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Management of idiopathic intracranial hypertension in parturients: anesthetic considerations

Prise en charge de l’hypertension intracrânienne idiopathique chez la parturiente: considérations anesthésiques

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Canadian Journal of Anesthesia/Journal canadien d'anesthésie Aims and scope Submit manuscript

Abstract

Purpose

Idiopathic intracranial hypertension (IIH) is a rare condition characterized by raised intracranial pressure (ICP) without related pathology in either the brain or the composition of cerebrospinal fluid (CSF). Herein, we provide a brief review of the clinical presentation of IIH and the anesthetic considerations in parturients diagnosed with the disorder.

Source

We conducted a MEDLINE® literature search for all types of articles published in English with restriction for year of publication, and we used the search terms “idiopathic intracranial hypertension”, “pseudotumor cerebri”, “benign intracranial hypertension”, “pregnancy”, “cesarean section”, “labour analgesia”, “epidural”, and “anesthesia”.

Principal findings

Idiopathic intracranial hypertension affects primarily obese women of childbearing age. The main symptom is headache, and the cardinal sign is papilledema. The main goal of management is to preserve visual function. Treatment lies in the administration of diuretics and corticosteroids, control of excessive weight gain, and surgical management, such as cerebrospinal fluid diversion or optic nerve sheath fenestration for refractory cases. For the parturient with IIH, Cesarean delivery is not necessarily indicated. Neuraxial anesthesia has been used uneventfully for both labour analgesia and for Cesarean delivery. There are reports describing successful use of both spinal and epidural anesthesia, even in IIH patients with CSF diversion devices in situ.

Conclusion

Although IIH is rare, there are special considerations for anesthetic management in the parturient. Despite the presence of raised ICP in these patients, there are no specific contraindications to neuraxial techniques, and uncal herniation has not been reported to occur in patients with IIH.

Résumé

Objectif

L’hypertension intracrânienne idiopathique (HII) est une condition rare qui se caractérise par une pression intracrânienne (PIC) élevée sans pathologie connexe au niveau du cerveau ou de la composition du liquide céphalorachidien (LCR). Nous proposons ici une brève synthèse de la présentation clinique de l’HII et quelques considérations anesthésiques chez les parturientes avec un diagnostic de ce trouble.

Source

Nous avons réalisé une recherche de la littérature sur MEDLINE® pour extraire tous les articles publiés en anglais en posant comme contrainte l’année de publication, et avons utilisé les termes de recherche « idiopathic intracranial hypertension » (hypertension intracrânienne idiopathique), « pseudotumor cerebri » (méningite séreuse), « benign intracranial hypertension » (hypertension intracrânienne bénigne), « pregnancy » (grossesse), « cesarean section » (césarienne), « labour analgesia » (analgésie pour le travail obstétrical), « epidural » (péridurale), et « anesthesia » (anesthésie).

Constatations principales

L’hypertension intracrânienne idiopathique affecte principalement les femmes obèses en âge de procréer. Les céphalées sont le symptôme principal, et le symptôme cardinal est l’œdème papillaire. L’objectif principal de la prise en charge est de conserver la fonction visuelle. Le traitement consiste à administrer des diurétiques et des corticostéroïdes, à contrôler une prise de poids excessive, et à effectuer une prise en charge chirurgicale, telle que le détournement du liquide céphalorachidien ou la fenestration de la gaine du nerf optique dans les cas réfractaires. L’accouchement par césarienne n’est pas forcément indiqué chez la parturiente atteinte d’HII. L’anesthésie neuraxiale a été utilisée sans complication pour l’analgésie du travail obstétrical et pour les accouchements par césarienne. Certains cas rapportés décrivent l’utilisation réussie d’anesthésie rachidienne et de péridurale, même chez les patientes atteintes d’HII et chez lesquelles étaient positionnés des appareils de dérivation du LCR.

