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Monsour M, Pressman E, Pressman K, Cain MA, Vakharia K. Safety of labor, Valsalva maneuver, and neuraxial anesthesia for pregnant women after decompressive craniectomy: Case series and review of the literature. Int J Gynaecol Obstet 2024. [PMID: 39254365 DOI: 10.1002/ijgo.15894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/14/2024] [Accepted: 08/27/2024] [Indexed: 09/11/2024]
Abstract
Decompressive craniectomies are a neurosurgical operation aimed at normalizing intracranial pressure (ICP). Occasionally, there is delayed replacement of the skull resulting in an acquired skull defect. When managing laboring patients with an acquired skull defect there is often fear associated with traditional labor involving the Valsalva maneuver and with neuraxial anesthesia. These fears typically stem from potential ICP changes and risk of herniation. In reviewing the literature, only 15 cases are described detailing labor management after decompressive craniectomy (DC), mostly with incomplete labor histories. We aim to expand that literature by reporting two cases of safe labor with epidural anesthesia in patients with large skull defects. The first described patient underwent a cranioplasty during pregnancy because of trauma. Later, because of concerns for pre-eclampsia, induction of labor was initiated and she received neuraxial anesthesia via epidural. The patient ultimately underwent cesarean delivery 48 h after induction began due to nonreassuring fetal heart tones. The second patient underwent a cranioplasty because of infection prior to pregnancy. Once in labor, she was cleared by neurosurgery and the anesthesia team placed her epidural. She later underwent an uncomplicated standard vaginal delivery. The existing literature on labor following DC is sparse. Retrospective review of case reports can advance discussion and standardization regarding care for laboring women with a history of DC. We advocate that the Valsalva maneuver and epidural anesthesia is safe for pregnant women who are neurologically asymptomatic.
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Affiliation(s)
- M Monsour
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - E Pressman
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - K Pressman
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - M A Cain
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - K Vakharia
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Neuraxial Techniques in Obstetric Patients with Intracranial Lesions. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023. [DOI: 10.1007/s13669-023-00345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31-81. [PMID: 34762729 DOI: 10.1097/aln.0000000000004002] [Citation(s) in RCA: 383] [Impact Index Per Article: 191.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
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Nie Y, Zhou W, Huang S. Anesthetic management for cesarean delivery in a woman with congenital atlantoaxial dislocation and Chiari type I anomaly: a case report and literature review. BMC Pregnancy Childbirth 2021; 21:272. [PMID: 33794807 PMCID: PMC8017883 DOI: 10.1186/s12884-021-03751-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background The preferable choice of anesthesia for the patients with congenital atlantoaxial dislocation (CAAD) and type I Arnold Chiari malformations (ACM-I) has been a very confusing issue in clinical practice. We describe the successful administration of combined spinal-epidural anesthesia for a woman with CAAD and ACM-1 accompanied by syringomyelia. Case presentation Our case report presents the successful management of a challenging obstetric patient with CAAD and ACM-1 accompanied by syringomyelia. She had high risks of difficult airway and aspiration. The injection of bolus drugs through the spinal or epidural needle may worsen the previous neurological complications. The patient was well evaluated with a multidisciplinary technique before surgery and the anesthesia was provided by a skilled anesthesiologist with slow spinal injection. Conclusions An interdisciplinary team approach is needed to weigh risks and benefits for patients with CAAD and ACM-1 undergoing cesarean delivery. Therefore, an individual anesthetic plan should be made basing on the available anesthetic equipments and physicians’ clinical experience on anesthetic techniques.
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Affiliation(s)
- Yuyan Nie
- Department of Anesthesiology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Weimin Zhou
- Department of Anesthesiology, Anyang Maternity and Child Care Center, Anyang City, Henan Province, China
| | - Shaoqiang Huang
- Department of Anesthesiology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
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5
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Bryan A, Montilla E, Steinberg S, Farah F, Muse IO. Successful Use of Peripheral Nerve Blocks as the Primary Anesthetic in High-Risk Patients Undergoing Hip Surgery: A Case Series. A A Pract 2021; 15:e01367. [PMID: 33512905 DOI: 10.1213/xaa.0000000000001367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of hip fractures in the United States is increasing as the population ages. Elderly patients are more likely to have extensive comorbidities, which contribute to long-term consequences after a hip fracture. These patients often experience permanent disability, restrictions in activities of daily life, higher rates of depression, cardiovascular disease, and mortality rate. The authors describe a combination of peripheral nerve blocks to provide surgical anesthesia for corrective hip surgery in 5 high-risk patients.
