When seconds count - ethical and evidence-based management of neurosurgical emergencies in pregnancy

Introduction. Neurosurgical emergencies during pregnancy are associated with maternal and fetal risk and require rapid, coordinated, and ethically sound decision-making. Conditions such as traumatic brain injury, intracranial hemorrhage, rapidly expanding intracranial tumors, acute hydrocephalus, and spinal cord compression often necessitate urgent intervention despite the physiological adaptations of pregnancy, altered pharmacokinetics, anesthetic constraints, and limitations in diagnostic imaging. Owing to the predominance of case reports and small series in the literature, management strategies are frequently individualized. Material and Methods. This narrative review synthesizes the available literature on urgent neurosurgical care in pregnant patients, with particular emphasis on maternal and fetal outcomes, pregnancy-specific modifications of neurocritical and surgical management, and ethical considerations. A structured search of PubMed and Scopus was conducted to identify relevant studies addressing surgical timing, perioperative strategies, multidisciplinary coordination, and reported ethical dilemmas. Conclusion. The reviewed evidence underscores the importance of early diagnosis, prioritization of maternal stabilization, and close collaboration among neurosurgery, obstetrics, anesthesia, and neonatology teams. When indicated, neurosurgical procedures should generally not be delayed solely due to pregnancy, and individualized anesthetic strategies may help minimize fetal exposure. Ethical issues - including informed consent, maternal autonomy, and consideration of fetal interests - require clear communication and shared decision-making. Despite improvements in care, standardized management guidelines remain limited, highlighting the need for higher-quality evidence and structured interdisciplinary treatment pathways.