ANESTHETIC CONSIDERATIONS FOR CESAREAN DELIVERY IN A

PATIENT WITH HISTORY OF ANTEPARTUM HEMICRANIECTOMY

DR. JEREMY ALTMAN MD, DR. MARGARET O’DONOGHUE M.D.

ALBANY MEDICAL CENTER

ALBANY NY

 

INTRODUCTION:

• Neurosurgical emergencies during pregnancy are rare but challenging, sometimes requiring

urgent craniectomy to prevent maternal deterioration

• Simultaneous management of maternal survival, neurological function, and fetal well-being

• Further obstetric care requiring a balance between intracranial pressure (ICP) and

hemodynamic stability

• Case: Parturient who underwent a craniotomy and subsequent craniectomy followed by

successful cesarean delivery under neuraxial anesthesia

• Key Points: Anesthetic considerations for active labor, neuraxial vs general anesthesia, role

of craniectomy

 

CASE: A 39-YEAR-OLD FEMALE (G6P1131) WITH A HISTORY OF ASTHMA,

HYPOTHYROIDISM, AND GESTATIONAL DIABETES PRESENTED FOR

ELECTIVE CESAREAN DELIVERY AT 37 WEEKS.

16 weeks gestation - Underwent endoscopic resection of a meningioma and bilateral optic nerve decompression

37 weeks gestation - Neuraxial anesthesia deemed safe per neurosurgery; craniectomy serving as a pressure release valve to reduce risk of herniation

18 weeks gestation - Patient required an emergent right hemicraniectomy for subdural empyema

Anesthetic Plan - Spinal: 0.75% Bupivacaine + Fentanyl 15 mcg + Morphine 100 mcg; GA avoided to prevent hypertension with laryngoscopy & ICP increases from volatile anesthetic

Outcome

- Healthy male neonate delivered, mother neurologically intact, eventually discharged on PPD#2; Successful cranioplasty 8 weeks post-delivery.

 

TEACHING POINTS

Avoiding Active Labor

Active labor raises intracranial pressure via Valsalva. Cesarean delivery mitigates this risk factor, providing a controlled hemodynamic environment for parturient with underlying neuropathology.

Neuraxial vs. General Anesthesia

General anesthesia carries risk of significant hypertension during laryngoscopy and volatile agents can increase ICP. Neuraxial anesthesia avoids these risks when herniation risk is low.

Role of Craniectomy

The right hemicraniectomy served as a pressure release valve, substantially lowering herniation risk. Reports of safe epidural use in prior craniectomy without neurologic symptoms support this approach.