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Correspondence |
San Diego, California
To the Editor:
Arnold-Chiari type I malformation (ACM-I) consists of elongation and prolapse of the cerebellar tonsils below the foramen magnum.1 The most common clinical symptoms of this condition include headaches, vertigo, nystagmus, neck and upper extremity pain and/or weakness, respiratory impairment, and seizures. Increased intracranial pressure (ICP) has been reported in patients with ACM-I.2 The obstetric and anesthetic management of women affected by ACM-I is scarcely addressed in the literature,3–5 and subsequently no uniform recommendations regarding mode of delivery (vaginal vs abdominal) and choice of anesthesia (regional vs general) can be made. Although some5 have cautioned that dural puncture for anesthetic management of vaginal or abdominal delivery may initiate and/or exacerbate neurological symptoms of this condition, others have documented the safe use of regional anesthesia in these patients.3
A 35-yr-old gravida 1 para 0 otherwise healthy female with newly diagnosed (first trimester of pregnancy) and mildly symptomatic (recurrent headaches, vertigo, and numbness of both upper extremities) ACM-I malformation was evaluated by a multidisciplinary team of experts including the obstetrician, obstetric anesthesiologist, neurologist, and neonatologist at 37 weeks of gestation. The peripartum care plan aimed at avoidance of labour-induced stress, and particularly pushing-induced increase in the ICP in the second stage of labour. The peripartum plan was accomplished two weeks later by performing an elective Cesarean section under single-dose spinal anesthesia (with 12 mg of 0.75% bupivacaine, 10 µg of fentanyl, and 0.2 mg of preservative free morphine induced with a 27-gauge atraumatic needle). No exacerbation of preexisting maternal symptoms was reported postpartum.
In conclusion, this report not only emphasizes the importance of a multidisciplinary and individualized approach to pregnant women with uncommon, non-pregnancy specific disorders such as ACM-I, but also provides further evidence that spinal anesthesia can be safely and effectively performed in pregnant patients with ACM-I undergoing Cesarean delivery. However, for parturients with other types of ACM accompanied by other clinical manifestations, a different choice of obstetric and anesthetic management may prove more appropriate.
References
1 Sicuranza GB, Steinberg T, Figueroa R. Arnold-Chiari malformation in a pregnant woman. Obstet Gynecol 2003; 102 (5 Pt 2): 1191–4.
2 Heiss JD, Patrons N, DeVroom HT, et al. Elucidating the pathophysiology of syringomyelia. J Neurosurg 1999; 91: 553–62.[Medline]
3 Semple DA, McClure JH. Arnold-Chiari malformation in pregnancy. Anaesthesia 1996; 51: 580–2.[Medline]
4 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: 253–5.
5 Hullander RM, Bogard TD, Leivers D, Moran D, Dewan DM. Chiari I malformation presenting as recurrent spinal headache. Anesth Analg 1992; 75: 1025–6.
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