Background: The incidence of cerebral aneurysm in pregnancy is similar to that in the general population (2%), but its rupture is more common during pregnancy.1 In a planned caesarean section the main question is whether to perform general or spinal/epidural anesthesia, but there are no formal recommendations or guidelines regarding which technique to choose and very few cases have been reported. We report such a case and discuss its management. 
Case report: The choice was to perform general anesthesia. Remifentanil (Remi) by effect site Target Controlled Infusion (TCI) was started at a concentration effect (Ce) of 2,5ng/ml before placement of an arterial line. Propofol was given slowly until loss of conscience and then by effect site TCI. Remi was increased to 4 and rocuronium was given. After tracheal intubation Remi was stopped and propofol titrated to Bispectral index (BIS) 40 to 60. Mean arterial blood pressure was 91 and 104 mmHg before and after intubation. 9min after intubation, a 3395g fetus was born. Apgar scores were 5 and 9 at 1 and 5 min. Assisted mask ventilation was required for 1,75min. The Remi Ce at umbilical cord clamping was 2,0 ng ml-1, and was then increased.
Discussion: Spinal anesthesia was not used because lumbar punctures have been associated with aneurysm ruptures.2 Epidural anesthesia could be an option, but the danger of lumbar puncture could not be excluded. General anesthesia implies tracheal intubation with the risk of sympathetic activation. Opioids obtund this response, but may depress the fetus. Both intubation and skin incision represent powerful noxious stimuli that may result in aneurysm rupture. Remi, given its rapid action, is a good option. Remi by TCI allows tight control of concentrations and allowed us to provide safe maternal anesthesia without harming the fetus.3 Food and Drug Administration information says that Remi Ce of 2ng/ml does not cause respiratory depression in the adult. In the fetus Remi elimination is fast.
Referencies:
1.Rev Neurologique 2008; 164: 781-786; 
2. Indian J Anaesth 2002; 46: 386-390; 
3. International Journal of Obstetric Anesthesia 2004; 13: 153-158. 
Learning Points: In a cesarean section in a parturient with a cerebral aneurysm, total intravenous anaesthesia with TCI of remifentanil allowed titration of the opioid concentration in order to obtund sympathetic responses to intubation and incision providing safe maternal anesthesia without depressing the fetus.

General anesthesia with target controlled infusion of propofol and remifentanil for planned caesarean section in a parturient with unruptured intracranial aneurysm