Conclusion

Bien que l’HII soit rare, certaines considérations particulières s’appliquent à la prise en charge anesthésique de la parturiente atteinte de ce trouble. Malgré la présence d’une PIC élevée chez ces patientes, il n’existe pas de contre-indication spécifique aux techniques neuraxiales, et on n’a pas rapporté d’hernie uncinée chez les patientes atteintes d’HII.

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References

  1. Dandy WE. Intracranial pressure without brain tumor: diagnosis and treatment. Ann Surg 1937; 106: 492-513.

    Article  CAS  Google Scholar 

  2. Quincke H. Uber Meningitis serosa: Sammlung linische Vortra 67. Inn Med 1893; 23: 655-94.

    Google Scholar 

  3. Corbett JJ, Thompson HS. The rational management of idiopathic intracranial hypertension. Arch Neurol 1989; 46: 1049-51.

    Article  CAS  Google Scholar 

  4. Durcan FJ, Corbett JJ, Wall M. The incidence of pseudotumor cerebri. Population studies in Iowa and Louisiana. Arch Neurol 1988; 45: 875-7.

    Article  CAS  Google Scholar 

  5. Dhungana S, Sharrack B, Woodroofe N. Idiopathic intracranial hypertension. Acta Neurol Scand 2010; 121: 71-82.

    Article  CAS  Google Scholar 

  6. Hannerz J, Ericson K. The relationship between idiopathic intracranial hypertension and obesity. Headache 2009; 49: 178-84.

    Article  Google Scholar 

  7. Rowe FJ, Sarkies NJ. The relationship between obesity and idiopathic intracranial hypertension. Int J Obes Relat Metab Disord 1999; 23: 54-9.

    Article  CAS  Google Scholar 

  8. Ooi LY, Walker BR, Bodkin PA, Whittle IR. Idiopathic intracranial hypertension: can studies of obesity provide the key to understanding pathogenesis? Br J Neurosurg 2008; 22: 187-94.

    Article  Google Scholar 

  9. Tang RA. Management of idiopathic intracranial hypertension in pregnancy. MedGenMed 2005; 7: 40.

    PubMed  PubMed Central  Google Scholar 

  10. Tang RA, Dorotheo EU, Schiffman JS, Bahrani HM. Medical and surgical management of idiopathic intracranial hypertension in pregnancy. Curr Neurol Neurosci Rep 2004; 4: 398-409.

    Article  Google Scholar 

  11. Rothner AD, Brust JC. Pseudotumor cerebri. Report of a familial occurrence. Arch Neurol 1974; 30: 110-1.

    Article  CAS  Google Scholar 

  12. Traviesa DC, Schwartzman RJ, Glaser JS, Savino P. Familial benign intracranial hypertension. J Neurol Neurosurg Psychiatry 1976; 39: 420-3.

    Article  CAS  Google Scholar 

  13. Gumma AD. Recurrent benign intracranial hypertension in pregnancy. Eur J Obstet Gynecol Reprod Biol 2004; 115: 244.

    Article  CAS  Google Scholar 

  14. Kaul B, Vallejo MC, Ramanathan S, Mandell GL, Krohner RG. Accidental spinal analgesia in the presence of a lumboperitoneal shunt in an obese parturient receiving enoxaparin therapy. Anesth Analg 2002; 95: 441-3.

    PubMed  Google Scholar 

  15. Peterson CM, Kelly JV. Pseudotumor cerebri in pregnancy. Case reports and review of literature. Obstet Gynecol Surv 1985; 40: 323-9.

    Article  CAS  Google Scholar 

  16. Wall M. The headache profile of idiopathic intracranial hypertension. Cephalalgia 1990; 10: 331-5.

    Article  CAS  Google Scholar 

  17. Friedman DI. Pseudotumor cerebri presenting as headache. Expert Rev Neurother 2008; 8: 397-407.

    Article  Google Scholar 

  18. Randhawa S, Van Stavern GP. Idiopathic intracranial hypertension (pseudotumor cerebri). Curr Opin Ophthalmol 2008; 19: 445-53.

