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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 50-51

Total intravenous anesthesia for anesthetic management of emergency caesarean section in a patient with moyamoya disease

1 Department of Anaesthesiology and Intensive Care, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Anaesthesiology and Intensive Care, St. Michael's Hospital, Toronto, Canada
3 Department of Anaesthesiology, Pain Medicine and Intensive Care, AIIMS, New Delhi, India

Date of Submission29-Sep-2020
Date of Acceptance21-Dec-2020
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Anju Gupta
Room No. 6, Porta Cabin, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOACC.JOACC_104_20

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How to cite this article:
Pande D, Gandotra S, Gupta A. Total intravenous anesthesia for anesthetic management of emergency caesarean section in a patient with moyamoya disease. J Obstet Anaesth Crit Care 2021;11:50-1

How to cite this URL:
Pande D, Gandotra S, Gupta A. Total intravenous anesthesia for anesthetic management of emergency caesarean section in a patient with moyamoya disease. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Jun 15];11:50-1. Available from: https://www.joacc.com/text.asp?2021/11/1/50/313904


A 24-year-old female was posted for emergency cesarean section (CS) in view of fetal bradycardia. At 32 weeks of gestation, she suffered from an episode of severe headache with left-sided motor weakness along with deviation of angle of mouth to the right. This episode spontaneously resolved within 5 min with minimal residual weakness. There was no history of seizure, loss of consciousness, or hypertension. Her brain magnetic resonance angiography showed marked narrowing of the right internal carotid artery beyond the origin of the right posterior communicating artery with nonvisualization of the right middle carotid artery and proximal part of the right anterior carotid artery [Figure 1]. Her antilupus antibody, anticardiolipin, and β2 glycoprotein were unremarkable. A diagnosis of MMD was made, and she was started on tablet clopidogrel 75 mg, ecosprin 75 mg, and atorvastatin 20 mg once a daily.
Figure 1: Magnetic resonance angiography image of the patient

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At 36 weeks of gestation, she was switched to unfractionated heparin 5000 IU subcutaneously. She developed fetal bradycardia at 37 weeks and was taken up for CS. She was transfused four units of fresh frozen plasma before the surgery as she had received her last dose of heparin 2 h back.

In the operation room, routine monitoring was applied along with monitoring of invasive blood pressure and bispectral index (BIS). Injection fentanyl 100 mcg and esmolol 30 mg were administered intravenously for blunting intubation response. Rapid sequence induction was performed with etomidate and rocuronium, anesthesia was maintained with propofol infusion (50–150 μg/kg/min) to achieve BIS between 40 and 60, and mean arterial pressure (MAP) was maintained in the range of 80–85 mm Hg. Hemodynamic response to extubation was blunted with an esmolol intravenous bolus dose of 30 mg.

In the postoperative period, no neurological deficit was noticed. She was restarted on unfractionated heparin 5000 IU after 24 h following surgery, which was changed to oral anticoagulants on the 2nd postoperative day.

Moyamoya disease (MMD) is a rare occlusive cerebrovascular disease affecting the circle of Willis and its feeding vessels in adults with an incidence is 3.5 per million individuals with a mortality rate of 10%.[1] The incidence of cerebrovascular accidents (CVA) in MMD is up to 50%–75%.[2] Pregnancy increases the risk of ischemic and hemorrhagic stroke by 34% due to hypercoagulable state and circulatory changes in pregnancy.[3] Also, any decrease in cerebral blood flow (CBF) predisposes to ischemic infarction as blood vessels are already maximally dilated. Therefore, a meticulous balance of CBF and cerebral oxygenation consumption (CMRO2) is necessary. CVA during late pregnancy in MMD has a poor prognosis.[2]

In the literature, general anesthesia (GA), epidural anesthesia, and combined spinal-epidural anesthesia have been successfully employed in such patients presenting for cesarean section. We opted for GA as the patient had received her heparin dose just before the surgery and for better maintenance of CMRO2.

Hypertensive response during laryngoscopy, intubation, and extubation should be avoided as it can cause hemorrhagic infarct due to rupture of dilated blood vessels.[1] We effectively blunted this with the use of esmolol and fentanyl. Propofol was used for the maintenance of anesthesia and continued at a low dose during extubation. In MMD patients, the use of intravenous anesthesia with propofol was found to provide cerebral protection and preserve regional CBF.[4] During the perioperative period, we ensured normotension, normocapnia, and normothermia to preserve CBF.[5]

With meticulous planning and monitoring during anesthesia, we were able to maintain stable hemodynamics, and the patient could be discharged without any neurological deficit.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Colli Neto JA, Costa JZ, Barreta AT, Zen JH Jr, Junqueira FEF, Brandão MJN. General anesthesia for elective cesarean section in a patient with moyamoya disease. J Anesth Clin Res 2019;10:1000879. doi: 10.4172/2155-6148.1000879.  Back to cited text no. 1
Komiyama M, Yasui T, Kitanoo S, Sakamoto H, Fujitani K, Matsuo S. Moyamoya disease and pregnancy: Case report and review of literature. Neurosurgery 1998;43:360-8.  Back to cited text no. 2
Ma JC, Burlingame JM. Moyamoya disease in pregnancy: A case series and review of management options. Hawaii Med J 2011;70:161-3.  Back to cited text no. 3
Kikuta K, Takagi Y, Nozaki K, Yamada K, Miyamoto S, Kataoka H, et al. Effects of intravenous anesthesia with propofol on regional cortical blood flow and intracranial pressure in surgery for moyamoya disease. Surg Neurol 2007;68:421-4.  Back to cited text no. 4
Dutta B, Dehran M, Sinha R. Anaesthetic management of a parturient with Moyamoya disease. Singapore Med J 2011;52:e108.  Back to cited text no. 5


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