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A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "204" "paginaFinal" => "207" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Sampaio, G. Norte, M.J. Campos, A. Raimundo, C. Carreira, R. Órfão" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Sampaio" "email" => array:1 [ 0 => "anasssampaio@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Norte" ] 2 => array:2 [ "nombre" => "M.J." "apellidos" => "Campos" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Raimundo" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Carreira" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Órfão" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo anestésico de hipertensión intracraneal y embarazo. Informe de un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Rekate<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> proposed the following definition of hydrocephalus: “… an active distension of the ventricular system of the brain resulting from inadequate passage of CSF from its point of production within the cerebral ventricles to its point of absorption into the systemic circulation” Hydrocephalus can have many causes, but most involve obstructed CSF circulation or impaired absorption.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The improvement in survival rates of patients with neurosurgical disease (patients with residual tumours, CSF shunts, therapeutic implants, stents, etc.) has been accompanied by an increase in the number of non-neurosurgical procedures in these patients,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> including obstetric interventions in patients with intracranial or spinal disease, and interventions in patients with neurosurgical or neuroradiological implants.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">As a result, anaesthesiologists are now faced with the challenge of anaesthetising and managing neurosurgical patients with therapeutic devices that require non-neurosurgical surgery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Idiopathic intracranial hypertension (IIH) in young women has an estimated incidence of 0.9/100,000.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> The real incidence of pregnancy in patients with controlled obstructive hydrocephalus with ventriculoperitoneal shunt (VPS) is uncertain. So far, 204 cases of pregnancy in 117 VPS-dependent women have been described. In this unusual scenario, therefore, anaesthesiologists face the challenge of carefully managing the delicate well-being of the mother, her brain and the foetus.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 34-year-old pregnant woman with VPS (Sophysa adjustable valve) implanted 20 years prior due to obstructive hydrocephalus, was admitted to the Emergency Room (ER) with a Glasgow Coma Scale (GCS) of 8 (O1M5V2), and dilated and non-reactive pupils. Gestation time was 25 weeks and 6 days. Lumbar puncture was performed without incident, and showed CSF leak with no evidence of high pressure. The valve was readjusted to 11l<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, with clinical improvement. After this procedure, the patient's GCS score increased to 14 (O4M6V4), with equal pupils. The first brain computed tomography (CT) scan showed supratentorial ventricular dilatation and right-sided VPS catheter. Cisterns and sulci remained unobstructed, with mild transependymal oedema in the anterior and temporal peduncles. The follow-up CT scan showed a decrease in CSF volume in the ventricular system. One month later the patient returned to the ER with the same clinical status, which was also reversed by draining 20 cc of CSF and readjusting the valve to 9<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. After a third episode (3 days later), a further 30 cc of CSF were drained and the patient was admitted to the Neurosurgery department. The CT performed at that time did not show hydrocephalus. During each episode, the corresponding obstetrician performed an ultrasound examination, which showed normal foetal development with no warning signs. The patient was scheduled for caesarean section which would include a VPS revision and tubal sterilization.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The caesarean section was performed at 34 weeks of gestation. The patient entered the operating room clinically and haemodynamic stable, GCS of 15, with no neurological deficits and normal pre-anaesthesia diagnostic tests. She was premedicated with ranitidine 50<span class="elsevierStyleHsp" style=""></span>mg and metoclopramide 10<span class="elsevierStyleHsp" style=""></span>mg, and received balanced general anaesthesia. Rapid sequence induction was performed with fentanyl 50 μg and propofol 150<span class="elsevierStyleHsp" style=""></span>mg, neuromuscular blockade with rocuronium 70<span class="elsevierStyleHsp" style=""></span>mg, and anaesthesia maintenance with sevoflurane (MAC <1). Standard ASA monitoring was used, with bispectral index (BIS), urine output and invasive blood pressure. The patient remained haemodynamically stable during surgery, the caesarean section was uneventful, and the infant was born without complications, with an Apgar score of 9-10-10.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Conversion to total intravenous anaesthesia (TIVA) had originally been planned for VPS revision. However, after extraction of the foetus, the device was tested and found to be in good working order, so the surgeons decided against performing the review.