    Article  Google Scholar 

  19. Giuseffi V, Wall M, Siegel PZ, Rojas PB. Symptoms and disease associations in idiopathic intracranial hypertension (pseudotumor cerebri): a case-control study. Neurology 1991; 41: 239-44.

    Article  CAS  Google Scholar 

  20. Wall M. Idiopathic intracranial hypertension (pseudotumor cerebri). Curr Neurol Neurosci Rep 2008; 8: 87-93.

    Article  Google Scholar 

  21. Evans RW, Friedman DI. Expert opinion: the management of pseudotumor cerebri during pregnancy. Headache 2000; 40: 495-7.

    Article  CAS  Google Scholar 

  22. Marcelis J, Silberstein SD. Idiopathic intracranial hypertension without papilledema. Arch Neurol 1991; 48: 392-9.

    Article  CAS  Google Scholar 

  23. Wang SJ, Silberstein SD, Patterson S, Young WB. Idiopathic intracranial hypertension without papilledema: a case-control study in a headache center. Neurology 1998; 51: 245-9.

    Article  CAS  Google Scholar 

  24. Sher NA, Wirtschafter J, Shapiro SK, See C, Shapiro I. Unilateral papilledema in ‘benign’ intracranial hypertension (pseudotumor cerebri). JAMA 1983; 250: 2346-7.

    Article  CAS  Google Scholar 

  25. Wattamwar PR, Baheti NN, Radhakrishnan A. Idiopathic intracranial hypertension presenting as unilateral papilledema. Neurol India 2010; 58: 818-9.

    Article  Google Scholar 

  26. Zamecki KJ, Frohman LP, Turbin RE. Severe visual loss associated with idiopathic intracranial hypertension (IIH) in pregnancy. Clin Ophthalmol 2007; 1: 99-103.

    PubMed  PubMed Central  Google Scholar 

  27. Aly EE, Lawther BK. Anaesthetic management of uncontrolled idiopathic intracranial hypertension during labour and delivery using an intrathecal catheter. Anaesthesia 2007; 62: 178-81.

    Article  CAS  Google Scholar 

  28. Huna-Baron R, Kupersmith MJ. Idiopathic intracranial hypertension in pregnancy. J Neurol 2002; 249: 1078-81.

    Article  Google Scholar 

  29. Capobianco DJ, Brazis PW, Cheshire WP. Idiopathic intracranial hypertension and seventh nerve palsy. Headache 1997; 37: 286-8.

    Article  CAS  Google Scholar 

  30. Speer C, Pearlman J, Phillips PH, Cooney M, Repka MX. Fourth cranial nerve palsy in pediatric patients with pseudotumor cerebri. Am J Ophthalmol 1999; 127: 236-7.

    Article  CAS  Google Scholar 

  31. Bagga R, Jain V, Das CP, et al. Choice of therapy, mode of delivery in idiopathic intracranial hypertension during pregnancy. MedGenMed 2005; 7: 42.

    PubMed  PubMed Central  Google Scholar 

  32. Koontz WL, Herbert WN, Cefalo RC. Pseudotumor cerebri in pregnancy. Obstet Gynecol 1983; 62: 324-7.

    Article  CAS  Google Scholar 

  33. Janny P, Chazal J, Colnet G, Irthum B, Georget AM. Benign intracranial hypertension and disorders of CSF absorption. Surg Neurol 1981; 15: 168-74.

    Article  CAS  Google Scholar 

  34. Johnston I, Kollar C, Dunkley S, Assaad N, Parker G. Cranial venous outflow obstruction in the pseudotumour syndrome: incidence, nature and relevance. J Clin Neurosci 2002; 9: 273-8.

    Article  CAS  Google Scholar 

  35. Karahalios DG, Rekate HL, Khayata MH, Apostolides PJ. Elevated intracranial venous pressure as a universal mechanism in pseudotumor cerebri of varying etiologies. Neurology 1996; 46: 198-202.