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Affiliation(s)
- Andre Bryan
- From the Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Sastry R, Sufianov R, Laviv Y, Young BC, Rojas R, Bhadelia R, Boone MD, Kasper EM. Chiari I malformation and pregnancy: a comprehensive review of the literature to address common questions and to guide management. Acta Neurochir (Wien) 2020; 162:1565-1573. [PMID: 32306160 DOI: 10.1007/s00701-020-04308-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal management of Chiari I malformation during pregnancy remains uncertain. Labor contractions, which increase intracranial pressure, and neuraxial anesthesia both carry the theoretical risk of brainstem herniation given the altered CSF dynamics inherent to the condition. Mode of delivery and planned anesthesia, therefore, require forethought to avoid potentially life-threatening complications. Since the assumed potential risks are significant, we seek to systematically review published literature regarding Chiari I malformation in pregnancy and, therefore, to establish a best practice recommendation based on available evidence. METHODS The English-language literature was systematically reviewed from 1991 to 2018 according to PRISMA guidelines to assess all pregnancies reported in patients with Chiari I malformation. After analysis, a total of 34 patients and 35 deliveries were included in this investigation. Additionally, a single case from our institutional experience is presented for illustrative purposes but not included in the statistical analysis. RESULTS No instances of brain herniation during pregnancy in patients with Chiari I malformation were reported. Cesarean deliveries (51%) and vaginal deliveries (49%) under neuraxial blockade and general anesthesia were both reported as safe and suitable modes of delivery. Across all publications, only one patient experienced a worsening of neurologic symptoms, which was only later discovered to be the result of a previously undiagnosed Chiari I malformation. Several patients underwent decompressive suboccipital craniectomy to treat the Chiari I malformation during the preconception period (31%), during pregnancy (3%), and after birth (6%). Specific data regarding maternal management were not reported for a large number (21) of these patients (60%). Aside from one abortion in our own institutional experience, there was no report of any therapeutic abortion or of adverse fetal outcome. CONCLUSIONS Although devastating maternal complications are frequently feared, very few adverse outcomes have ever been reported in pregnant patients with a Chiari I malformation. The available evidence is, however, rather limited. Based on our survey of available data, we recommend vaginal delivery under neuraxial blockade for truly asymptomatic patients. Furthermore, based on our own experience and physiological conceptual considerations, we recommend limiting maternal Valsalva efforts either via Cesarean delivery under regional or general anesthesia or by choosing assisted vaginal delivery under neuraxial blockade. There is no compelling reason to offer suboccipital decompression for Chiari I malformation during pregnancy. For patients with significant neurologic symptoms prior to conception, decompression prior to pregnancy should be considered.
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Affiliation(s)
- Rahul Sastry
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Rinat Sufianov
- Department of Radiology, Division of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yosef Laviv
- Department of Radiology, Division of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Brett C Young
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rafael Rojas
- Department of Radiology, Division of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rafeeque Bhadelia
- Department of Radiology, Division of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Myles D Boone
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, DeGroote Medical School, McMaster University, Hamilton, ON, Canada.
- Hamilton General Hospital, 237, Barton Street East, Hamilton, ON, L8L 2X2, Canada.
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Mushambi MC, Athanassoglou V, Kinsella SM. Anticipated difficult airway during obstetric general anaesthesia: narrative literature review and management recommendations. Anaesthesia 2020; 75:945-961. [DOI: 10.1111/anae.15007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 12/16/2022]
Affiliation(s)
- M. C. Mushambi
- Department of Anaesthesia University Hospitals of Leicester LeicesterUK
| | - V. Athanassoglou
- Nuffield Department of Anaesthetics Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - S. M. Kinsella
- Department of Anaesthesia St Michael's Hospital Bristol UK
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Waters JFR, OʼNeal MA, Pilato M, Waters S, Larkin JC, Waters JH. Management of Anesthesia and Delivery in Women With Chiari I Malformations. Obstet Gynecol 2019; 132:1180-1184. [PMID: 30303901 DOI: 10.1097/aog.0000000000002943] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate whether vaginal delivery or neuraxial anesthesia poses a risk of neurologic deterioration in women with uncorrected Chiari I malformation. METHODS To assemble this case series, electronic record databases were used to identify women with Chiari I malformation who delivered on two busy tertiary care obstetric services over a 5-year period from January 2010 through December 2015. Women who had undergone surgical decompression were not included in the study. The size of the Chiari malformation, neurologic symptoms before delivery, mode of delivery, anesthetic method used, and neurologic complications were recorded. RESULTS Ninety-five deliveries in 63 patients were identified. The size of the Chiari malformation was 9.3±4.3 mm (mean±SD). In 58 pregnancies, women reported no headaches; in 36 they did. There was no association between the size of the Chiari malformation and the incidence of headache. Forty-four neonates were delivered by cesarean delivery and 51 were delivered vaginally. No neurologic deterioration occurred in either group. Neuraxial anesthesia was administered before 62 deliveries. No neurologic complications occurred. None of the women who delivered vaginally or received neuraxial anesthesia had signs of increased intracranial pressure. The upper limit of the 95% CI for the risk of neurologic complications from our study of 95 deliveries was 3.1%. CONCLUSION This case series support that in patients with Chiari I malformation who have no signs of increased intracranial pressure, the mode of delivery should be based on obstetric rather than neurologic considerations. The absence of complications in patients who received epidural or spinal anesthesia suggests that these procedures should be made available to women with Chiari I malformation.