</p><p id="par0040" class="elsevierStylePara elsevierViewall">At the end of the surgery, the neuromuscular blockade was reversed with sugammadex 200<span class="elsevierStyleHsp" style=""></span>mg, and the patient was transferred to the post anaesthesia care unit, with GCS of 15 and no neurological deficits, clinically and haemodynamically stable.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Hydrocephalus and chronically high intracranial pressure (ICP) can be managed in the long-term with the insertion of a shunt and a one-way valve to bypass CSF from the third ventricle to the peritoneum, right atrium, or pleura. The greatest challenge faced by surgeons treating patients with shunts who require incidental surgery includes shunt infection with potential retrograde infective meningoencephalitis or ventriculitis and shunt failure with recurrent hydrocephalus.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">VPS malfunction can be asymptomatic, but can also cause headaches, nausea, vomiting, visual disturbances, and permanent neurological deficits. The main symptoms of VPS malfunction (headache, nausea and vomiting) are very similar to the symptoms associated with pregnancy, making it difficult to perform differential diagnosis in these cases. This distinction is essential to guarantee the best treatment for the mother and infant.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A malfunctioning VPS can be treated by caesarean section, transformation of VPS to ventriculo-auricular shunt, endoscopic third ventriculostomy and conservative treatment, such as repeat lumbar punctures, or valve pressure adjustments.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Anaesthesia in patients with neurosurgical disease or patients with therapeutic devices can be difficult. The baseline neurological status, including GCS and pre-existing focal neurological deficits, should be documented in the preoperative evaluation, and patients should be monitored for signs of high ICP, which can lead to brain herniation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">These patients must have a normal physiological status before surgery, additional increases in ICP should be prevented, and a return to normal neurological status should be achieved rapidly to allow postoperative assessment of neurological function. TIVA is usually the technique of choice for rapid induction of anaesthesia and reduction of cerebral metabolic rate of oxygen (CMRO<span class="elsevierStyleInf">2</span>). Balanced general anaesthesia (BGA) can also be used, provided MAC ≤1 is maintained to avoid excessive cerebral vasodilation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Many articles on anaesthesia in pregnant women with high ICP discuss IIH, recommending that only the obstetrician can decide which type of delivery is best. The decision is not determined by the presence of IIH, as this is not in itself an indication for caesarean section.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> However, given the cerebral status of women in labour, caesarean section is usually chosen, even though vaginal delivery is also an option.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Neuraxial, subarachnoid, or epidural anaesthesia have been used in caesarean section for patients with IIH.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6–8</span></a> Although dural puncture may be contraindicated in patients with high ICP due to space-occupying lesions with risk of brain herniation, lumbar puncture for CSF drainage is also used to treat high ICP,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> so spinal anaesthesia is not contraindicated in these patients.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> However, when using epidural techniques for caesarean sections, it is important to bear in mind that large volumes administered in the epidural space can increase ICP, and women who have recently undergone CSF drainage are at risk of greater than expected block or even complete block.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Shunt failure can occur during pregnancy due to the enlarged uterus obstructing the VPS or to a change in the pressure gradient between the valve and intra-abdominal pressure.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,6</span></a> After delivery, shunt failure can be caused by blood clots.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">General anaesthesia for caesarean section in women with IIH is only recommended when unavoidable, since the goal of treatment is to minimize increases in ICP. In this case, hyperventilation and hypoxia should be avoided.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">If there are no anaesthetic complications in the postoperative period, only frequent neurological observations will be required in addition to standard recovery procedures and postoperative care. The decision to admit the patient to intensive care or a high-dependency unit should be based on the type of surgery performed, the presence of neurological deficits, or the appearance of new symptoms or unexpected signs in the immediate postoperative period. Multimodal analgesia should be used to reduce the risk of high-dose opioid requirement, as these can sedate the patient and mask neurological deterioration, or suppress ventilatory drive and cough.