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  1. Home
  2. Books
  3. Case Studies in Neuroanesthesia and Neurocritical Care
  • Cited by 1
Publisher:
Cambridge University Press
Online publication date:
May 2011
Print publication year:
2011
Online ISBN:
9780511997426
DOI:
https://doi.org/10.1017/CBO9780511997426
Subjects:
Anesthesia, Intensive Care, Pain Management, Neurology and Clinical Neuroscience, Medicine
Series:
Case Studies in Neurology
Information

Book description

The anesthetic considerations and procedures involved in the perioperative care of the neurosurgical patient are among the most complex in anesthesiology. The practice of neurosurgery and neuroanesthesiology encompasses a wide range of cases, from major spine surgery, to aneurysm clipping and awake craniotomy. Case Studies in Neuroanesthesia and Neurocritical Care provides a comprehensive view of real-world clinical practice. It contains over 90 case presentations with accompanying focussed discussions, covering the broad range of procedures and monitoring protocols involved in the care of the neurosurgical patient, including preoperative and postoperative care. The book is illustrated throughout with practical algorithms, useful tables and examples of neuroimaging. Written by leading neuroanesthesiologists, neurologists, neuroradiologists and neurosurgeons from the University of Michigan Medical School and the Cleveland Clinic, these clear, concise cases are an excellent way to prepare for specific surgical cases or to aid study for both written and oral board examinations.

Reviews

'This textbook is very useful for teaching … we would wholeheartedly recommend this book to anaesthetic trainees and all clinicians involved in neuroanaesthesia or intensive care. It complements traditional neuroanaesthesia textbooks and would be an excellent portable book to dip in and out of during a busy clinical day.'

Source: British Journal of Anesthesia

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Contents

Page 3 of 4

Contents
  • Case 54 - Rheumatoiddisease
    pp 172-176
  • View abstract

    Summary

    Neurofibromatosis type 1 (NF1) patients are complex and present for a variety of neurosurgical interventions. The most typical manifestations are multiple neurofibromas and melanogenic abnormalities (both of neural crest origin), but the phenotype may also include skeletal abnormalities. This chapter presents a case study of a 39-year-old female with a history of NF1 and four previous spine surgeries, the last of which occurred at the age of 16. It results from a mutation of the NF1 gene on chromosome 17, which encodes the tumor suppressor neurofibromin. Patients with NF1 may present for surgical procedures involving peripheral nervous system tumors (neurofibromas, malignant peripheral nerve sheath tumors), central nervous system tumors (benign optic gliomas, astrocytomas), scoliosis or other skeletal abnormalities, and a host of other disorders. Given the multisystem involvement and variable phenotype, a systematic approach to the NF1 patient is necessary for safe perioperative care.
  • Case 55 - Preoperativeevaluation
    pp 177-181
  • View abstract

    Summary

    Anesthesia for complex spine surgery requires invasive monitoring, large-bore intravenous access, and awareness of the potential for disaster. Anesthesiologists involved in the care of patients undergoing complicated spine surgery should be cognitive of this infrequent but serious complication. This chapter presents a case study of a 75-year-old female who was scheduled for removal of instrumentation at L4-S1 and re-exploration of a previous posterior lumbar inter-body fusion. The intraoperative course was also complicated by significant coagulopathy from massive blood loss and transfusion. The postoperative course was complicated by nonoliguric renal failure, pneumonia, and urinary tract infection. The role of central venous monitoring is always debated in the context of major spine surgery. However, central venous pressure readings in the prone position may not reflect accurate data and large bore intravascular access and invasive blood pressure monitoring are probably more important in the hemodynamic management of these cases.
  • Case 56 - Acromegalyand gigantism
    pp 182-183
  • View abstract

    Summary

    Jehovah's Witness (JW) is an evangelical Christian denomination best known to physicians for beliefs regarding the refusal of all blood product transfusions. This chapter presents a case study of a 54-year-old female with a history of obstructive sleep apnea, hyperlipidemia, and scoliosis who presented for T10-L5 posterior spinal fusion. The arterial blood gas analysis was used not only to assess respiratory and metabolic state but also the hematocrit. The antifibrinolytic drug aminocaproic acid was infused during the case to reduce blood loss. Erythropoietin is a blood-stimulating hormone normally synthesized in the kidney that stimulates red blood cell production in the bone marrow. While complex spine procedures in the JW patient may be challenging, successful outcomes can be achieved. With active preoperative assessment, communication, blood conservation strategies, proper positioning and meticulous surgical and anesthetic technique, complex spine surgeries are possible in the JW population.
  • Case 57 - Perioperativediabetes insipidus
    pp 184-186
  • View abstract

