Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report

Samina Mir; Rajpreet Bal; Anne-Marie Githaiga

doi:doi:10.11648/j.wjmcr.20210204.12

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Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report

Samina Mir, Rajpreet Bal, Anne-Marie Githaiga

Published in World Journal of Medical Case Reports (Volume 2, Issue 4)

Received: 5 November 2021 Accepted: 2 December 2021 Published: 24 December 2021

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Abstract

Background: Chiari malformation is a group of congenital abnormalities involving the cerebellar tonsillar herniation through the foramen magnum which affects the relationships between the cerebellum, brainstem, upper cervical cord, and the base of the cranium. CM-I (Chiari Malformation 1), is seen in adult patients and is associated with cranio-cervical abnormalities. Most of the patients with CM-I get symptoms when a cerebellar tonsillar herniation is greater than 5 mm. Case Information: This case report highlights the anaesthetic management of Chiari malformation with 8 mm cerebellar tonsillar descent in a pregnant patient with known difficult airway due to concurrent Temporo-mandibular joint dysfunction, who presented to the hospital for an elective cesarean section. Discussion: Childbearing women with Type I CM have concerns related to an increased cranial CSF pressure during pregnancy and labor. This difference in pressure above and below the foramen magnum may become worse following a lumbar puncture or spinal injection for spinal anesthesia and may lead to worsening of the cerebellar herniation leading to strangulation of the brainstem. These risk factors affect the choice of anaesthetic in these patients. Conclusion: As shown in this case report, the multidisciplinary discussion raised concerns with competing safety concerns of difficult airway if given general anesthesia and the risk of brainstem herniation with neuraxial anesthesia, despite evidence showing infrequent complications regardless of choice of anesthetic. Careful administration of the anesthetic technique, general or regional anesthesia in this group of patients can lead to favorable outcomes following multi-disciplinary discussion.

Published in	World Journal of Medical Case Reports (Volume 2, Issue 4)
DOI	10.11648/j.wjmcr.20210204.12
Page(s)	69-72
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2021. Published by Science Publishing Group

Keywords

Chiari 1 Malformation, Temporo-Mandibular Dysfunction, Pregnancy, General Anesthesia, Difficult Intubation

