Combined emergency Caesarean section and intracerebral aneurysm clipping

Management of cerebral aneurysm clipping with acute subarachnoid haemorrhage during pregnancy involves medical issues and poses an interesting challenge to anaesthesiologists, obstetricians and neurosurgeons [1–3]. We present a case of acute subarachnoid bleeding in a pregnant patient in whom emergency Caesarean section was performed followed by craniotomy and clip obliteration of the aneurysm. A 38-year-old patient at 36 weeks gestation experienced severe headache with loss of consciousness induced by Hunt and Hess Grade IV subarachnoid haemorrhage. Following emergency intubation with methohexitone and succinylcholine, anaesthesia was maintained with fentanyl, midazolam and atracurium. The fetal heart rate was monitored by Doppler sonography in addition to monitoring of maternal heart rate, invasive arterial blood pressure, end-expiratory CO2 and urine output. Computed tomography and intra-arterial digital subtraction angiography revealed a large ruptured aneurysm of the right internal carotid artery (Figs 11 and 12). Superselective angiography was performed under moderate hypotension (mean arterial pressure ± 75 mmHg) and hyperventilation (arterial carbon dioxide pressure ± 36 mmHg). Owing to fetal bradycardia, the indication for scheduled craniotomy was revised and emergency Caesarean section was performed. The neonate was delivered 70 min after induction of anaesthesia; the Apgar scores were 2 and 7 at 1 and 5 min, respectively. Following intubation and ventilation, the neonate emerged from anaesthesia 12 h later. After Caesarean section, an external ventricular drainage system was installed and craniotomy and clip obliteration of the aneurysm were carried out consecutively. Due to the intracranial oedema, the patient was sedated with midazolam and fentanyl and hyperventilated for the next 5 days. Postoperative course was uneventful. Only minor neurological deficits were recognised which completely recovered within the first 2 months postoperatively. Axial CT scan without contrast showing a severe aneurysmal subarachnoid haemorrhage that fills the basal cisterns and produces a hydrocephalus (note the marked brain swelling). Aneurysmal subarachnoid haemorrhage during pregnancy is an infrequent complication, presenting a hazard to both the mother and the fetus. Over 80% of aneurysmal subarachnoid haemorrhages during pregnancy occur during the second and third trimester [4]. Successful treatment requires thorough diagnostics and close monitoring in a flexible teamwork to address both the varying maternal and fetal needs. The fundamental aims of anaesthesia are to maintain oxygenation and stable systemic, cerebral and placental haemodynamics and to avoid increased intracranial pressure. In the situation of acute fetal distress, as occurred in the present case, one must, at any time, be prepared for immediate Caesarean section. Under these circumstances, it has proven helpful to have a special neonatal care team and unit to care for the ‘co-anaesthetised’ baby delivered at an unexpected time during the procedure. We strongly encourage the development of working relationships for guidelines for the management of aneurysmal subarachnoid haemorrhage and similar cerebrovascular diseases during pregnancy.