    Summary

    Visual disturbances are known to occur after spine surgery; this chapter describes a case of postoperative diplopia. This chapter presents a case study of a 34-year-old woman presented to the clinic with post-laminectomy kyphosis and subsequently underwent posterior fusion and fixation in the prone position. The patient developed facial edema and reported diplopia on the first postoperative day. Abducens nerve palsy, which causes diplopia without any other neurologic signs, is reported to be the most common cranial nerve palsy. Abducens nerve palsy was reported to be a complication of different procedures such as lumbar puncture, shunt surgery, maxillary osteotomy, cranial trauma, and skull traction. Prone spine cases are associated with postoperative visual disturbances. The present case suggests that diplopia in this context may be a self-limiting process due to sixth nerve stretch after fluid overload.
  • Case 58 - Craniotomy
    pp 187-190
  • View abstract

    Summary

    Postoperative visual loss (POVL) is a rare but catastrophic complication of spine surgery. The extremely low incidence has made its study and prevention a challenge for neuroanesthesiologists. This chapter presents a case study of a 62-year-old female who presented for a revision L4-5 foraminotomy and L4-S1 transverse lumbar interbody fusion. There are multiple causes of POVL, including cortical infarction, direct injuries to the eye and ischemic injuries to the retina and optic nerve. The most common permanent injuries are ischemic in nature including central retinal artery occlusion (CRAO) and ischemic optic neuropathy (ION). Many risk factors have been proposed yet understanding of the etiology of ION remains inadequate. Until we have a better understanding of these risk factors, careful attention to the eyes, staged procedures, vigilance with regard to intraocular pressure and the optimization of oxygen-carrying capacity are the best preventative measures available.
  • Case 59 - Ventriculoperitonealshunt
    pp 191-194
  • View abstract

    Summary

    Neurosurgical procedures are very rarely performed in a straightforward supine position. This chapter presents a case study of a 69-year-old female with a history of renal cell carcinoma developed new back pain and radiculopathy. Resuscitation efforts continued while the wound was packed and the patient was repositioned supine to facilitate external cardiac compressions. The wound continued to bleed during the unsuccessful resuscitation effort. This case was an exposure to the surgical site of bleeding was poorly accessible due to the need to perform cardiopulmonary resuscitation (CPR) in the supine position. The patient will already have a definitive airway and intravenous access established, thereby eliminating potentially the largest drawbacks of prone CPR: the hindrance of airway and intravenous catheter acquisition. Intraoperative scenarios in which the patient is in the prone position, as in cases of spinal surgery, are unique settings for which prone CPR may be well-suited as a resuscitation technique.
  • Case 60 - Craniosynostosisrepair
    pp 195-198
  • View abstract

    Summary

    Open spine stabilization with polymethylmethacrylate (PMMA) augmentation procedures requires significant attention during anesthetic management due to the complication of PMMA embolization. This chapter presents a case study of a 54-year-old male with a T12 burst fracture presented for a second stage posterior instrumentation of T9-L4. It presents a case of hemodynamic instability due to embolization during surgery as well as its management. Myocardial ischemia, pulmonary embolism (PE) from deep venous thrombosis or PMMA, and anaphylactoid/anaphylaxis reaction were considered. This patient had osteoporosis, a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fractures. Cardiopulmonary presentation is either immediate or delayed and can be catastrophic. Consider a chest X-ray, echocardiogram, and computed tomography scan as diagnostic tools. If strongly symptomatic, consult cardiothoracic surgery for possible embolectomy.
  • Case 61 - Scoliosis
    pp 199-202
  • View abstract

    Summary

    Airway difficulties after complex spine surgeries in prolonged prone position can cause catastrophic complications including severe hypoxia and death. This chapter presents a case study of a patient was a 22-year-old male with severe scoliosis scheduled for a T3-ilium fusion with vertebral column resections. This case discusses the importance of an appropriate extubation strategy in light of the known postoperative complications of prolonged prone positioning. Analgesia was administered using intravenous morphine, titrated to effect. Prone positioning during anesthesia is required to provide operative access for a wide variety of surgical procedures. The leak test and visual inspection of airway swelling are the most common risk assessment tests for extubation. Given the numerous complications unique to patients undergoing complex spine surgeries in the prone position, a systematic approach to extubation should begin as early as possible to optimize safe perioperative care.
  • Case 62 - Hemispherectomyfor treatment of intractable epilepsy in an infant with congenital antithrombin III deficiency
    pp 203-206
  • View abstract