References

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[2]	Gruffi TR, Peralta FM, Thakkar MS, Arif A, Anderson RF, Orlando B, Coffman JC, Nathan N, McCarthy RJ, Toledo P, Habib AS. Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study. Int J Obstet Anesth. 2019; 37: 52-56.
[3]	Chantigian RC, Koehn MA, Ramin KD, Warner MA. Chiari I malformation in parturients. J Clin Anesth. 2002; 14 (3): 201-5.
[4]	Mueller DM, Oro J. Chiari I malformation with or without syringomyelia and pregnancy: Case studies and review of the literature. Am J Perinatol 2005; 22: 67-70.
[5]	Mrinalini Balki, Mary Ellen Cooke, Susan Dunington, Aliya Salman, Eric Goldszmidt; Unanticipated Difficult Airway in Obstetric Patients: Development of a New Algorithm for Formative Assessment in High-fidelity Simulation. Anesthesiology 2012; 117: 883–897.
[6]	Meadows J, Kraut M, Guarnieri M, Haroun RI, Carson BS. Asymptomatic Chiari Type I malformations identified on magnetic resonance imaging. J Neurosurg. 2000; 92: 920–6.
[7]	Hullander RM, Bogard TD, Leivers D, Moran D, Dewan DM. Chiari I malformation presenting as recurrent spinal headache. Anesth Analg. 1992; 75: 1025–6.
[8]	Agustí M, Adàlia R, Fernández C, Gomar C. Anaesthesia for caesarean section in a patient with syringomyelia and Arnold-Chiari type I malformation. Int J Obstet Anesth. 2004; 13: 114–6.
[9]	Landau R, Giraud R, Delrue V, Kern C. Spinal anesthesia for cesarean delivery in a woman with a surgically corrected type I Arnold Chiai malformation. Anesth Analg. 2003; 97: 253–5.
[10]	Kuczkowski KM. Spinal anesthesia for Cesarean delivery in a parturient with Arnold-Chiari type I malformation. Can J Anaesth. 2004; 51: 639.
[11]	Sastry R, Sufianov R, Laviv Y, Young BC, Rojas R, Bhadelia R, Boone MD, Kasper EM. Chiari I malformation and pregnancy: a comprehensive review of the literature to address common questions and to guide management. Acta Neurochir (Wien). 2020 Jul; 162 (7): 1565-1573. doi: 10.1007/s00701-020-04308-7. Epub 2020 Apr 18. PMID: 32306160.
[12]	Roper JC, Al Wattar BH, Silva AHD, Samarasekera S, Flint G, Pirie AM. Management and birth outcomes of pregnant women with Chiari malformations: A 14 years retrospective case series. Eur J Obstet Gynecol Reprod Biol. 2018 Nov; 230: 1-5. doi: 10.1016/j.ejogrb.2018.09.006. Epub 2018 Sep 10. PMID: 30223175.
[13]	Sicuranza GB, Steinberg P, Figueroa R. Arnold-Chiari malformation in a pregnant woman. Obstet Gynecol. 2003 Nov; 102 (5 Pt 2): 1191-4. doi: 10.1016/s0029-7844(03)00682-3. PMID: 14607053.
[14]	Teo MM. Spinal neuraxial anaesthesia for caesarean section in a parturient with type I Arnold Chiari malformation and syringomyelia. SAGE Open Med Case Rep. 2018 Jun 28; 6: 2050313X18786114. doi: 10.1177/2050313X18786114. PMID: 30013789; PMCID: PMC6041851.
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APA Style

Samina Mir, Rajpreet Bal, Anne-Marie Githaiga. (2021). Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report. World Journal of Medical Case Reports, 2(4), 69-72. https://doi.org/10.11648/j.wjmcr.20210204.12

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ACS Style

Samina Mir; Rajpreet Bal; Anne-Marie Githaiga. Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report. World J. Med. Case Rep. 2021, 2(4), 69-72. doi: 10.11648/j.wjmcr.20210204.12

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AMA Style

Samina Mir, Rajpreet Bal, Anne-Marie Githaiga. Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report. World J Med Case Rep. 2021;2(4):69-72. doi: 10.11648/j.wjmcr.20210204.12

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@article{10.11648/j.wjmcr.20210204.12,
  author = {Samina Mir and Rajpreet Bal and Anne-Marie Githaiga},
  title = {Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report},
  journal = {World Journal of Medical Case Reports},
  volume = {2},
  number = {4},
  pages = {69-72},
  doi = {10.11648/j.wjmcr.20210204.12},
  url = {https://doi.org/10.11648/j.wjmcr.20210204.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.wjmcr.20210204.12},
  abstract = {Background: Chiari malformation is a group of congenital abnormalities involving the cerebellar tonsillar herniation through the foramen magnum which affects the relationships between the cerebellum, brainstem, upper cervical cord, and the base of the cranium. CM-I (Chiari Malformation 1), is seen in adult patients and is associated with cranio-cervical abnormalities. Most of the patients with CM-I get symptoms when a cerebellar tonsillar herniation is greater than 5 mm. Case Information: This case report highlights the anaesthetic management of Chiari malformation with 8 mm cerebellar tonsillar descent in a pregnant patient with known difficult airway due to concurrent Temporo-mandibular joint dysfunction, who presented to the hospital for an elective cesarean section. Discussion: Childbearing women with Type I CM have concerns related to an increased cranial CSF pressure during pregnancy and labor. This difference in pressure above and below the foramen magnum may become worse following a lumbar puncture or spinal injection for spinal anesthesia and may lead to worsening of the cerebellar herniation leading to strangulation of the brainstem. These risk factors affect the choice of anaesthetic in these patients. Conclusion: As shown in this case report, the multidisciplinary discussion raised concerns with competing safety concerns of difficult airway if given general anesthesia and the risk of brainstem herniation with neuraxial anesthesia, despite evidence showing infrequent complications regardless of choice of anesthetic. Careful administration of the anesthetic technique, general or regional anesthesia in this group of patients can lead to favorable outcomes following multi-disciplinary discussion.},
 year = {2021}
}

