Intra-operative monitoring of cerebral haemodynamics in a patient with Takayasu's arteritis

Successful low-dose spinal anaesthesia for lower segment caesarean section in a patient with Takayasu arteritis

Takayasu arteritis is a rare, chronic idiopathic, occlusive inflammation of the aorta and its major branches. It is a rare form of non-specific obliterative panarteritis of unknown aetiology. Anaesthesia for the patient with Takayasu arteritis is complicated by severe uncontrolled hypertension leading to end organ dysfunction, stenosis of major blood vessel affecting regional circulation and difficulties in the monitoring of arterial blood pressure. We report a 26-year-old woman multigravida who was diagnosed with Takayasu arteritis who underwent an emergency caesarean section under spinal anaesthesia. In this case study, the whole course of anaesthesia and operation was uneventful due to thorough systemic evaluation and planned anaesthetic management.

[How to manage Takayasu arteritis?]

Thorough clinical and imaging assessment of the arterial tree when a diagnosis of Takayasu arteritis is established. Glucocorticoïd as intiation therapy. Immunosuppresive agent should be considered as adjunctive therapy if resistance or dependance to glucocorticoïd therapy. Supportive care, antihypertensive drugs, glucocorticoïd induced osteoporosis preventive therapy, tuberculosis screening should not be forgiven. Monitoring of therapy should be clinical and supported by biological markers and imaging. Reconstructive surgery should be performed in the quiescent phase of disease.

Takayasus's arteritis in pregnancy. Case report and literature review

BACKGROUND AND OBJECTIVES

Takayasus's Arteritis (TA) is a chronic, inflammatory, progressive, idiopathic disease that causes narrowing, occlusion, and aneurysms of systemic and pulmonary arteries affecting especially the aorta and its branches. During pregnancy, one should pay special attention to these patients. The objective of this report was to present the peripartum anesthetic care of a patient with TA and a review of the literature.

CASE REPORT

This is a 31-year old gravida who underwent exchange of the aortic arch and placement of a metallic aortic valve for TA four years ago. She had no complications during pregnancy, and she was admitted at 34 weeks of pregnancy for anticoagulation management. Elective cesarean section was performed at 39 weeks with continuous epidural anesthesia. Fractionated doses of local anesthetic were administered to guarantee slow installation of the blockade. The patient remained hemodynamically stable and was transferred to the ICU in the postoperative period.

CONCLUSIONS

Several complications can affect gravidas with TA. Careful patient evaluation, treatment of TA complications, and anestheticsurgical planning are fundamental. Maintenance of perfusion is the main concern in these patients, and neuraxial blocks may be used without harming the mother and fetus. In patients with compensated TA complications, monitoring does not differ from that routinely used in cesarean sections. Continuous epidural anesthesia with slow installation maintains hemodynamic stability and allows monitoring cerebral perfusion through the level of consciousness. To avoid postoperative hypoperfusion or hypertensive complications patients should be monitored in an intensive or semi-intensive care unit for 24 hours.

Cerebral vasculitis: diagnosis and follow-up with transcranial Doppler ultrasonography

The authors report a patient with postpartum intracerebral hemorrhage associated with cerebral vasculitis. Cerebral circulation was assessed with transcranial Doppler (TCD) ultrasonography, magnetic resonance angiography, and conventional cerebral angiography. Initial TCD studies demonstrated bilateral patchy increased cerebral blood flow velocity (CBFV) in the anterior circulation with complete normalization during remission. This case report provides evidence that cerebral vasculitis leads to relevant CBFV changes and that the TCD technique may assist in diagnosis and follow-up of these patients.

Anesthetic management of patients with Takayasu's arteritis: a case series and review

Takayasu's arteritis is a rare, chronic progressive panendarteritis involving the aorta and its main branches. Anesthesia for patients with Takayasu's arteritis is complicated by their severe uncontrolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. Takayasu's arteritis is an uncommon disease and previous descriptions of the anesthetic management of patients with this disease have been limited to isolated case reports in the anesthetic literature, mostly in women undergoing cesarean delivery. We present our experience in this series of eight patients for various emergency and elective surgical procedures and review their perioperative problems and management.

IMPLICATIONS

This case series describes the anesthetic problems and management of patients with pulseless disease.

Anaesthesia for Caesarean section in Takayasu's disease

PURPOSE

We present a case of Takayasu's Disease (Occlusive Thromboaortopathy-OTAP) in which general anaesthesia was used for Caesarean section with processed encephalographic monitoring to detect cerebral ischaemia.

CLINICAL FEATURES

The patient was a 33-year-old woman in whom OTAP had been the cause of cerebrovascular events. She had the typical pulseless upper body of OTAP and had documented severe bilateral carotid artery stenoses. Regional anaesthesia had failed in the past and she demanded general anaesthesia for Caesarean section. Processed electroencephalography was used to assist in monitoring for signs of cerebral ischaemia and the surgery was uncomplicated.

CONCLUSION

The use of processed electroencephalographic monitoring allows some assessment of cerebral haemodynamics during general anaesthesia in patients who refuse regional techniques.

Extreme arterial blood pressure differentials in a patient with Takayasu's arteritis

PURPOSE

To describe the extreme arterial blood pressure differentials in a patient with Takayasu's arteritis and its implications for the preservation of cerebral perfusion during anaesthesia.

CLINICAL FEATURES

A 26-yr-old woman with Type III Takayasu's arteritis presented with a tentative diagnosis of mesenteric ischaemia. Determination of systolic arterial blood pressure assisted by oximetry revealed pressures of 114 mmHg in the left and 90 mmHg in the right arm while direct arterial line pressure monitoring of the left posterior tibial artery showed a pressure of 322/113 mmHg. Following induction of anaesthesia with thiopentone and succinylcholine and maintenance with N2O, isoflurane and fentanyl, posterior tibial arterial pressures were maintained (low of 213/96 mmHg) to maintain cerebral blood flow despite surgical requests to lower blood pressure. Epidural local anaesthesia was not considered for intra- or postoperative management due to the regional differences in blood pressure and the effect that sympatholysis may have had on cerebral perfusion.

CONCLUSION

In patients with Takayasu's arteritis, extreme arterial blood pressure differentials may exist which may affect regional blood flow, and monitoring of both upper and lower extremity arterial blood pressure should be considered.