis, myasthenia gravis, epilepsy, spinal cord injury, and subarachnoid hemorrhage are encountered with increasing frequency in pregnant women worldwide. Although there is absence of uniform anesthetic guidelines for pregnant patients with most of these (and other) neurological disorders, and the decision whether or not to administer regional anesthesia is based on an individual risk-to-benefit ratio on a case-by-case basis, few of these disorders contraindicate the use of neuraxial anesthesia. This article attempts to review the specific concerns for administration of labor analgesia posed by multiple sclerosis, myasthenia gravis, epilepsy, paraplegia and subarachnoid hemorrhage.
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Affiliation(s)
- Krzysztof M Kuczkowski
- Department of Anesthesiology, University of California, San Diego Medical Center, CA 92103-8770, USA.
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