    Summary

    Neurosurgical procedures are often performed with patients in the prone, lateral, and other non-supine positions. This creates the risk of perioperative neurologic deficit due to peripheral nerve injury (PNI). This chapter presents a case study of a 55-year-old female presented for scoliosis correction with posterior instrumentation at T5-L5. The patient was presumed to have a right brachial plexus injury and was started on dexamethasone. Neurology and physical therapy were consulted after admission to the neurosurgical intensive care unit. Vigilance with respect to positioning and appropriate padding of pressure points is critical, especially in patients with diabetes mellitus, hypertension, and a history of tobacco use. Neurophysiologic monitoring may aid in the intraoperative detection of injury and should be taken seriously. Evidence of PNI should prompt an evaluation by neurology, as well as the involvement of physical and occupational therapy.
  • Case 63 - Neurosurgicalprocedures for pediatric patients with cardiac malformations
    pp 207-209
  • View abstract

    Summary

    Each year in the USA there are approximately 10000 new cases of spinal injury and the cervical spine is most commonly affected. This chapter presents a case study of a 27-year-old male who was immobilized on a spinal board, with rigid cervical collar. The anterior portion of the cervical collar was removed, manual in-line stabilization (MILS) maintained and cricoid pressure was applied. The immobilization of the spine in trauma patients until injuries have either been excluded or definitively treated remains a cornerstone of modern trauma care. The anesthesia provider must maintain the mechanical integrity of the spinal cord by limiting neck movement, as well as ensure adequate spinal cord perfusion by avoiding hypotension and subsequent tissue hypoxia. The degree of movement and angulation in spinal segments with any of these intubation techniques is of uncertain clinical significance.
  • Case 64 - Neuroprotectionduring pediatric cardiac anesthesia
    pp 210-214
  • View abstract

    Summary

    Cervical spine mobility is central to the conventional safe management of the airway. Acquired causes are mainly degenerative diseases (osteoarthritis, degenerative disc disease), inflammatory processes (rheumatoid arthritis, ankylosing spondylitis), trauma, and prior surgical fusion. This chapter presents a case study of a 68-year-old male with severe ankylosing spondylitis who sustained a fracture through the C6 vertebral body following a fall. The patient was positioned in the prone position with care taken to avoid cervical spine extension and to preserve the alignment of the cervico-thoracic spine, to the extent that was possible given the underlying deformity. The blood pressure was maintained at preinduction values at all times. The patient presented in this case demonstrated several of the features that predict difficulty in airway management. Awake flexible fiberoptic intubation is considered to be the gold standard in this challenging patient group.
  • Case 65 - Pregnantpatient with aneurysm
    pp 215-217
  • View abstract

    Summary

    Rheumatoid arthritis (RA) is a progressive symmetrical, deforming inflammatory polyarthropathy with numerous extra-articular features. The skeletal effects of RA are characterized by an inflammatory synovitis with progressive destruction of cartilage. This chapter presents a case study of a 62-year-old female with seropositive rheumatoid arthritis presented for anterior cervical discectomy and fusion for long-term progressive pain and upper extremity myelopathy. Preoperative imaging consisted of plain radiographs and magnetic resonance imaging of the cervical spine. This case illustrates several important issues that must be considered when identifying the airway management options for patients with cervical spine pathology. When considering the airway options for a patient with disease at the occipito-atlanto-axial (OAA) complex an appreciation of the importance of this area in overall airway management is necessary. Careful preoperative evaluation and planning are essential; adequate time and personnel should be allocated to securing the airway in a controlled and safe manner.
  • Case 66 - Anestheticmanagement of pregnant patients with brain tumors
    pp 218-220
  • View abstract

