CLINICAL REPORT
Anesthetic Management of Neurosurgical Procedures During Pregnancy: A Case Series Pooya Kazemi, MD,* Giselle Villar, MD, FRCPC,*w and Alana M. Flexman, MD, FRCPC*z
Introduction: Neurosurgical disorders are rare during pregnancy and challenge the anesthesiologist with conflicting anesthetic considerations and little evidence to guide decision-making. Our objective was to review the anesthetic management of pregnant patients undergoing intracranial neurosurgery at our institution and to describe the perioperative complications and outcomes. Methods: We used our institutional Discharge Abstract Database to identify patients assigned both neurological and obstetrical International Classification of Disease 10-A codes between April 1, 2001 and March 1, 2012. Pregnant patients who underwent intracranial neurosurgical procedures underwent a detailed chart review to extract demographic data and details about their anesthetic management and outcome. Results: Nine patients underwent full chart review with a median age of 28 (range, 17 to 35) years and a gestational age of 23 (range, 7 to 30) weeks. Patients underwent a craniotomy for vascular lesions (4), neoplasms (3), and traumatic brain injuries (2). One patient was hyperventilated (PaCO2 28 mmHg), and mannitol and furosemide were used in 6 and 3 patients, respectively, without complication. Maternal neurological outcomes were good in 5 patients (Glasgow Outcome Scale of >3), poor in 3 patients (Glasgow Outcome Scale 3), and 1 patient died. Fetal outcomes were good in 5 patients and poor in 4 patients (1 therapeutic abortion, 3 intrauterine fetal demises). All cases of fetal distress or demise were either remote or occurred before the anesthetic management. Conclusions: Pregnant patients undergoing neurosurgery experience a high rate of morbidity and mortality. There were no adverse outcomes directly attributed to the use of osmotic diuretics and hyperventilation in our series. Received for publication July 5, 2013; accepted October 24, 2013. From the *Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia; wDepartment of Anesthesia, British Columbia’s Women’s Hospital; and zDepartment of Anesthesiology and Perioperative Care, Vancouver General Hospital, Vancouver, BC, Canada. The authors have no funding or conflicts of interest to disclose. Reprints: Alana M. Flexman, MD, FRCPC, Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Room 2449, 899 West 12th Avenue, Vancouver, BC, Canada V5Z 1M9 (e-mail: alana.fl[email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.jnsa.com. Copyright r 2013 by Lippincott Williams & Wilkins
234 | www.jnsa.com
Key Words: pregnancy, neurosurgery, craniotomy, complications, outcomes, anesthesia (J Neurosurg Anesthesiol 2014;26:234–240)
N
eurosurgery is rarely undertaken during pregnancy, and cases are typically performed in an urgent or emergent setting. Although uncommon, neurosurgical disorders are important causes of morbidity and mortality in the pregnant population.1,2 The anesthesia literature on the neurosurgical pregnant patient is limited to isolated case reports,3–8 and the anesthetic management for such procedures is largely based on theoretical principles rather than evidence.1 The anesthetic considerations for both neurosurgery and pregnancy are often conflicting, and create a unique and challenging clinical situation for the anesthesiologist. Neurosurgical conditions that present during pregnancy include traumatic brain injury (TBI), intracranial neoplasms, and intracranial hemorrhage.1,2,9 Trauma is the leading nonobstetric cause of maternal death during pregnancy in the United States and may include TBIs.10 Intracranial neoplasms are uncommon, with an incidence of 3.2 to 3.6 per 1 million live births.11,12 Although rare, intracranial neoplasms may present more frequently during pregnancy because of increased vascularity and intensified tumor growth from the presence of estrogen or progesterone receptors.13,14 Intracerebral hemorrhage is another important contributor to peripartum mortality, accounting for 7% of all deaths during pregnancy, with pregnancy-induced hypertension playing an important role.15 Pregnant patients may also experience intracranial bleeding from a subarachnoid hemorrhage or a ruptured arteriovenous malformation (AVM). Some evidence suggests that the incidence of subarachnoid hemorrhage is increased during pregnancy, although the etiology is more likely to be nonaneurysmal and these patients may have a more favorable outcome than nonpregnant patients.16 Similarly, the risk of a first rupture and the risk of rebleeding of AVMs appears to be increased during pregnancy, particularly in the last trimester, and prophylactic or early neurosurgical intervention has been recommended.17 Although several institutional case series have described the neurosurgical management of pregnant patients,13,18,19 J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
r
2013 Lippincott Williams & Wilkins
28 35 21 7 8 9
*GCS, Glascow coma scale immediately before the operative procedure, modified with T used to indicate whether an endotracheal tube was present. wThis patient underwent 2 neurosurgical procedures at 23 and 28 weeks gestational age, respectively. Fetal demise was noted preoperatively at the time of the second procedure. AVM indicates arteriovenous malformation; LOC, level of consciousness; MVA, motor vehicle accident.
