Neuraxial labor analgesia in a pregnant patient with cystic hygroma and aberrant neurovasculature: a case report

Abstract

Cervicofacial lymphatic and venous malformations, when combined with intracranial venous anomalies, present unique anesthetic challenges during pregnancy, particularly with respect to airway management and the safety of neuraxial techniques. We report the anesthetic management of a 28-year-old gravida at 38 weeks' gestation, who presented for induction of labor with gestational hypertension and new neurologic symptoms. Her medical history was notable for a large cervicofacial cystic hygroma with associated superficial venous malformations and known cerebellar developmental venous anomaly. On presentation, she reported episodic visual disturbances, unilateral paresthesia, and severe headaches. Multidisciplinary evaluation, including non-contrast magnetic resonance imaging of the brain and spine and cardiology assessment, demonstrated no evidence of intracranial hemorrhage, mass effect, cerebrospinal fluid flow obstruction, or elevated intracranial pressure. Given the anticipated difficult airway and the absence of contraindications to neuraxial anesthesia, labor epidural analgesia was selected to minimize airway manipulation and avoid abrupt cerebrospinal fluid pressure changes. The epidural procedure was uneventful, and effective analgesia throughout labor was provided, allowing for continuous neurologic monitoring. The patient proceeded to an uncomplicated vaginal delivery without neurologic deterioration or anesthetic complication. This case highlights the importance of individualized, multidisciplinary risk assessment and supports the safe use of carefully selected neuraxial labor analgesia in pregnant patients with complex airway anatomy and stable intracranial venous anomalies.

Keywords: Airway management; Cerebral venous sinus thrombosis; Cystic hygroma; Developmental venous anomaly; Neuraxial labor analgesia; Vascular malformation.