General Anesthesia for Elective Cesarean Section in a Patient with Moyamoya Disease

Abstract

Moyamoya disease (MMD) is defined by vaso-occlusive changes at the internal carotid and cerebral arteries, leading to proliferation of an abnormal vascular network at the base of the brain. The disease is manifested by ischemic, hemorrhagic strokes or transient ischemic attacks. Pregnant and puerperal MMD patients may be at a higher risk of developing new strokes as well as during the peripartum period. The aim of the current study is to report a case of an obstetric MMD patient. A 22 year-old term female patient was diagnosed with MMD after having a stroke at 2 years of age, resulting in hemiparesis and paresthesia of the left upper and left lower limbs. Intravenous general anesthesia was performed with continuous remifentanil and propofol infusions. Hemodynamic alterations did not occur before childbirth. After childbirth, hypotension occurred and was reversed with metaraminol. We chose general anesthesia for better control of hypotension, in addition to prevention of hyperventilation, which produces hypocapnia and decreases cerebral blood flow. Disadvantages of general anesthesia include hemodynamic response to airway manipulation leading to alterations in cerebral blood flow and perfusion, difficulty in diagnosing neurologic alterations intraoperatively and impossibility of skin-o-skin contact at birth.