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Affiliation(s)
- Janet F R Waters
- Department of Neurology, Division of Women's Neurology, the Department of Neurology, and the Departments of Anesthesiology and Bioengineering, McGowan Institute for Regenerative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; the Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts; and the Department of Bioengineering, University of Pittsburgh, and the Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Wilkinson DA, Johnson K, Castaneda PR, Nadel JL, Garton HJL, Muraszko KM, Maher CO. Obstetric Management and Maternal Outcomes of Childbirth Among Patients With Chiari Malformation Type I. Neurosurgery 2019; 87:45-52. [DOI: 10.1093/neuros/nyz341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/06/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
A range of opinions exist in the literature regarding obstetric management of pregnant women with Chiari malformation type I (CM-I).
OBJECTIVE
To examine obstetrical practices and outcomes with childbirth of women with CM-I.
METHODS
We examined insurance claims data from a large, privately insured health care network and identified admissions for childbirth from 2004 to 2014. Women with a diagnosis of CM-I as well as normal controls were analyzed for demographic characteristics, type of obstetric management, and complications of childbirth.
RESULTS
We identified 866 patients with CM-I diagnosis who had 1048 hospitalizations for delivery, including 103 deliveries to 83 patients who underwent performance of CM-I decompression (CMD) either before or after childbirth. Among 400 births that occurred after CM-I diagnosis, rates of caesarean section (C-section) were higher (42.3% vs 36.2%, OR 1.29, 95% CI 1.00-1.66, P = .05) and rates of epidural analgesia were lower (45.3% vs 55.4%, OR 0.67, 95% CI 0.52-0.85, P = .001) compared to 648 births before CM-I diagnosis. The rate of serious maternal morbidity was similar among deliveries to women with CM-I diagnosis (both before and after delivery) compared to 11 000 normal controls.
CONCLUSION
A diagnosis of CM-I prior to delivery is associated with a higher rate of C-section and a lower rate of epidural analgesia. Rates of serious maternal morbidity among women with CM-I were similar to those for normal controls. The data suggest a predelivery diagnosis of CM-I may influence obstetric decisions despite no evidence of substantially increased delivery risk in this group.
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Affiliation(s)
| | - Kyle Johnson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Peris R Castaneda
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey L Nadel
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Gruffi TR, Peralta FM, Thakkar MS, Arif A, Anderson RF, Orlando B, Coffman JC, Nathan N, McCarthy RJ, Toledo P, Habib AS. Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study. Int J Obstet Anesth 2018; 37:52-56. [PMID: 30414718 DOI: 10.1016/j.ijoa.2018.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/18/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Consensus regarding the safest mode of delivery and anesthetic management for parturients with Arnold Chiari malformation-I (ACM-I) remains controversial. This study assessed their anesthetic management and reported anesthetic complications during hospitalization for delivery. METHODS This was a multicenter, retrospective, cohort study of patients with ACM-I undergoing vaginal or cesarean delivery. Data were obtained from the electronic databases of four United States academic institutions using International Classification of Diseases (ICD) codes from 2007-2017 at three sites and 2004-2017 at one site. The primary outcome was anesthetic complications. RESULTS Data were analyzed for 185 deliveries in 148 patients. Diagnosis of ACM-I was made prior to delivery in 147 (80%) cases. Pre-delivery neurosurgical consultation for management of ACM-I was performed in 53 (36%) patients. Pre-existing symptoms were recorded for 89 (48%) of the deliveries. Vaginal deliveries occurred in 80 (43%) cases, and 62 women (78%) received neuraxial labor analgesia. Cesarean delivery was performed in 105 (57%) cases, of which 70 women (67%) had neuraxial anesthesia and 34 (32%) received general anesthesia. Post-dural puncture headache was reported in three (2%) patients who had neuraxial anesthesia, and in two (12%) patients with syringomyelia. There was one (3%) reported case of aspiration pneumonia with general anesthesia. CONCLUSIONS The findings suggest that anesthetic complications occur infrequently in patients with ACM-I regardless of the anesthetic management. Although institutional preference in anesthetic and obstetric care appears to drive patient management, the findings suggest that an individualized approach has favorable outcomes in this population.