Intracerebral hemorrhage (AVM) Intracranial AVM Intracerebral hemorrhage (AVM) 6T 15 2T Singleton Singleton Singleton G2P1 Unknown G2P0
31 21 24 4 5 6
8 20 25
31 17 35 1 2 3
26 23, 28w 7
G2P0 G2P0 G3P2
Twin Singleton Singleton
15 12, 15w 3T
Traumatic brain injury Traumatic brain injury Temporoparietal oligodendroglioma Frontal oligodendroglioma Medulloblastoma Intracerebral hemorrhage (AVM) 5T 2T 2T Singleton Singleton Singleton G3P2 G2P0 G3P2
GCS* Gestational Number Gravity/ Parity
TABLE 1. Maternal Characteristics Before the Neurosurgical Procedure
RESULTS Thirty-three patients were identified using our search strategy and underwent chart review for possible inclusion in the study. Upon further review, 23 patients were excluded: 16 did not undergo neurosurgery, and 7 were not pregnant at the time of neurosurgery. One additional patient had undergone spine surgery and was excluded. Overall, 9 patients were included in the study and underwent a detailed chart review. Demographic data for all study patients are summarized in Table 1. The
Neurosurgical Diagnosis
METHODS This retrospective chart review was conducted with approval from the University of British Columbia Clinical Research Ethics Board (H12-00325) with a waiver for informed consent. We included all pregnant patients of any gestation age who underwent intracranial neurosurgery at Vancouver General Hospital between April 1, 2001 and March 1, 2012. Patients who did not undergo a neurosurgical procedure or who were not pregnant at the time of their procedure were excluded from the study. The Discharge Abstract Database (DAD) was used to identify eligible patients from our center. Vancouver General Hospital is a tertiary academic teaching center and the major referral center for neurosurgery in the province of British Columbia, serving a population of approximately 4 million. The DAD contains demographic, administrative, and clinical data for all hospital discharges collected for the Canadian Institute for Health Information national registry. All patients are assigned discharge diagnoses using the International Classification of Disease (ICD) 10-CA coding system. The DAD was used to identify patients assigned both neurological ICD 10-A codes (I60-69, C70-72, G00-G09, G40-47, G50-59, G80-83, G90-99, Q28, S00-S19) and obstetrical ICD 10-A codes (O00-O99) between April 1, 2001 and March 1, 2012 at Vancouver General Hospital. These dates represent the maximum searchable range in the DAD. The medical records of all patients identified through our preliminary search were examined for possible inclusion in the study. Demographic data, details about the patient’s neurosurgical and anesthetic management, and the maternal and fetal outcomes at the time of discharge from hospital were extracted from paper and electronic medical records using a standardized Data Collection Form (Appendix 1, Supplemental Digital Content 1, http:// links.lww.com/JNA/A14). Maternal outcomes were graded according to the Glasgow Coma Outcome Scale (GOS).20 The GOS defines 1 as death, 2 as persistent vegetative state, 3 as severe disability, 4 as moderate disability, and 5 as a good recovery.
30 16 25
Presenting Signs and Symptoms
none has specifically described the anesthetic management of pregnant patients undergoing neurosurgical procedures. Our study objective was to review the anesthetic management of all pregnant patients undergoing intracranial neurosurgery in our institution and describe the perioperative complications and outcomes.
