Skip to main content

Advertisement

SpringerLink
Log in

Neuraxial Techniques in Obstetric Patients with Intracranial Lesions

  • REVIEW
  • Published:
Current Obstetrics and Gynecology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

A pregnant woman with intracranial pathology can pose unique considerations and challenges on the specific mode of delivery and anesthetic choice. This review aims to summarize the current understanding and data on neuraxial techniques in obstetric patients with intracranial lesions.

Recent Findings

In a majority of cases, neuraxial techniques can be performed safely in obstetric patients with intracranial pathology; however, high-quality data are lacking to support a formulaic approach so decisions should be individualized. Neuraxial techniques should be avoided in those with imaging evidence of significant mass effect causing midline or downward shift of brain tissue, or obstruction to cerebrospinal fluid flow at or above the foramen magnum.

Summary

Any patients with new or worsening neurologic symptoms should be evaluated for raised intracranial pressure. Neuroradiological and neurosurgical consultations are particularly valuable in the decision-making process regarding the mode of delivery and anesthetic technique. In addition to the individual clinical features of each case, the final decision should always take into consideration the patient’s motivation, risk tolerance, and personal preference.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: •   Of importance •• Of major importance

  1. Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb Blood Flow Metab. 2016;36(8):1338–50. https://doi.org/10.1177/0271678X16648711.

  2. Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesth Analg. 1986;65(3):316–7.

    Article  CAS  PubMed  Google Scholar 

  3. Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 1: conservative and pharmacological management. Int J Obstet Anesth. 2019;38:93–103. https://doi.org/10.1016/j.ijoa.2018.12.006.

  4. Johnson AC, Cipolla MJ. The cerebral circulation during pregnancy: adapting to preserve normalcy. Physiology (Bethesda). 2015;30(2):139–47. https://doi.org/10.1152/physiol.00048.2014.

    Article  CAS  PubMed  Google Scholar 

  5. Fish SA, Morrison JC, Bucovaz ET, Wiser WL, Whybrew WD. Cerebral spinal fluid studies in eclampsia. Am J Obstet Gynecol. 1972;112(4):502–12. https://doi.org/10.1016/0002-9378(72)90310-9.

    Article  CAS  PubMed  Google Scholar 

  6. Marx GF, Zemaitis MT, Orkin LR. Cerebrospinal fluid pressures during labor and obstetrical anesthesia. Anesthesiology. 1961;22:348–54. https://doi.org/10.1097/00000542-196105000-00003.

    Article  CAS  PubMed  Google Scholar 

  7. Hopkins EL, Hendricks CH, Cibils LA. Cerebrospinal fluid pressure in labor. Am J Obstet Gynecol. 1965;93(7):907–16. https://doi.org/10.1016/0002-9378(65)90149-3.

    Article  CAS  PubMed  Google Scholar 

  8. Miller EC, Leffert L. Stroke in pregnancy: a focused update. Anesth Analg. 2020;130(4):1085–96. https://doi.org/10.1213/ANE.0000000000004203.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Moore DM, Meela M, Kealy D, Crowley L, McMorrow R, O’Kelly B. An intrathecal catheter in a pregnant patient with idiopathic intracranial hypertension: analgesia, monitor and therapy? Int J Obstet Anesth. 2014;23(2):175–8. https://doi.org/10.1016/j.ijoa.2013.10.007.

    Article  CAS  PubMed  Google Scholar 

  10. Kate MP, Thomas B, Sylaja PN. Cerebral venous thrombosis in post-lumbar puncture intracranial hypotension: case report and review of literature. F1000Res. 2014;3:41. https://doi.org/10.12688/f1000research.3-41.v1.

  11. Koziarz A, Sne N, Kegel F, Nath S, Badhiwala JH, Nassiri F, et al. Bedside optic nerve ultrasonography for diagnosing increased intracranial pressure: a systematic review and meta-analysis. Ann Intern Med. 2019;171(12):896–905. https://doi.org/10.7326/M19-0812.