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Affiliation(s)
- T R Gruffi
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - F M Peralta
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
| | - M S Thakkar
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - A Arif
- Department of Anesthesiology, Icahn School of Medicine, Mount Sinai West Hospital, New York, NY, United States
| | - R F Anderson
- Department of Anesthesiology, Duke University Hospital, Durham, NC, United States
| | - B Orlando
- Department of Anesthesiology, Icahn School of Medicine, Mount Sinai West Hospital, New York, NY, United States
| | - J C Coffman
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - N Nathan
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - R J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
| | - P Toledo
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - A S Habib
- Department of Anesthesiology, Duke University Hospital, Durham, NC, United States
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Zukin VD, Grigimalsky YV, Garga AY. Choosing an anesthetic technique in pregnant women with Arnold – Chiari malformation. PAIN MEDICINE 2018. [DOI: 10.31636/pmjua.v3i2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We want to present the clinical case of a female patient with the asymptomatic Chiari I type malformation, without surgical correction and with concomitant epilepsy who underwent planned C-section under epidural anesthesia. A 29-year old pregnant women on the 39 week of pregnancy entered the maternity hospital for the delivery. It was decided to conduct a planned caesarean section. The epidural anesthesia with 0.75 % solution of the ropivacaine was chosen as the method of anesthesia. The patient did not receive antiepileptic treatment due to her implacable refusal. She underwent surgery and anesthesia well. On the third day after surgery, the patient suffered of a convulsive as sault, which was stopped by intravenous administration of diazepam. This article briefly describes the genetic background, classification, clinical manifestations and treatment tactics for patients with Chiari malformation and the features of C-section anesthesia in pregnant women with this pathology.
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12
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Garvey GP, Wasade VS, Murphy KE, Balki M. Anesthetic and Obstetric Management of Syringomyelia During Labor and Delivery. Anesth Analg 2017; 125:913-924. [DOI: 10.1213/ane.0000000000001987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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13
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Anesthetic considerations for labor and delivery in women with cerebrospinal fluid shunts. Int J Obstet Anesth 2017; 30:23-29. [PMID: 28202311 DOI: 10.1016/j.ijoa.2017.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 01/03/2017] [Accepted: 01/08/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The anesthetic management of labor and delivery in pregnant women with cerebrospinal fluid shunts can be challenging. We conducted a literature review to understand the anesthetic implications in pregnant women with cerebrospinal fluid shunts. METHODS We searched PubMed, EMBASE, and Medline databases to identify reports of pregnant women with cerebrospinal fluid shunts during the 30-year period from 1985 to 2015. Twenty-four studies reporting anesthetic techniques for labor and delivery were included in the analyses. RESULTS A total of 97 women with 130 pregnancies were included. Ventriculo-peritoneal shunts (77%) were the most common type of shunt. Twenty-eight (29%) women had shunt malfunction during pregnancy, with 20 (71%) requiring shunt revision. Overall, 73 women (56%) delivered vaginally and 23 (40%) received epidural analgesia. Fifty-seven women (44%) underwent cesarean delivery and general anesthesia was used in 45% of cases. CONCLUSION This review suggests that shunt malfunctions occurred commonly during pregnancy. The presence of neurological symptoms warrants careful evaluation of shunt function. Anesthetic management for labor and delivery varied and was dependent on shunt function. Epidural analgesia appears to be safe in women with functional shunts.