    Article  CAS  Google Scholar 

  36. Sugerman HJ, DeMaria EJ, Felton WL 3rd, Nakatsuka M, Sismanis A. Increased intra-abdominal pressure and cardiac filling pressures in obesity-associated pseudotumor cerebri. Neurology 1997; 49: 507-11.

    Article  CAS  Google Scholar 

  37. Nedelmann M, Kaps M, Mueller-Forell W. Venous obstruction and jugular valve insufficiency in idiopathic intracranial hypertension. J Neurol 2009; 256: 964-9.

    Article  Google Scholar 

  38. Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002; 59: 1492-5.

    Article  Google Scholar 

  39. Friedman DI, Jacobson DM. Idiopathic intracranial hypertension. J Neuroophthalmol 2004; 24: 138-45.

    Article  Google Scholar 

  40. Brodsky MC, Vaphiades M. Magnetic resonance imaging in pseudotumor cerebri. Ophthalmology 1998; 105: 1686-93.

    Article  CAS  Google Scholar 

  41. De Simone R, Ranieri A, Bonavita V. Advancement in idiopathic intracranial hypertension pathogenesis: focus on sinus venous stenosis. Neurol Sci 2010; 31(Suppl 1): S33-9.

    Article  Google Scholar 

  42. Scoffings DJ, Pickard JD, Higgins JN. Resolution of transverse sinus stenoses immediately after CSF withdrawal in idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry 2007; 78: 911-2.

    Article  Google Scholar 

  43. Lee SW, Gates P, Morris P, Whan A, Riddington L. Idiopathic intracranial hypertension; immediate resolution of venous sinus “obstruction” after reducing cerebrospinal fluid pressure to < 10cmH(2)O. J Clin Neurosci 2009; 16: 1690-2.

    Article  Google Scholar 

  44. Acheson JF. Idiopathic intracranial hypertension and visual function. Br Med Bull 2006; 79-80: 233-44.

    Article  Google Scholar 

  45. Henry SD, Jacques S. Benign intracranial hypertension in pregnancy. JACEP 1979; 8: 323-5.

    Article  CAS  Google Scholar 

  46. Babur H, Torres Q, Savitz MH. Lumboperitoneal shunts. Mt Sinai J Med 2000; 67: 272-3.

    CAS  PubMed  Google Scholar 

  47. Burgett RA, Purvin VA, Kawasaki A. Lumboperitoneal shunting for pseudotumor cerebri. Neurology 1997; 49: 734-9.

    Article  CAS  Google Scholar 

  48. Woodworth GF, McGirt MJ, Elfert P, Sciubba DM, Rigamonti D. Frameless stereotactic ventricular shunt placement for idiopathic intracranial hypertension. Stereotact Funct Neurosurg 2005; 83: 12-6.

    Article  Google Scholar 

  49. Abu-Serieh B, Ghassempour K, Duprez T, Raftopoulos C. Stereotactic ventriculoperitoneal shunting for refractory idiopathic intracranial hypertension. Neurosurgery 2007; 60: 1039-43.

    Article  Google Scholar 

  50. Banta JT, Farris BK. Pseudotumor cerebri and optic nerve sheath decompression. Ophthalmology 2000; 107: 1907-12.

    Article  CAS  Google Scholar 

  51. Acheson JF, Green WT, Sanders MD. Optic nerve sheath decompression for the treatment of visual failure in chronic raised intracranial pressure. J Neurol Neurosurg Psychiatry 1994; 57: 1426-9.

    Article  CAS  Google Scholar 

  52. Uretsky S. Surgical interventions for idiopathic intracranial hypertension. Curr Opin Ophthalmol 2009; 20: 451-5.

    Article  Google Scholar 

  53. Ko MW. Idiopathic intracranial hypertension. Curr Treat Options Neurol 2011; 13: 101-8.

    Article  Google Scholar 

  54. Landwehr JB Jr, Isada NB, Pryde PG, Johnson MP. Evans Mi, Canady AI. Maternal neurosurgical shunts and pregnancy outcome. Obstet Gynecol 1994; 83: 134-7.