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TY  - JOUR
T1  - Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report
AU  - Samina Mir
AU  - Rajpreet Bal
AU  - Anne-Marie Githaiga
Y1  - 2021/12/24
PY  - 2021
N1  - https://doi.org/10.11648/j.wjmcr.20210204.12
DO  - 10.11648/j.wjmcr.20210204.12
T2  - World Journal of Medical Case Reports
JF  - World Journal of Medical Case Reports
JO  - World Journal of Medical Case Reports
SP  - 69
EP  - 72
PB  - Science Publishing Group
SN  - 2994-726X
UR  - https://doi.org/10.11648/j.wjmcr.20210204.12
AB  - Background: Chiari malformation is a group of congenital abnormalities involving the cerebellar tonsillar herniation through the foramen magnum which affects the relationships between the cerebellum, brainstem, upper cervical cord, and the base of the cranium. CM-I (Chiari Malformation 1), is seen in adult patients and is associated with cranio-cervical abnormalities. Most of the patients with CM-I get symptoms when a cerebellar tonsillar herniation is greater than 5 mm. Case Information: This case report highlights the anaesthetic management of Chiari malformation with 8 mm cerebellar tonsillar descent in a pregnant patient with known difficult airway due to concurrent Temporo-mandibular joint dysfunction, who presented to the hospital for an elective cesarean section. Discussion: Childbearing women with Type I CM have concerns related to an increased cranial CSF pressure during pregnancy and labor. This difference in pressure above and below the foramen magnum may become worse following a lumbar puncture or spinal injection for spinal anesthesia and may lead to worsening of the cerebellar herniation leading to strangulation of the brainstem. These risk factors affect the choice of anaesthetic in these patients. Conclusion: As shown in this case report, the multidisciplinary discussion raised concerns with competing safety concerns of difficult airway if given general anesthesia and the risk of brainstem herniation with neuraxial anesthesia, despite evidence showing infrequent complications regardless of choice of anesthetic. Careful administration of the anesthetic technique, general or regional anesthesia in this group of patients can lead to favorable outcomes following multi-disciplinary discussion.
VL  - 2
IS  - 4
ER  -

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Author Information

Samina Mir

Department of Anaesthesia, Aga Khan University, Nairobi, Kenya
Rajpreet Bal

Department of Anaesthesia, Aga Khan University, Nairobi, Kenya
Anne-Marie Githaiga

Department of Anaesthesia, Aga Khan University, Nairobi, Kenya

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APA Style

Samina Mir, Rajpreet Bal, Anne-Marie Githaiga. (2021). Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report. World Journal of Medical Case Reports, 2(4), 69-72. https://doi.org/10.11648/j.wjmcr.20210204.12

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ACS Style

Samina Mir; Rajpreet Bal; Anne-Marie Githaiga. Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report. World J. Med. Case Rep. 2021, 2(4), 69-72. doi: 10.11648/j.wjmcr.20210204.12

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AMA Style

Samina Mir, Rajpreet Bal, Anne-Marie Githaiga. Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report. World J Med Case Rep. 2021;2(4):69-72. doi: 10.11648/j.wjmcr.20210204.12

