Management of sporadic intracranial vascular malformations in pregnancy: a retrospective analysis.

BACKGROUND: Sporadic intracranial vascular malformations can pose significant risk to parturients, and additional reports of management may inform patient care. Here we describe the peripartum management of parturients with intracranial vascular malformations. METHODS: After Institutional Review Board approval, we performed a retrospective analysis of parturients with a known sporadic intracranial vascular malformation including cavernous malformation, developmental venous anomaly, or arteriovenous malformation who delivered at our institution between 2007 and 2020. RESULTS: We identified 10 parturients (five cavernous malformations, three developmental venous anomalies, and two arteriovenous malformations) with 16 deliveries. Among all deliveries, 13 (81.3%) were cesarean deliveries without trial of labor; 11 of these (84.6%) received a single-shot spinal and two (15.4%) received an epidural for surgical anesthesia. Two deliveries (12.5%) began with attempted trial of labor but ultimately required cesarean delivery for failure to progress; one of these cases received epidural anesthesia and the other received combined spinal-epidural anesthesia. One delivery was via spontaneous vaginal delivery with epidural analgesia. Overall, our study's cesarean delivery rate was 93.8% and spontaneous vaginal delivery rate was 6.2%. Three of 16 pregnancies were complicated by seizure, obstructive hydrocephalus, or intracranial hemorrhage. There were no intensive care unit admissions or maternal deaths. CONCLUSIONS: In our case series of 16 deliveries, there were no complications directly resulting from neuraxial procedures. It remains unclear whether intracranial developmental venous anomalies or unruptured arteriovenous malformations impart increased risk during pregnancy. Antepartum planning with a multidisciplinary team approach enables risk stratification and optimal management.

Thoracic epidural anesthesia improves outcome after breast surgery.

OBJECTIVE: The authors' objective was to compare the outcomes, including the incidence of nausea and vomiting and the time until discharge to home, of patients undergoing general anesthesia and thoracic epidural anesthesia for oncologic breast procedures. SUMMARY BACKGROUND DATA: General anesthesia is the traditional anesthetic technique used in oncologic breast procedures. In March 1993, the authors initiated the use of high thoracic epidural anesthesia for patients undergoing oncologic breast surgery and reconstructive procedures. METHODS: A retrospective analysis was undertaken of 136 operations performed by one surgeon (T.J.E.) at Brigham and Women's Hospital. A chi square analysis was used to compare the outcomes of patients undergoing general anesthesia and thoracic epidural anesthesia. RESULTS: Compared with general anesthesia, thoracic epidural anesthesia was associated with a statistically significant earlier hospital discharge (p = 0.01). For quadrantectomy/axillary node dissection procedures, 20 of 39 patients (51%) having thoracic epidural anesthesia were discharged on the operative day versus 7 of 32 patients (22%) in the general anesthesia group. Furthermore, 8 of 39 patients (20%) in the thoracic epidural group experienced nausea and/or vomiting during their hospital stay versus 18 of 32 patients (56%) in the general anesthesia group (p = 0.002). CONCLUSION: Thoracic epidural anesthesia is a safe technique not associated with neurologic or respiratory complications. The use of thoracic epidural anesthesia for breast surgery could improve patients recovery and reduce the cost of these procedures.