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In our case, we treated a pregnant woman with hydrocephalus, a malfunctioning VPS, and recurrent symptomatic increases in ICP. Given the need for tubal sterilization and VPS revision, we chose to perform caesarean section, and since these procedures would be performed during the caesarean section, our only option was general anaesthesia. Although we knew that TIVA could be performed for the procedures scheduled, we chose to start BGA with sevoflurane while maintaining MAC <1, since we had no experience with TIVA in caesarean section. We chose rapid sequence induction to minimize the risk of pulmonary aspiration, and administered rocuronium for neuromuscular blockade in order eliminate the risk of increased brain blood volume and ICP associated with succinylcholine. Weighing up the risk of sudden increase in ICP and risk of depression in the infant, we used opioids during anaesthesia induction to achieve sufficient depth and reduce as far as possible the stimulation of intubation and surgery. We informed the paediatrician of this prior to extraction.</p><p id="par0095" class="elsevierStylePara elsevierViewall">We had initially planned to convert BGA to TIVA after delivery, given its benefits in patients with intracranial hypertension. However, this was not necessary given the normal functioning of the PVS after extraction of the infant.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although these cases are still rare, the progress made in neurosurgical therapies and the subsequent increase in survival rates of patients with neurosurgical disease increase the likelihood of them presenting for non-neurosurgical procedures. This poses new challenges for anaesthesiologists, who have to carefully consider the risks and benefits in order to provide the best care.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In pregnant women with PVS and asymptomatic controlled ICP, the type of delivery should be decided by the obstetrician, since there are no contraindications in this regard. In these cases, there are no contraindications for neuraxial or general anaesthesia. The primary goal of caesarean section is to maintain ICP stable and prevent further increases. Neurosurgeons, obstetricians, and anaesthesiologists need to work together to assess, supervise, and decide the best management for these patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1330893" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1226239" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1330892" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1226238" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-15" "fechaAceptado" => "2019-11-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1226239" "palabras" => array:7 [ 0 => "Neurosurgery" 1 => "Brain" 2 => "Intracranial hypertension" 3 => "Hydrocephalus" 4 => "Prostheses and implants" 5 => "Ventriculoperitoneal shunt" 6 => "Pregnancy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1226238" "palabras" => array:7 [ 0 => "Neurocirugía" 1 => "Cerebro" 2 => "Hipertensión intracraneal" 3 => "Hidrocefalia" 4 => "Prótesis e implantes" 5 => "Derivación ventriculoperitoneal" 6 => "Embarazo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hydrocephalus is an active distension of the ventricular system of the brain. The improved survival rates of patients with neurosurgical pathology is accompanied by a greater number of non-neurosurgical procedures in patients who have therapeutic neurosurgical devices.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The real incidence of pregnancy in patients with obstructive hydrocephalus controlled with ventriculoperitoneal shunt (VPS) is unclear.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We present a case of a pregnant 34-year-old female with a VPS for obstructive hydrocephalus. Due to VPS obstruction secondary to uterus volume, she presented several episodes of neurological impairment during pregnancy. An elective caesarean section (C-section) and VPS review were planned for the same operative time.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This rare case reflects the challenge that the anaesthesiologist has to face in order to provide the best and simultaneous management of the wellbeing of the mother, the mother's brain and the foetus.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La hidrocefalia es una distensión activa del sistema ventricular del cerebro. Las mejores tasas de supervivencia de los pacientes con enfermedad neuroquirúrgica se acompañan de un mayor número de procedimientos no neuroquirúrgicos en pacientes que tienen dispositivos neuroquirúrgicos terapéuticos.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">No está clara la verdadera incidencia del embarazo en pacientes con hidrocefalia obstructiva controlada con derivación ventriculoperitoneal (DVP).</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presentamos un caso de una mujer embarazada de 34 años con una DVP para hidrocefalia obstructiva. Debido a la obstrucción de la DVP secundaria al volumen del útero, ella presentó varios episodios de deterioro neurológico durante el embarazo. Se planificaron una cesárea electiva y una revisión de la DVP para el mismo tiempo operatorio.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Este caso inusual representa un desafío al que el anestesiólogo debe enfrentarse para proporcionar el mejor manejo simultáneo del delicado bienestar de la madre, su cerebro, y el feto.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sampaio A, Norte G, Campos MJ, Raimundo A, Carreira C, Órfão R. Manejo anestésico de hipertensión intracraneal y embarazo. Informe de un caso. Rev Esp Anestesiol Reanim. 2020;67:204–207.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The definition and classification of hydrocephalus: a personal recommendation to stimulate debate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.L. 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