    PubMed  Google Scholar 

  55. Shapiro S, Yee R, Brown H. Surgical management of pseudotumor cerebri in pregnancy: case report. Neurosurgery 1995; 37: 829-31.

    Article  CAS  Google Scholar 

  56. Holmes LB, Kawanishi H, Munoz A. Acetazolamide: maternal toxicity, pattern of malformations, and litter effect. Teratology 1988; 37: 335-42.

    Article  CAS  Google Scholar 

  57. Holmes LB, Trelstad RL. The early limb deformity caused by acetazolamide. Teratology 1979; 20: 289-95.

    Article  CAS  Google Scholar 

  58. Tellone CI, Baldwin JK, Sofia RD. Teratogenic activity in the mouse after oral administration of acetazolamide. Drug Chem Toxicol 1980; 3: 83-98.

    Article  CAS  Google Scholar 

  59. Lee AG, Pless M, Falardeau J, Cappozoli T, Wall M, Kardon RH. The use of acetazolamide in idiopathic intracranial hypertension during pregnancy. Am J Ophthalmol 2005; 139: 855-9.

    Article  CAS  Google Scholar 

  60. Paruchuri SR, Lawlor M, Kleinhomer K, Mason L, Johnson C. Risk of cerebellar tonsillar herniation after diagnostic lumbar puncture in pseudotumor cerebri. Anesth Analg 1993; 77: 403-4.

    Article  CAS  Google Scholar 

  61. Sullivan HC. Fatal tonsillar herniation in pseudotumor cerebri. Neurology 1991; 41: 1142-4.

    Article  CAS  Google Scholar 

  62. Hart A, David K, Powell M. The treatment of ‘acquired tonsillar herniation’ in pseudotumour cerebri. Br J Neurosurg 2000; 14: 563-5.

    Article  CAS  Google Scholar 

  63. Lam FC, Wheatley MB, Mehta V. Treatment of secondary tonsillar herniation by lumboperitoneal shunt revision. Can J Neurol Sci 2007; 34: 237-42.

    Article  Google Scholar 

  64. Payner TD, Prenger E, Berger TS, Crone KR. Acquired Chiari malformations: incidence, diagnosis, and management. Neurosurgery 1994; 34: 429-34.

    Article  CAS  Google Scholar 

  65. Galbert MW, Marx GF. Extradural pressures in the parturient patient. Anesthesiology 1974; 40: 499-502.

    Article  CAS  Google Scholar 

  66. Palop R, Choed-Amphai E, Miller R. Epidural anesthesia for delivery complicated by benign intracranial hypertension. Anesthesiology 1979; 50: 159-60.

    Article  CAS  Google Scholar 

  67. Worrell J, Lane S. Impact of pseudotumor cerebri (idiopathic intracranial hypertension) in pregnancy: a case report. AANA J 2007; 75: 199-204.

    PubMed  Google Scholar 

  68. Grocott HP, Mutch WA. Epidural anesthesia and acutely increased intracranial pressure. Lumbar epidural space hydrodynamics in a porcine model. Anesthesiology 1996; 85: 1086-91.

    Article  CAS  Google Scholar 

  69. Hilt H, Gramm HJ, Link J. Changes in intracranial pressure associated with extradural anaesthesia. Br J Anaesth 1986; 58: 676-80.

    Article  CAS  Google Scholar 

  70. Bedson CR, Plaat F. Benign intracranial hypertension and anaesthesia for caesarean section. Int J Obstet Anesth 1999; 8: 288-90.

    Article  CAS  Google Scholar 

  71. Abouleish E, Ali V, Tang RA. Benign intracranial hypertension and anesthesia for cesarean section. Anesthesiology 1985; 63: 705-7.

    Article  CAS  Google Scholar 

  72. Kim K, Orbegozo M. Epidural anesthesia for cesarean section in a parturient with pseudotumor cerebri and lumboperitoneal shunt. J Clin Anesth 2000; 12: 213-5.