    Summary

    Preoperative evaluation of patients presenting for transsphenoidal resection of pituitary tumors is a very complex process, requiring careful assessment of the patient's symptoms and the proper preoperative laboratory tests. This chapter presents two case studies, which highlight the proper preoperative evaluation for different types of pituitary tumors. The first case study is about a 32-year-old male who was referred for evaluation of a possible neuroendocrine disorder. The second case study is about a 36-year-old female with the appearance of purple abdominal striae and multiple ecchymoses on her arms and legs. Cushing's syndrome (CS) is the clinical manifestation of cortisol excess, and Cushing's disease (CD) specifically describes cortisol excess caused by an adrenocorticotropic hormone (ACTH) -secreting pituitary adenoma. The treatment of CD involves surgical resection of the pituitary adenoma, because removal of the lesion and rapid normalization of the serum cortisol improves survival in these patients.
  • Case 68 - Postpartumheadache
    pp 227-229
  • View abstract

    Summary

    An excess of growth hormone (GH) from a pituitary adenoma can result in gigantism and acromegaly; neurosurgical intervention is often required. This chapter presents a case study of a 36-year-old female weighed 115 kg and was 218.5 cm tall. She was scheduled for a transsphenoidal resection of the pituitary adenoma that had caused her gigantism. From the viewpoint of airway management in the acromegalic patient, several concerns exist: the tongue may be enlarged; redundant folds of tissue may be present in the oropharynx; the epiglottis is often enlarged; and laryngeal stenosis occurs more frequently compared with the general population. In the case of gigantism, several additional potential problems should also be considered: possible need for an extra long operating table; possible need for an extra large laryngoscope; endotracheal tubes may need to be placed deeper than usual; and an extra large face mask may be needed as in our case.
  • Case 69 - Increasedintracranial pressure with acute liver failure
    pp 230-232
  • View abstract

    Summary

    Sodium disturbances are common in patients presenting with neurologic disease. However, postoperative development of sodium dysregulation may be seen after transphenoidal surgery. This chapter presents a case study of a 45-year-old male with a 1-year history of right temporal anopsia and impotence underwent a successful transphenoidal resection of a 21 mm suprasellar mass under general anesthesia. Due to the clinical suspicion of central diabetes insipidus (DI), he was treated conservatively with liberal access to oral intake of water and intravenous fluids. Perioperative central DI is a common finding in patients undergoing pituitary surgery. Preoperative DI can be part of a panhypopituitarism syndrome in patients with large pituitary prolactinomas or nonprolactinomas. The clinical manifestation of central DI ranges from mild thirst to significant polyuria, polydipsia, dehydration and, if severe, hypotension. Serum sodium has to be followed during vasopressin administration because the excessive retention of free water can lead to hyponatremia.
  • Case 70 - Permissivehypertension in a patient with von Willebrand's disease and a preexisting ventriculoperitoneal shunt
    pp 233-237
  • View abstract

    Summary

    Pediatric surgical patients present special anesthetic challenges including induction without intravenous (IV) access, a higher incidence of airway complications, and a greater incidence of hemodynamic instability due to surgical blood loss. Supratentorial tumors are the second most common location and include low-grade astrocytoma, malignant and mixed glioma, ependymoma, ganglioglioma, oligodendroglioma, choroid plexus tumor, and meningioma. This chapter presents a case study of a 8-year-old child presented with partial complex seizures characterized by staring spells accompanied by oral and manual automatisms. Preoperative evaluation (magnetic resonance imaging) demonstrated a non-enhancing heterogeneous lesion in the mesial aspect of the right temporal lobe consistent with lowgrade glial neoplasm. A neurologic assessment was performed after extubation and it showed no neurologic deficits. Subsequently the patient was transported to the pediatric intensive care unit where his recovery was satisfactory. Anticonvulsant medications should be continued and administered the day of surgery to prevent intraoperative and postoperative seizures.
  • Case 72 - Neurologiccomplications following cardiothoracic surgery
    pp 241-243
  • View abstract

    Summary

    A ventriculoperitoneal (VP) shunt, a series of catheters with a unidirectional valve to divert cerebrospinal fluid (CSF) from the brain by draining it into the peritoneum, may be implanted from birth onwards as a definitive surgical correction for hydrocephalus. This chapter presents a case study of a 15-month-old female with a history significant for stenosis of the aqueduct of Sylvius, epilepsy, and VP shunt placement as an infant, presented to the emergency department for evaluation. Endotracheal intubation via direct laryngoscopy was confirmed and general anesthesia was maintained with intravenous anesthesia and intermittent opioids. Communicating hydrocephalus means that CSF can still flow between ventricles but flow is blocked as it exits the ventricles. The obtunded child with acute hydrocephalus requires careful preoperative assessment and monitoring in order to formulate an appropriate anesthetic plan to avoid further rises in intracranial pressure (ICP).
  • Case 73 - Anestheticmanagement for subdural hematoma evacuation in a patient with a left ventricular assist device
    pp 244-248
  • View abstract