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Ghaly RF, Tverdohleb T, Candido KD, Knezevic NN. Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia. Surg Neurol Int 2017; 8:10. [PMID: 28217389 PMCID: PMC5288987 DOI: 10.4103/2152-7806.198737] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/09/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Arnold-Chiari malformation Type 1 (ACM-1) in parturients is a topic of ongoing discussion between obstetricians and anesthesiologists. The primary unanswered question remains; How should the anesthesia provider proceed with labor analgesia and anesthesia for cesarean section when confronted with an advanced, asymptomatic, or minimally symptomatic case of ACM-1 during labor? CASE DESCRIPTION A 24-year-old, ASA II, G1P0 full-term parturient presented to Labor and Delivery for vaginal delivery. A diagnosis of ACM-1 was made 12 years ago when a brain magnetic resonance imaging (MRI) was performed for right-sided numbness following a rear-end motor vehicle collision. The patient had been asymptomatic since then and had been seen by an outside neurologist frequently for the past 10 years. During the anesthesia evaluation, it was noted that she had an exaggerated patellar reflex, and a questionable left-sided Babinski; subsequently, an MRI study was requested. Review of a brain MRI demonstrated an advanced form of ACM with a 1.7 cm transtonsillar herniation and a large syrinx extending from C1 down to C5. Following a discussion with the patient, family, and primary OB team, a plan for elective cesarean section was made per neurosurgical recommendations. This was conducted uneventfully under general anesthesia. The patient had no complaints in the post-anesthesia care unit. CONCLUSION Unfamiliarity of health care providers with regards to ACM-1 parturients can be countered by increasing awareness of this condition throughout medical specialties involved in their care. The Ghaly Obstetric Guide to Arnold-Chiari malformation Type 1, along with proper training of anesthesia care providers regarding the specificities of ACM-1 parturients aids in better management and understanding of this complex condition.
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Affiliation(s)
- Ramsis F Ghaly
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; Department of Anesthesiology, JHS Hospital of Cook County, Chicago, Illinois, USA; Ghaly Neurosurgical Associates, Aurora, Chicago, Illinois, USA; Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA
| | - Tatiana Tverdohleb
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA
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Ip P, Pankaja S, O’Mahony F. A Successful Pregnancy Outcome after Surgical Decompression of Type I Arnold-Chiari Malformation. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ojog.2015.51007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Hopkins AN, Alshaeri T, Akst SA, Berger JS. Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist. Semin Perinatol 2014; 38:359-69. [PMID: 25176638 DOI: 10.1053/j.semperi.2014.07.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. This article reviews current literature for some of the more common or complex neurologic conditions affecting pregnancy with special consideration for anesthetic management. In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension-Arnold-Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders-myasthenia gravis; and hereditary neuromuscular disorders-myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.
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Affiliation(s)
- Amanda N Hopkins
- Department of Anesthesiology & Critical Care Medicine, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | | | - Seth A Akst
- Department of Anesthesiology & Critical Care Medicine, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Jeffrey S Berger
- Department of Anesthesiology & Critical Care Medicine, The George Washington University School of Medicine & Health Sciences, Washington, DC.
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17
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Ghaly RF. Do neurosurgeons need Neuroanesthesiologists? Should every neurosurgical case be done by a Neuroanesthesiologist? Surg Neurol Int 2014; 5:76. [PMID: 24949219 PMCID: PMC4061581 DOI: 10.4103/2152-7806.133106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/19/2014] [Indexed: 11/30/2022] Open
Abstract
Neuroscience is exponentially growing and accompanied with everyday innovations and intriguing developments. There are new branches of science that are being developed within neuroscience. For instance, the fields of computer interface nanotechnology, molecular biology, ultra cellular, and gene therapy. The neuroscience programs have been established nationwide and worldwide. There is strong belief that better patient care is obtained through high volume and specialty physicians and hospitals. In fact, there are new subspecialties that already developed from within the specialty itself. Neuroanesthesia is one of the specialties that has contributed tremendously over the years to neuroscience yet it remained non-accredited and supported. In fact, there is a discouraging trend to pursue advocating the necessity of neurosurgery cases to be done by neuroanesthesiologists. It is one of the specialties that is lagging behind compared with other specialties and subspecialties in neuroscience. There is an ongoing debate within the neuroanesthesia society about the role of neuroanesthesiologists in neurosurgery. The author, being a neurosurgeon, neuroanesthesiologist, and neurointensivist, is presenting the topic, the views and expressing his opinion.