    Article  PubMed  Google Scholar 

  12. Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Kyeremanteng K, et al. Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis. BMJ. 2019;366:l4225. https://doi.org/10.1136/bmj.l4225.

  13. •• Leffert LR, Schwamm LH. Neuraxial anesthesia in parturients with intracranial pathology. Anesthesiology. 2013;119(3):703–18. https://doi.org/10.1097/aln.0b013e31829374c2. This is a comprehensive review of paturients with intracranial pathology that includes a decision tree outlining the critical elements to be considered with assessing the risks of neuraxial techniques in these patients.

  14. Pinto VL, Tadi P, Adeyinka A. Increased intracranial pressure. StatPearls. Treasure Island (FL) 2022.

  15. Low JA, Boston RW, Cervenko FW. Effect of low maternal carbon dioxide tension on placental gas exchange. Am J Obstet Gynecol. 1970;106(7):1032–43. https://doi.org/10.1016/s0002-9378(16)34089-3.

    Article  CAS  PubMed  Google Scholar 

  16. Anson JA, Vaida S, Giampetro DM, McQuillan PM. Anesthetic management of labor and delivery in patients with elevated intracranial pressure. Int J Obstet Anesth. 2015;24(2):147–60. https://doi.org/10.1016/j.ijoa.2015.01.004.

    Article  CAS  PubMed  Google Scholar 

  17. Boker A, Ong BY. Anesthesia for cesarean section and posterior fossa craniotomy in a patient with von Hippel-Lindau disease. Can J Anaesth. 2001;48(4):387–90. https://doi.org/10.1007/BF03014969.

    Article  CAS  PubMed  Google Scholar 

  18. Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain Med. 2016;41(2):251–60. https://doi.org/10.1097/aap.0000000000000184.

    Article  PubMed  Google Scholar 

  19. Pallud J, Mandonnet E, Deroulers C, Fontaine D, Badoual M, Capelle L, et al. Pregnancy increases the growth rates of World Health Organization grade II gliomas. Ann Neurol. 2010;67(3):398–404. https://doi.org/10.1002/ana.21888.

    Article  PubMed  Google Scholar 

  20. Pravdenkova S, Al-Mefty O, Sawyer J, Husain M. Progesterone and estrogen receptors: opposing prognostic indicators in meningiomas. J Neurosurg. 2006;105(2):163–73. https://doi.org/10.3171/jns.2006.105.2.163.

    Article  CAS  PubMed  Google Scholar 

  21. Su TM, Lan CM, Yang LC, Lee TC, Wang KW, Hung KS. Brain tumor presenting with fatal herniation following delivery under epidural anesthesia. Anesthesiology. 2002;96(2):508–9. https://doi.org/10.1097/00000542-200202000-00041.

    Article  PubMed  Google Scholar 

  22. Remadevi R, Babu DD, Sureshkumar K, Patil SA. Epidural anesthesia for caesarean section in a pregnant patient with pituitary macroadenoma. J Clin Diagn Res. 2014;8(7):GD01–2. https://doi.org/10.7860/JCDR/2014/9666.4552.

  23. Reschke M, Sweeney JM, Wong N. Spinal anesthesia performed for cesarean delivery after external ventricular drain placement in a parturient with symptomatology from an intracranial mass. Int J Obstet Anesth. 2019;37:122–5. https://doi.org/10.1016/j.ijoa.2018.08.010.

    Article  CAS  PubMed  Google Scholar 

  24. Goroszeniuk T, Howard RS, Wright JT. The management of labour using continuous lumbar epidural analgesia in a patient with a malignant cerebral tumour. Anaesthesia. 1986;41(11):1128–9. https://doi.org/10.1111/j.1365-2044.1986.tb12962.x.

    Article  CAS  PubMed  Google Scholar 

  25. Singh G, Dash HH, Arora D. Inadvertent neuraxial anesthesia in a patient with an intracranial space-occupying lesion. J Neurosurg Anesthesiol. 2016;28(4):428–9. https://doi.org/10.1097/ANA.0000000000000214.