MVA, decreased LOC MVA, decreased LOC Speech difficulty; headache; weakness followed by decreased LOC Tonic-clonic seizure Confusion, speech difficulty Neck pain, photophobia, nausea followed by decreased LOC Headache; vomiting, decreased LOC None (elective procedure) Weakness, aphasia followed by decreased LOC
Anesthesia for Pregnant Patients Undergoing Neurosurgery
Gestational Age (wk)
Volume 26, Number 3, July 2014
Age (y)
Patient
J Neurosurg Anesthesiol
www.jnsa.com |
235
236 | www.jnsa.com
Intracerebral hemorrhage (AVM)
Evacuation of intracranial hematoma, EVD insertion
Evacuation of intracranial hematoma, EVD insertion Evacuation of Intracerebral hemorrhage intracranial (AVM) hematoma, resection of AVM Intracranial AVM Resection of AVM
No
No
Yes 0.8 mg/kg
No
Yes 1.7 mg/kg
No
Yes 1 mg/kg Yes Yes, intermittent 0.9 mg/kg after procedure only
No
No
Yes, No FHR before start of procedure No
No
No
Yes, intermittent Yes, intraoperative 1 mg/kg
No
No
No
Yes, 40 mg
No
No
Yes, 20 mg
No
Yes, 20 mg
No
No
No
No
No
No
No
No
No
Yes
No
No
U/S POD0: Normal U/S POD12: Normal
No assessment
U/S POD4: nonviable 8 wk pregnancy
No assessment
Not applicable
U/S POD6: Normal Normal FHR POD16 before discharge home U/S POD12: Normal twin pregnancy U/S POD15: Normal
U/S POD5: Normal U/S POD12: Normal U/S POD1: viable fetus
Postoperative Mannitol Furosemide Hyperventilation* Fetal Assessment
Yes, continuous Yes, intraoperative 1.5 mg/kg
FHR Monitoring
Discharge home (4)
Discharge home (5)
Discharge to rehabilitation center (4)
Maternal death POD4 from brain herniation (1)
Palliative (3)
Discharge to rehabilitation center (3) Discharge home (5)
Discharge to rehabilitation center (4) Palliative (3)
Discharge to rehabilitation center (3)
Maternal Outcome (GOS Scorew)
Elective C/S at term with good outcome Elective C/S at 30 wk with good outcome
Intrauterine fetal demise
Maternal death with fetus in situ
Intrauterine fetal demise at 28 wk
Elective C/S at 33 wk with good outcome of twin babies Viable fetus at discharge
Urgent C/S for fetal distress at 28 wk with good outcome
Therapeutic abortion on POD4
Emergency C/S for fetal distress at 32 wk with good outcome
Fetal Outcome
J Neurosurg Anesthesiol
r
*Hyperventilation was defined as an intraoperative documented PaCO2
Anesthetic Management of Neurosurgical Procedures During Pregnancy: A Case Series Pooya Kazemi, MD,* Giselle Villar, MD, FRCPC,*w and Alana M. Flexman, MD, FRCPC*z
Introduction: Neurosurgical disorders are rare during pregnancy and challenge the anesthesiologist with conflicting anesthetic considerations and little evidence to guide decision-making. Our objective was to review the anesthetic management of pregnant patients undergoing intracranial neurosurgery at our institution and to describe the perioperative complications and outcomes. Methods: We used our institutional Discharge Abstract Database to identify patients assigned both neurological and obstetrical International Classification of Disease 10-A codes between April 1, 2001 and March 1, 2012. Pregnant patients who underwent intracranial neurosurgical procedures underwent a detailed chart review to extract demographic data and details about their anesthetic management and outcome. Results: Nine patients underwent full chart review with a median age of 28 (range, 17 to 35) years and a gestational age of 23 (range, 7 to 30) weeks. Patients underwent a craniotomy for vascular lesions (4), neoplasms (3), and traumatic brain injuries (2). One patient was hyperventilated (PaCO2 28 mmHg), and mannitol and furosemide were used in 6 and 3 patients, respectively, without complication. Maternal neurological outcomes were good in 5 patients (Glasgow Outcome Scale of >3), poor in 3 patients (Glasgow Outcome Scale 3), and 1 patient died. Fetal outcomes were good in 5 patients and poor in 4 patients (1 therapeutic abortion, 3 intrauterine fetal demises). All cases of fetal distress or demise were either remote or occurred before the anesthetic management. Conclusions: Pregnant patients undergoing neurosurgery experience a high rate of morbidity and mortality. There were no adverse outcomes directly attributed to the use of osmotic diuretics and hyperventilation in our series. Received for publication July 5, 2013; accepted October 24, 2013. From the *Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia; wDepartment of Anesthesia, British Columbia’s Women’s Hospital; and zDepartment of Anesthesiology and Perioperative Care, Vancouver General Hospital, Vancouver, BC, Canada. The authors have no funding or conflicts of interest to disclose. Reprints: Alana M. Flexman, MD, FRCPC, Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Room 2449, 899 West 12th Avenue, Vancouver, BC, Canada V5Z 1M9 (e-mail: alana.fl[email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.jnsa.com. Copyright r 2013 by Lippincott Williams & Wilkins
234 | www.jnsa.com
Key Words: pregnancy, neurosurgery, craniotomy, complications, outcomes, anesthesia (J Neurosurg Anesthesiol 2014;26:234–240)
N
