The multidisciplinary management of aneurysmal subarachnoid haemorrhage at term

Tom Grant, Sally Anne Shiels

John Radcliffe Hospital, Oxford, UK

 

41/40 transfer to tertiary centre from DGH, for Immediate Caesarean delivery + EVD

§ 1 day ago sudden onset severe headache

§ Normal MRV at that time, Δ migraine

§ Collapse today, Δ acute large volume SAH,

§ GCS 15, nil focal deficit, Normal CTG

 

Location: Neuro theatres with 5 teams

1) Obstetricians 2) Neurosurgery 3) Neonates 4) Obs Anaes 5) Neuro Anaes

Prep: Awake arterial line, draped pre induction

GA: Modified RSI propofol + remifentanil, rocuronium + phenylephrine

Uneventful intubation (VL) Maintenance: TIVA

Healthy male infant born 4 minutes after knife to skin

Cardiovascular stability throughout

Total obstetric operating time: 54 minutes followed by extraventricular drain

(EVD), EBL 500mL

Skin to skin under GA facilitated at request of mother

Remained intubated and ventilated on neuro ICU post-operatively

Angiography and successful clipping of 7mm ICA aneurysm later that morning

Discharged from neuro ICU following day

Uncomplicated two-week admission

Follow-up 9 month follow-up:

Some fatigue and intermittent headache

No other neurological sequelae

 

Key factors contributing to favourable outcome:

DGH Team: prompt identification of a neurosurgical emergency

Appropriate consideration of term pregnancy, however decisions not impeded by this

Rapid transfer to definitive care

Anaesthetic and theatre teams from both sub-specialties

Combined experience of routine practice to perform to a high standard in the service of mother and baby, even out of hours

Facilitating skin to skin with neonatal team

 

The risk of stroke among pregnant and postpartum women is to favourable outcome

around three times greater in comparison with non-pregnant

women of similar age, and is the most frequent cause of

serious long-term disability after pregnancy1.

 

Reference

1. Elgendy, S. Bukhari, A. Barakat et al. Maternal Stroke: A Call for

Action. Circulation. 2021; 143:7