    Summary

    This chapter presents a case study of a 3-month-old male who had an uncomplicated term delivery presented for repair of craniosynostosis. Premedication was avoided and a peripheral intravenous catheter was started because of the young age, presence of mid-facial hypoplasia, and concern regarding potential problems with ventilation and intubation. Probably the most challenging part of the anesthetic management of craniosynostosis repair is the significant blood loss and frequent rate of blood product transfusion. Craniosynostosis repair presents a number of challenges to the anesthesiologist: (1) small size of the patients; (2) significant and often unavoidable blood loss; (3) need for intraoperative transfusion of blood products; and (4) associated anomalies including airway problems and obstructive sleep apnea. All of these potential complications call for careful preoperative and intraoperative planning, meticulous attention to intravascular volume status and hemodynamic stability as well as maintenance of normothermia.
  • Case 74 - Hypotension
    pp 251-252
  • View abstract

    Summary

    Scoliosis is a complex deformity of the spine with lateral curvature and rotation of the thoracolumbar vertebrae leading to rib cage deformity. The goals for surgical treatment are to prevent progression, improve alignment and balance, and to avoid negative outcomes of the natural history of the disease without introducing iatrogenic complications. This chapter presents a case study of a 16-year-old female presented for posterior spinal instrumentation and fusion from T4-L2. The possibility of postoperative facial swelling and the remote chance of postoperative mechanical ventilation were also discussed. The most common form of scoliosis encountered is adolescent idiopathic scoliosis followed by neuromuscular scoliosis and their management can be quite different. Despite modern technology, scoliosis still carries a small but grave risk of mortality and morbidity. The key for an uneventful anesthetic is proper planning and knowledge of potential complications in order to avoid them.
  • Case 75 - Mechanicalventilation
    pp 253-256
  • View abstract

    Summary

    Patients who are refractory to medical management can be candidates for surgical treatment such as anatomical or functional hemispherectomy. This chapter presents a case study of a 10-month-old male with left-sided hemiparesis. The patient subsequently developed seizures refractory to medical treatment and presented for a right functional hemispherectomy. Postoperatively, antithrombin III (ATIII) levels were checked twice daily and infusions of thrombate III were dosed accordingly. Early surgery for intractable epilepsy is recommended as it has been shown to improve functional outcomes. Anatomic hemispherectomy consists of the resection of the frontal, parietal and occipital cortices, complete temporal lobectomy and insular resection. Perioperative complications associated with this procedure include significant changes in systemic and pulmonary vascular resistance, arrhythmias, cardiac arrest, neurogenic pulmonary edema, seizures, cerebral edema, massive blood loss, and coagulopathy. Patients undergoing hemispherectomy are usually on chronic anticonvulsant therapy.
  • Case 76 - Mechanicalventilation for acute lung injury in the neurosurgical patient
    pp 257-259
  • View abstract

    Summary

    This chapter presents a case study of a 7-year-old female with a history of hypoplastic left heart syndrome (HLHS) who was status post Fontan completion operation 3 years ago and who presented for resection of a right temporal lobe mass. The primary concerns of the anesthesiology team included the avoidance of increased pulmonary vascular resistance (PVR), the maintenance of adequate systemic oxygenation, the avoidance of increased intracranial pressure, and the maintenance of adequate cerebral perfusion pressure. When managing a congenital heart disease (CHD) patient for noncardiac surgery it is imperative to address the specific anatomy and physiology following any palliative procedures. The history and physical examination is essential in determining the presence of congestive heart failure. Postoperative pain management can include carefully titrated opioids such as fentanyl, hydromorphone, or morphine with special care to avoid respiratory compromise that can result in hypercarbia, hypoxia, atelectasis, and increased PVR.
  • Case 77 - Change in mentalstatus
    pp 260-261
  • View abstract