eurosurgery is rarely undertaken during pregnancy, and cases are typically performed in an urgent or emergent setting. Although uncommon, neurosurgical disorders are important causes of morbidity and mortality in the pregnant population.1,2 The anesthesia literature on the neurosurgical pregnant patient is limited to isolated case reports,3–8 and the anesthetic management for such procedures is largely based on theoretical principles rather than evidence.1 The anesthetic considerations for both neurosurgery and pregnancy are often conflicting, and create a unique and challenging clinical situation for the anesthesiologist. Neurosurgical conditions that present during pregnancy include traumatic brain injury (TBI), intracranial neoplasms, and intracranial hemorrhage.1,2,9 Trauma is the leading nonobstetric cause of maternal death during pregnancy in the United States and may include TBIs.10 Intracranial neoplasms are uncommon, with an incidence of 3.2 to 3.6 per 1 million live births.11,12 Although rare, intracranial neoplasms may present more frequently during pregnancy because of increased vascularity and intensified tumor growth from the presence of estrogen or progesterone receptors.13,14 Intracerebral hemorrhage is another important contributor to peripartum mortality, accounting for 7% of all deaths during pregnancy, with pregnancy-induced hypertension playing an important role.15 Pregnant patients may also experience intracranial bleeding from a subarachnoid hemorrhage or a ruptured arteriovenous malformation (AVM). Some evidence suggests that the incidence of subarachnoid hemorrhage is increased during pregnancy, although the etiology is more likely to be nonaneurysmal and these patients may have a more favorable outcome than nonpregnant patients.16 Similarly, the risk of a first rupture and the risk of rebleeding of AVMs appears to be increased during pregnancy, particularly in the last trimester, and prophylactic or early neurosurgical intervention has been recommended.17 Although several institutional case series have described the neurosurgical management of pregnant patients,13,18,19 J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
r
2013 Lippincott Williams & Wilkins
28 35 21 7 8 9
*GCS, Glascow coma scale immediately before the operative procedure, modified with T used to indicate whether an endotracheal tube was present. wThis patient underwent 2 neurosurgical procedures at 23 and 28 weeks gestational age, respectively. Fetal demise was noted preoperatively at the time of the second procedure. AVM indicates arteriovenous malformation; LOC, level of consciousness; MVA, motor vehicle accident.
Intracerebral hemorrhage (AVM) Intracranial AVM Intracerebral hemorrhage (AVM) 6T 15 2T Singleton Singleton Singleton G2P1 Unknown G2P0
31 21 24 4 5 6
8 20 25
31 17 35 1 2 3
26 23, 28w 7
G2P0 G2P0 G3P2
Twin Singleton Singleton
15 12, 15w 3T
Traumatic brain injury Traumatic brain injury Temporoparietal oligodendroglioma Frontal oligodendroglioma Medulloblastoma Intracerebral hemorrhage (AVM) 5T 2T 2T Singleton Singleton Singleton G3P2 G2P0 G3P2
GCS* Gestational Number Gravity/ Parity
TABLE 1. Maternal Characteristics Before the Neurosurgical Procedure
RESULTS Thirty-three patients were identified using our search strategy and underwent chart review for possible inclusion in the study. Upon further review, 23 patients were excluded: 16 did not undergo neurosurgery, and 7 were not pregnant at the time of neurosurgery. One additional patient had undergone spine surgery and was excluded. Overall, 9 patients were included in the study and underwent a detailed chart review. Demographic data for all study patients are summarized in Table 1. The
Neurosurgical Diagnosis
METHODS This retrospective chart review was conducted with approval from the University of British Columbia Clinical Research Ethics Board (H12-00325) with a waiver for informed consent. We included all pregnant patients of any gestation age who underwent intracranial neurosurgery at Vancouver General Hospital between April 1, 2001 and March 1, 2012. Patients who did not undergo a neurosurgical procedure or who were not pregnant at the time of their procedure were excluded from the study. The Discharge Abstract Database (DAD) was used to identify eligible patients from our center. Vancouver General Hospital is a tertiary academic teaching center and the major referral center for neurosurgery in the province of British Columbia, serving a population of approximately 4 million. The DAD contains demographic, administrative, and clinical data for all hospital discharges collected for the Canadian Institute for Health Information national registry. All patients are assigned discharge diagnoses using the International Classification of Disease (ICD) 10-CA coding system. The DAD was used to identify patients assigned both neurological ICD 10-A codes (I60-69, C70-72, G00-G09, G40-47, G50-59, G80-83, G90-99, Q28, S00-S19) and obstetrical ICD 10-A codes (O00-O99) between April 1, 2001 and March 1, 2012 at Vancouver General Hospital. These dates represent the maximum searchable range in the DAD. The medical records of all patients identified through our preliminary search were examined for possible inclusion in the study. Demographic data, details about the patient’s neurosurgical and anesthetic management, and the maternal and fetal outcomes at the time of discharge from hospital were extracted from paper and electronic medical records using a standardized Data Collection Form (Appendix 1, Supplemental Digital Content 1, http:// links.lww.com/JNA/A14). Maternal outcomes were graded according to the Glasgow Coma Outcome Scale (GOS).20 The GOS defines 1 as death, 2 as persistent vegetative state, 3 as severe disability, 4 as moderate disability, and 5 as a good recovery.