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@article{10.11648/j.wjmcr.20210204.12,
  author = {Samina Mir and Rajpreet Bal and Anne-Marie Githaiga},
  title = {Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report},
  journal = {World Journal of Medical Case Reports},
  volume = {2},
  number = {4},
  pages = {69-72},
  doi = {10.11648/j.wjmcr.20210204.12},
  url = {https://doi.org/10.11648/j.wjmcr.20210204.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.wjmcr.20210204.12},
  abstract = {Background: Chiari malformation is a group of congenital abnormalities involving the cerebellar tonsillar herniation through the foramen magnum which affects the relationships between the cerebellum, brainstem, upper cervical cord, and the base of the cranium. CM-I (Chiari Malformation 1), is seen in adult patients and is associated with cranio-cervical abnormalities. Most of the patients with CM-I get symptoms when a cerebellar tonsillar herniation is greater than 5 mm. Case Information: This case report highlights the anaesthetic management of Chiari malformation with 8 mm cerebellar tonsillar descent in a pregnant patient with known difficult airway due to concurrent Temporo-mandibular joint dysfunction, who presented to the hospital for an elective cesarean section. Discussion: Childbearing women with Type I CM have concerns related to an increased cranial CSF pressure during pregnancy and labor. This difference in pressure above and below the foramen magnum may become worse following a lumbar puncture or spinal injection for spinal anesthesia and may lead to worsening of the cerebellar herniation leading to strangulation of the brainstem. These risk factors affect the choice of anaesthetic in these patients. Conclusion: As shown in this case report, the multidisciplinary discussion raised concerns with competing safety concerns of difficult airway if given general anesthesia and the risk of brainstem herniation with neuraxial anesthesia, despite evidence showing infrequent complications regardless of choice of anesthetic. Careful administration of the anesthetic technique, general or regional anesthesia in this group of patients can lead to favorable outcomes following multi-disciplinary discussion.},
 year = {2021}
}

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TY  - JOUR
T1  - Successful Cesarean Section Under General Anesthesia in a Patient with Chiari 1 Malformation and Temporo-Mandibular Joint Dysfunction: A Case Report
AU  - Samina Mir
AU  - Rajpreet Bal
AU  - Anne-Marie Githaiga
Y1  - 2021/12/24
PY  - 2021
N1  - https://doi.org/10.11648/j.wjmcr.20210204.12
DO  - 10.11648/j.wjmcr.20210204.12
T2  - World Journal of Medical Case Reports
JF  - World Journal of Medical Case Reports
JO  - World Journal of Medical Case Reports
SP  - 69
EP  - 72
PB  - Science Publishing Group
SN  - 2994-726X
UR  - https://doi.org/10.11648/j.wjmcr.20210204.12
AB  - Background: Chiari malformation is a group of congenital abnormalities involving the cerebellar tonsillar herniation through the foramen magnum which affects the relationships between the cerebellum, brainstem, upper cervical cord, and the base of the cranium. CM-I (Chiari Malformation 1), is seen in adult patients and is associated with cranio-cervical abnormalities. Most of the patients with CM-I get symptoms when a cerebellar tonsillar herniation is greater than 5 mm. Case Information: This case report highlights the anaesthetic management of Chiari malformation with 8 mm cerebellar tonsillar descent in a pregnant patient with known difficult airway due to concurrent Temporo-mandibular joint dysfunction, who presented to the hospital for an elective cesarean section. Discussion: Childbearing women with Type I CM have concerns related to an increased cranial CSF pressure during pregnancy and labor. This difference in pressure above and below the foramen magnum may become worse following a lumbar puncture or spinal injection for spinal anesthesia and may lead to worsening of the cerebellar herniation leading to strangulation of the brainstem. These risk factors affect the choice of anaesthetic in these patients. Conclusion: As shown in this case report, the multidisciplinary discussion raised concerns with competing safety concerns of difficult airway if given general anesthesia and the risk of brainstem herniation with neuraxial anesthesia, despite evidence showing infrequent complications regardless of choice of anesthetic. Careful administration of the anesthetic technique, general or regional anesthesia in this group of patients can lead to favorable outcomes following multi-disciplinary discussion.
VL  - 2
IS  - 4
ER  -

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