A Pregnant Woman With Cerebellar Hemorrhage

Key TakeawaysSevere neurologic symptoms during pregnancy should prompt urgent evaluation for life-threatening complications, including stroke and intracranial hemorrhage. In patients with preeclampsia who deteriorate neurologically, rapid stabilization and close multidisciplinary coordination are essential to optimizing maternal and fetal outcomes. When maternal condition permits, emergency delivery may need to be performed alongside neurosurgical intervention.A case report by anesthesiologist Teresa Ribeiro Boneco and colleagues at the Centro Hospitalar Universitário Lisboa Norte in Lisbon, Portugal, documents a spontaneous cerebellar stroke following severe preeclampsia in a 39-year-old pregnant woman.The Patient and Her Medical HistoryThe patient, who had been pregnant eight times and given birth four times, presented to the emergency department of the hospital in Lisbon at 32 weeks of gestation with acute bilateral temporal headaches, vomiting, and arterial hypertension.On presentation, her Glasgow Coma Scale (GCS) score was 9. She was unable to speak and had right-sided hemiplegia.FindingsUpon admission, the patient’s vital signs were measured. She was tachycardic with a heart rate of 100-110 beats/min in sinus rhythm and had irregular breathing.Inspection, auscultation, palpation, and percussion of the patient’s body revealed no significant findings.A urine sample revealed proteinuria. Following rapid induction, the patient was intubated. Magnesium sulfate was administered for the prevention of eclampsia. Betamethasone was given to accelerate fetal lung maturation. Initial fetal cardiotocography was unremarkable.DiagnosisCT and MRI revealed hemorrhages in the left cerebellar vermis and the left cerebellar hemisphere. Due to the mass effect of the hemorrhages, transtentorial and tonsillar herniation were present.An emergency craniotomy with intraventricular catheter placement was performed for decompression. Since the patient was already sedated and intubated and the need for postoperative sedation was anticipated, intravenous anesthesia with propofol and remifentanil was maintained continuously. Intracranial pressure was regulated with mannitol, hypertonic saline, and controlled hyperventilation to avoid uteroplacental vasoconstriction. A continuous labetalol infusion was used to prevent severe hypertension while maintaining adequate cerebral perfusion pressure.Due to deep and prolonged decelerations on the cardiotocogram during surgery, an emergency cesarean section was performed.Discussion“This case shows why pregnant women with neurological symptoms need a thorough neurological evaluation, and why obstetricians, anaesthesiologists, neurosurgeons, and neonatologists must work closely together to manage such complex cases,” the authors of the case report wrote. The first priority is patient stabilization. Subsequently, if indicated, an emergency cesarean section must be performed.This article was translated from Univadis German, part of the Medscape Professional Network.