30 16 25
Presenting Signs and Symptoms
none has specifically described the anesthetic management of pregnant patients undergoing neurosurgical procedures. Our study objective was to review the anesthetic management of all pregnant patients undergoing intracranial neurosurgery in our institution and describe the perioperative complications and outcomes.
MVA, decreased LOC MVA, decreased LOC Speech difficulty; headache; weakness followed by decreased LOC Tonic-clonic seizure Confusion, speech difficulty Neck pain, photophobia, nausea followed by decreased LOC Headache; vomiting, decreased LOC None (elective procedure) Weakness, aphasia followed by decreased LOC
Anesthesia for Pregnant Patients Undergoing Neurosurgery
Gestational Age (wk)
Volume 26, Number 3, July 2014
Age (y)
Patient
J Neurosurg Anesthesiol
www.jnsa.com |
235
236 | www.jnsa.com
Intracerebral hemorrhage (AVM)
Evacuation of intracranial hematoma, EVD insertion
Evacuation of intracranial hematoma, EVD insertion Evacuation of Intracerebral hemorrhage intracranial (AVM) hematoma, resection of AVM Intracranial AVM Resection of AVM
No
No
Yes 0.8 mg/kg
No
Yes 1.7 mg/kg
No
Yes 1 mg/kg Yes Yes, intermittent 0.9 mg/kg after procedure only
No
No
Yes, No FHR before start of procedure No
No
No
Yes, intermittent Yes, intraoperative 1 mg/kg
No
No
No
Yes, 40 mg
No
No
Yes, 20 mg
No
Yes, 20 mg
No
No
No
No
No
No
No
No
No
Yes
No
No
U/S POD0: Normal U/S POD12: Normal
No assessment
U/S POD4: nonviable 8 wk pregnancy
No assessment
Not applicable
U/S POD6: Normal Normal FHR POD16 before discharge home U/S POD12: Normal twin pregnancy U/S POD15: Normal
U/S POD5: Normal U/S POD12: Normal U/S POD1: viable fetus
Postoperative Mannitol Furosemide Hyperventilation* Fetal Assessment
Yes, continuous Yes, intraoperative 1.5 mg/kg
FHR Monitoring
Discharge home (4)
Discharge home (5)
Discharge to rehabilitation center (4)
Maternal death POD4 from brain herniation (1)
Palliative (3)
Discharge to rehabilitation center (3) Discharge home (5)
Discharge to rehabilitation center (4) Palliative (3)
Discharge to rehabilitation center (3)
Maternal Outcome (GOS Scorew)
Elective C/S at term with good outcome Elective C/S at 30 wk with good outcome
Intrauterine fetal demise
Maternal death with fetus in situ
Intrauterine fetal demise at 28 wk
Elective C/S at 33 wk with good outcome of twin babies Viable fetus at discharge
Urgent C/S for fetal distress at 28 wk with good outcome
Therapeutic abortion on POD4
Emergency C/S for fetal distress at 32 wk with good outcome
Fetal Outcome
J Neurosurg Anesthesiol
r
*Hyperventilation was defined as an intraoperative documented PaCO2
