Anesthetic management of idiopathic intracranial bleeding during pregnancy: a case report and review
Background: Intracranial hemorrhage (ICH) is uncommon during pregnancy representing 10 % of non-obstetrical causes of maternal death1. Most frequent cause is Subarachnoid Hemorrhage (SAH).We analyze anesthetic issues in the management of SAH during pregnancy.
Case report: A 29 week pregnant women, presented with headache, right side weakness, and disturbed sensorium (GCS 8/15).Cerebral Computed Tomography (CT) showed posterior fossa SAH extending to right suprasellar cistern and Cerebral Angiography (CA) showed a normal vasculature. Lab tests rule out coagulopathy. Patient developed progressive elevation of Intracranial Pressure (ICP) and urgent decompressive craniotomy was mandatory. Surgery was conducted without ending pregnancy under general anesthesia (GA).15 days later patient achieve neurological recovery and was discharged. An elective caesarean was performed at 37 week under GA.No complications were registered.
Discussion: Once diagnosed SAH during pregnancy, identifying the cause becomes essential to avoid rebleeding. We describe a rare case of SAH in which common causes as AVM or aneurysms were ruled out by CA. False negative findings could be explained by spontaneous thrombosis of small ruptured aneurysm.This tiny thrombosed vessels are barely visible. Prothrombotic changes of pregnancy facilitate this scenario. On doubtful cases Cerebral Digital Subtraction Angiography may be useful2.Acute treatment of the ICH must ensure maternal and fetal well being. Obstetrical and neurosurgical procedures in pregnant patients with SAH can be safely performed under anaesthesia. GA allows a better control of hemodynamic and respiratory variables. Less often regional anaesthesia can be used, but contraindications should be considered3.
Learning points: 
•	Election of anaesthetic technique will be determined by maintenance of cardiovascular stability 
•	Neuroprotection of these patients compels to set up a proper invasive monitoring and use of pharmacological and non-pharmacological interventions to treat ICP 
•	Perioperative care of this patients should be conducted by a multidisciplinary team
References: 
1. Mas JL,Et al.Stroke in pregnancy and the puerperium.J Neurol.1998;245:305-13.5 
2. Agid R,Et al.Negative CT angiography findings in patients with spontaneous SAH: when is DSA still needed?AJNR.2010;31(4):696
3. Anson JA, Et al.Anesthesic management of labor and delivery in patients with elevated intracranial pressure.Int J Obstet Anesth.2015;24:47-54

Anaesthetic management of idiopathic intracranial bleeding during pregnancy: a case report and review