Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments

Abstract

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Keywords: Cerebral autoregulation; Cerebral perfusion pressure; Intracranial hypertension; Intracranial pressure; Intracranial pressure monitoring; Pregnancy.

Fig. 1

Systemic changes induced by pregnancy. CO: cardiac output; HR: heart rate; SV: systolic volume; SVR: systemic vascular resistance; MAP: mean arterial pressure; RBF: renal blood flow; GFR: glomerular filtration rate; RR: respiratory rate; RFC: residual functional capacity; RV: residual volume; AwR: airway resistance; TV: tidal volume; AV: alveolar ventilation; MV: minute ventilation; VO2: oxygen consumption; IAP: intrabdominal pressure

Fig. 2

Changes in cerebrovascular autoregulation during pregnancy

Fig. 3

Management steps for control of intracranial hypertension (IHT). Interventions should be implemented in a stepwise, additive manner allowing for sufficient intervals and, when pertinent radiological reevaluation, between steps to ensure that proceeding to the next step is necessary. Fetal monitoring is indicated throughout this process and indispensable as the more advanced (and less safe) steps are implemented. CPP: cerebral perfusion pressure; ICP: intracranial pressure; MABP: mean arterial blood pressure; EML: evacuate mass lesion; DC: decompressive craniectomy; PNp: physiological neuroprotection; MV: mechanical ventilation; min: minutes; CT: computed tomography; CSF Dr: cerebrospinal fluid drainage; Analg: analgesia; HV: hyperventilation; BBT: barbiturates; Hypoth: hypothermia

Fig. 4

Physiological neuroprotection. Na⁺: serum sodium