    Article  CAS  Google Scholar 

  73. Bedard JM, Richardson MG, Wissler RN. Epidural anesthesia in a parturient with a lumboperitoneal shunt. Anesthesiology 1999; 90: 621-3.

    Article  CAS  Google Scholar 

  74. Heckathorn J, Cata JP, Barsoum S. Intrathecal anesthesia for cesarean delivery via a subarachnoid drain in a woman with benign intracranial hypertension. Int J Obstet Anesth 2010; 19: 109-11.

    Article  CAS  Google Scholar 

  75. Rosenberg ML, Corbett JJ, Smith C, et al. Cerebrospinal fluid diversion procedures in pseudotumor cerebri. Neurology 1993; 43: 1071-2.

    Article  CAS  Google Scholar 

  76. Goulart AP, Moro ET, Rios Rde P, Pires RT. Subarachnoid blockade for cesarean section in a patient with ventriculoperitoneal shunt: case report (Portuguese). Rev Bras Anestesiol 2009; 59: 471-5.

    Article  Google Scholar 

  77. Cusimano MD, Meffe FM, Gentili F, Sermer M. Ventriculoperitoneal shunt malfunction during pregnancy. Neurosurgery 1990; 27: 969-71.

    Article  CAS  Google Scholar 

  78. Samuels P, Driscoll DA, Landon MB, et al. Cerebrospinal fluid shunts in pregnancy. Report of two cases and review of the literature. Am J Perinatol 1988; 5: 22-5.

    Article  CAS  Google Scholar 

  79. Hwang SC, Kim TH, Kim BT, Im SB, Shin WH. Acute shunt malfunction after cesarean section delivery: a case report. J Korean Med Sci 2010; 25: 647-50.

    Article  Google Scholar 

  80. Douglas MJ, Flanagan ML, McMorland GH. Anaesthetic management of a complex morbidly obese parturient. Can J Anaesth 1991; 38: 900-3.

    Article  CAS  Google Scholar 

  81. Pilkington S, Carli F, Dakin MJ, et al. Increase in Mallampati score during pregnancy. Br J Anaesth 1995; 74: 638-42.

    Article  CAS  Google Scholar 

  82. Peng AT, Blancato LS, Motoyama EK. Effect of maternal hypocapnia v. eucapnia on the fetus during caesarean section. Br J Anaesth 1972; 44: 1173-8.

    Article  CAS  Google Scholar 

  83. Woda RP, Miner ME, McCandless C, McSweeney TD. The effect of right internal jugular vein cannulation on intracranial pressure. J Neurosurg Anesthesiol 1996; 8: 286-92.

    Article  CAS  Google Scholar 

  84. Frank RL. Lumbar puncture and post-dural puncture headaches: implications for the emergency physician. J Emerg Med 2008; 35: 149-57.

    Article  Google Scholar 

  85. Amorim JA, Valença MM. Postdural puncture headache is a risk factor for new postdural puncture headache. Cephalalgia 2008; 28: 5-8.

    Article  CAS  Google Scholar 

  86. Lussos SA, Loeffler C. Epidural blood patch improves postdural puncture headache in a patient with benign intracranial hypertension. Reg Anesth 1993; 18: 315-7.

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesia, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece

    Iosifina Karmaniolou MD, Georgios Petropoulos MD, PhD & Kassiani Theodoraki MD, PhD

  2. Halkomatadon 35, Perissos, 14232, Athens, Greece

    Iosifina Karmaniolou MD

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  1. Iosifina Karmaniolou MD
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  2. Georgios Petropoulos MD, PhD
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  3. Kassiani Theodoraki MD, PhD
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Correspondence to Iosifina Karmaniolou MD.

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Karmaniolou, I., Petropoulos, G. & Theodoraki, K. Management of idiopathic intracranial hypertension in parturients: anesthetic considerations. Can J Anesth/J Can Anesth 58, 650–657 (2011). https://doi.org/10.1007/s12630-011-9508-4

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