    Summary

    This chapter focuses on the neurologic outcomes of patients who have undergone congenital heart surgery. It presents a case study of a 3-day-old neonate with a history significant for hypoplastic left heart syndrome. In addition to standard ASA monitors, intraoperative monitoring included an arterial line, central venous line, and near infrared spectroscopy (NIRS). Cerebral injury after cardiac surgery continues to be a significant source of morbidity, and there are numerous pharmacologic and nonpharmacologic modalities that have been implemented to prevent such injury. With many patients surviving very complex congenital heart surgeries, the anesthesiologist should lead the way in preventing, assessing, and treating neurologic injury in order to obtain the highest quality of life possible for these children. While intraoperative neurologic monitoring for pediatric cardiac surgery is still a relatively new science, it shows a great deal of promise for future application in minimizing cerebral injury and optimizing neurodevelopmental outcome.
  • Case 78 - Therapeutic hypothermia using an endovascular approach in the neurocritical care patient
    pp 262-264
  • View abstract

    Summary

    Neurosurgery during pregnancy is rare and as a result there are few evidence-based recommendations in the literature to provide guidance. An understanding of maternal physiology and a multidisciplinary approach are imperative to ensure a successful outcome. This chapter presents a case study of a 37-year-old female with multiple hematologic co-morbidities presented at 18 weeks gestation with perioral and periocular twitching, memory lapses and a recent sensory loss and painful paresthesias affecting the right side of her body. After a multidisciplinary discussion involving neurosurgery, obstetrics, and hematology it was decided to proceed with intracranial aneurysm clipping via craniotomy at 18 weeks gestation. A smooth intravenous rapid sequence induction with cricoid pressure was performed using lidocaine, fentanyl, propofol, and succinylcholine. Neurosurgery in a pregnant patient is rare and requires a thorough understanding of the physiologic changes of pregnancy and the associated concomitant anesthetic risks to both mother and fetus.
  • Case 80 - Cerebralvasospasm
    pp 269-271
  • View abstract

    Summary

    Physiologic changes during pregnancy may result in the development or growth of nervous system tumors. Brain tumors tend to become larger during pregnancy due to fluid retention, increased blood volume, and hormonal changes. If the patient is stable, gestational advancement may be permitted into the early second trimester, where surgical management of the tumor can be undertaken. In a patient with worsening symptoms, radiotherapy may be an option to delaying surgery. Patients should be premedicated with a nonparticulate antacid and ranitidine to protect against the sequelae of vomiting and aspiration. Cesarean section in patients with neurologic risk factors. Mechanisms of anesthesia-induced neurotoxicity and selectivity of anesthesia-induced neurodegeneration are actively being investigated. Management of brain tumors in pregnant women is mainly reliant on case reports and inherited wisdom. Therefore, close communication among the neurosurgeon, neuroanesthesiologist, obstetrician, and patient is of paramount importance.
  • Case 81 - Ventriculoperitonealshunt dependence
    pp 272-274
  • View abstract

    Summary

    Eclampsia is associated with increased risk of maternal and fetal morbidity and mortality. Aggressive attempts should be made to control seizures and hypertension. It usually develops after 20 weeks of gestation and just over one-third of cases occur at term, usually developing intrapartum or within 48 hours of delivery. Two hypotheses have been proposed: (1) cerebral overregulation in response to high blood pressure results in vasospasm of cerebral arteries, localized ischemia, and intracellular edema; (2) loss of autoregulation of cerebral blood flow in response to high blood pressure results in hyperperfusion, and vasogenic edema. In addition to the management principles that apply to other seizures with different etiologies such as prevention of hypoxia, trauma, and recurrent seizures, management of eclamptic seizures includes control of severe hypertension if present, and evaluation for prompt delivery. Magnesium sulfate is considered the drug of choice for prevention and treatment of eclampsia.
  • Case 82 - Ventriculostomyinfection
    pp 275-276
  • View abstract

    Summary

    Postpartum headache (PPH) caused by internal carotid artery dissection (ICAD) is a rare yet treatable condition with a favorable prognosis when recognized. The consequent hypoperfusion or subsequent distal embolization may lead to an ischemic stroke which is already a recognized risk in the puerperium. Pregnancy and puerperium increase the risk for focal ischemic cerebrovascular events. The hypercoaguable state in pregnancy and the immediate puerperium most certainly contributes to this risk. Extracranial ICAD usually presents as a headache, cervical pain, Horner's syndrome, or pulsatile tinnitus without cerebral ischemia. Magnetic resonance imaging (MRI) can visualize morphological details, while magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) reflect intraluminal blood flow. Surgical intervention in ICAD is only required when anticoagulant therapy does not prevent progressive cerebral ischemic events. Teratogenic effects are severe and include anencephaly and spina bifida.

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