    Article  PubMed  Google Scholar 

  26. • Girault A, Dommergues M, Nizard J. Impact of maternal brain tumours on perinatal and maternal management and outcome: a single referral centre retrospective study. Eur J Obstet Gynecol Reprod Biol. 2014;183:132–6. https://doi.org/10.1016/j.ejogrb.2014.10.027. Findings from this review show that tumors diagnosed during pregnancy are associated with poor outcomes; however, vaginal deliveries with epidural anesthesia can be safe in specific patients.

  27. Wang LP, Paech MJ. Neuroanesthesia for the pregnant woman. Anesth Analg. 2008;107(1):193–200. https://doi.org/10.1213/ane.0b013e31816c8888.

    Article  PubMed  Google Scholar 

  28. Bateman BT, Olbrecht VA, Berman MF, Minehart RD, Schwamm LH, Leffert LR. Peripartum subarachnoid hemorrhage: nationwide data and institutional experience. Anesthesiology. 2012;116(2):324–33. https://doi.org/10.1097/ALN.0b013e3182410b22.

    Article  PubMed  Google Scholar 

  29. Mabray MC, Starcevich J, Hallstrom J, Robinson M, Bartlett M, Nelson J, et al. High prevalence of spinal cord cavernous malformations in the familial cerebral cavernous malformations type 1 cohort. AJNR Am J Neuroradiol. 2020;41(6):1126–30. https://doi.org/10.3174/ajnr.A6584.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Bayrak-Toydemir P, Mao R, Lewin S, McDonald J. Hereditary hemorrhagic telangiectasia: an overview of diagnosis and management in the molecular era for clinicians. Genet Med. 2004;6(4):175–91. https://doi.org/10.1097/01.gim.0000132689.25644.7c.

    Article  CAS  PubMed  Google Scholar 

  31. Hayashi M, Kakinohana M. Obstetric anesthesia for a pregnant woman with brainstem cavernous malformations: a case report. A A Case Rep. 2017;9(2):54–6. https://doi.org/10.1213/XAA.0000000000000525.

    Article  PubMed  Google Scholar 

  32. Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric patient. Br J Anaesth. 2001;86(3):442–4. https://doi.org/10.1093/bja/86.3.442.

    Article  CAS  PubMed  Google Scholar 

  33. von Knobelsdorff G, Paris A. [Intracerebral hemorrhage after cesarean section under spinal anesthesia. Coincidence or causality?]. Anaesthesist. 2004;53(1):41–4. https://doi.org/10.1007/s00101-003-0585-9.

  34. Parikh N, Parikh N. Management of anesthesia for cesarean delivery in a patient with an unruptured intracranial aneurysm. Int J Obstet Anesth. 2018;36:118–21. https://doi.org/10.1016/j.ijoa.2018.06.007.

    Article  CAS  PubMed  Google Scholar 

  35. Kim YW, Neal D, Hoh BL. Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery. 2013;72(2):143–9; discussion 50. https://doi.org/10.1227/NEU.0b013e3182796af9.

  36. Yih PS, Cheong KF. Anaesthesia for caesarean section in a patient with an intracranial arteriovenous malformation. Anaesth Intensive Care. 1999;27(1):66–8. https://doi.org/10.1177/0310057X9902700114.

    Article  CAS  PubMed  Google Scholar 

  37. Carvalho CS, Resende F, Centeno MJ, Ribeiro I, Moreira J. Anesthetic approach of pregnant woman with cerebral arteriovenous malformation and subarachnoid hemorrhage during pregnancy: Case report. Braz J Anesthesiol. 2013;63(2):223–6. https://doi.org/10.1016/j.bjane.2012.05.004.