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Affiliation(s)
- Ramsis F. Ghaly
- Professor of Neurological Surgery and Anesthesiology University of Illinois at Chicago, Ghaly Neurosurgical Associates, Aurora, Illinois, Advocate Illinois Masonic medical center and JSH of Cook County hospital, Chicago, Illinois, USA
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Hönemann C, Moormann S, Hagemann O, Doll D. Spinal anesthesia for cesarean delivery in a patient with syringomyelia. Int J Gynaecol Obstet 2014; 125:172-4. [DOI: 10.1016/j.ijgo.2013.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/27/2013] [Accepted: 02/04/2014] [Indexed: 11/16/2022]
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Abstract
The field of functional neurosurgery has developed a number of recent innovative neuromodulatory approaches to treat disease that remains resistant to the best medical therapy. These include novel surgical techniques to intervene in motor and cognitive sequelae of refractory epilepsy, neurodegenerative disease, and certain psychiatric conditions. To a large extent, much of the innovation in our field continues to be driven by a systems-level understanding of the impact of disease on the brain. For example, several groups have exploited findings from neuroimaging work to identify a number of new potential neuromodulatory targets for the treatment of refractory depression. Ongoing discoveries at the cellular and molecular level promise targeted gene or drug delivery aimed at curing disease. Neurosurgeons will certainly remain at the forefront of translating these strategies into practical clinical applications. Several randomized trials are now underway to assess the safety and efficacy of a number of new approaches, and we will continue to acquire better knowledge of optimal patient selection, identification of the most effective neuromodulatory targets, and recognition of adverse effects as these studies progress.
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Combined spinal-epidural analgesia for laboring parturient with Arnold-Chiari type I malformation: a case report and a review of the literature. Case Rep Anesthesiol 2013; 2013:512915. [PMID: 23606989 PMCID: PMC3623113 DOI: 10.1155/2013/512915] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 03/03/2013] [Indexed: 11/18/2022] Open
Abstract
Anesthetic management of laboring parturients with Arnold-Chiari type I malformation poses a difficult challenge for the anesthesiologist. The increase in intracranial pressure during uterine contractions, coughing, valsalva maneuvers, and expulsion of the fetus can be detrimental to the mother during the process of labor and delivery. No concrete evidence has implicated high cerebral spinal fluid pressure on maternal and fetal complications. The literature on the use of neuraxial techniques for managing parturients with Arnold-Chiari is extremely scarce. While most anesthesiologists advocate epidural analgesia for management of labor pain and spinal anesthesia for cesarean section, we are the first to report the use of combined spinal-epidural analgesia for managing labor pain in a pregnant woman with Arnold-Chiari type I malformation. Also, we have reviewed the literature and presented information from case reports and case series to support the safe usage of neuraxial techniques in these patients.
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Anesthetic management of a parturient with VACTERL association undergoing Cesarean delivery. Can J Anaesth 2013; 60:570-6. [DOI: 10.1007/s12630-013-9919-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/13/2013] [Indexed: 11/26/2022] Open
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Ghaly RF, Candido KD, Chupatanakul L, Knezevic NN. Magnetic resonance imaging is essential prior to spinal subarachnoid blockade for parturients with a history of brain tumor resection undergoing cesarean section. Surg Neurol Int 2012; 3:75. [PMID: 22937476 PMCID: PMC3424678 DOI: 10.4103/2152-7806.98504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 06/15/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Primary brain tumors are usually treated by surgical removal with the goal of complete resection within the constraints of preservation of neurological function. However, gross total resection may not mean complete tumor removal, and ongoing compression from a mass effect can lead to serious sequelae. Spinal subarachnoid blockade is contraindicated in patients with brain tumors or space occupying lesions. CASE DESCRIPTION A 32-year-old full term parturient presented to Labor and Delivery for semi-urgent repeat cesarean section. Three months ago, she underwent resection of a benign brain tumor and recovered with no new neurological deficits. The neurosurgeon was consulted by the anesthesia team and stated that the tumor was completely extirpated. Since there was no postoperative magnetic resonance imaging (MRI) and the patient still had some neurological deficits, the anesthesia team decided to proceed with a general anesthetic using a rapid sequence induction and intubation. Mild hyperventilation to maintain an end-tidal CO(2) of 30 mmHg was selected and conservative fluid management was maintained. Postcesarean MRI revealed residual tumor compressing the brain stem and a loculated cyst. If a spinal subarachnoid blockade technique had been selected, the risk of uncal herniation, based on the postoperative MRI findings, may have been realized. CONCLUSIONS The present case demonstrates the necessity of a comprehensive and thorough review prior to selecting the anesthetic approach to mange the patients with a history of brain tumor resection. Postoperative MR imaging should be performed to evaluate the extent of tumor resection and possible existence of residual tumor.
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Affiliation(s)
- Ramsis F Ghaly
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60504, USA
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