    Article  PubMed  Google Scholar 

  38. Asano S, Hayashi N, Edakubo S, Hosokawa M, Suwa J, Saito Y, et al. Successful perinatal management of a ruptured brain arteriovenous malformation in a pregnant patient by endovascular embolization followed by elective cesarean section: a single-case experience. JA Clinical Reports. 2016;2(1). https://doi.org/10.1186/s40981-016-0045-6.

  39. • Waters JFR, O’Neal MA, Pilato M, Waters S, Larkin JC, Waters JH. Management of anesthesia and delivery in women with Chiari I malformations. Obstet Gynecol. 2018;132(5):1180–4. https://doi.org/10.1097/AOG.0000000000002943. This case series provides data on 95 deliveries in patients with Chiari malformation, with neurologic complications associated with anesthetic technique.

  40. Chantigian RC, Koehn MA, Ramin KD, Warner MA. Chiari I malformation in parturients. J Clin Anesth. 2002;14(3):201–5. https://doi.org/10.1016/s0952-8180(02)00342-2.

    Article  PubMed  Google Scholar 

  41. Choi CK, Tyagaraj K. 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. https://doi.org/10.1155/2013/512915.

  42. Kuczkowski KM. Spinal anesthesia for Cesarean delivery in a parturient with Arnold-Chiari type I malformation. Can J Anaesth. 2004;51(6):639. https://doi.org/10.1007/bf03018412.

    Article  PubMed  Google Scholar 

  43. Landau R, Giraud R, Delrue V, Kern C. Spinal anesthesia for cesarean delivery in a woman with a surgically corrected type I Arnold Chiari malformation. Anesth Analg. 2003;97(1):253–5, table of contents. https://doi.org/10.1213/01.ane.0000066312.32029.8b.

  44. Nielsen JL, Bejjani GK, Vallejo MC. Cesarean delivery in a parturient with syringomyelia and worsening neurological symptoms. J Clin Anesth. 2011;23(8):653–6. https://doi.org/10.1016/j.jclinane.2011.03.007.

    Article  PubMed  Google Scholar 

  45. Ghaly RF, Candido KD, Sauer R, Knezevic NN. Anesthetic management during Cesarean section in a woman with residual Arnold-Chiari malformation Type I, cervical kyphosis, and syringomyelia. Surg Neurol Int. 2012;3:26. https://doi.org/10.4103/2152-7806.92940.

    Article  PubMed  PubMed Central  Google Scholar 

  46. • Gruffi TR, Peralta FM, Thakkar MS, Arif A, Anderson RF, Orlando B, et al. Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study. Int J Obstet Anesth. 2019;37:52–6. https://doi.org/10.1016/j.ijoa.2018.10.002. Findings from this study show that anesthetic complications occur infrequently in patients with Arnold-Chiari I regardless of the anesthetic management.

  47. 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. https://doi.org/10.4103/2152-7806.198737.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Gragasin FS, Chiarella AB. Use of an intrathecal catheter for analgesia, anesthesia, and therapy in an obstetric patient with pseudotumor cerebri syndrome. A A Case Rep. 2016;6(6):160–2. https://doi.org/10.1213/XAA.0000000000000279.

    Article  PubMed  Google Scholar 

  49. Alves S, Sousa N, Cardoso L, Alves J. Multidisciplinary management of idiopathic intracranial hypertension in pregnancy: case series and narrative review. Braz J Anesthesiol. 2021. https://doi.org/10.1016/j.bjane.2021.02.030.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC, 6H 3N1, Canada

    Kathryn J. Clark & Anthony Chau

  2. Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada

    Anthony Chau

  3. Department of Anesthesia, St. Paul’s Hospital, Vancouver, BC, Canada

    Anthony Chau

Authors
  1. Kathryn J. Clark
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anthony Chau
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anthony Chau.

Ethics declarations

Conflict of Interest

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Clark, K.J., Chau, A. Neuraxial Techniques in Obstetric Patients with Intracranial Lesions. Curr Obstet Gynecol Rep 12, 1–7 (2023). https://doi.org/10.1007/s13669-023-00345-y

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13669-023-00345-y

Keywords

Search

Navigation