title: Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia.
abstract: BACKGROUND
  Arnold-Chiari malformation Type 1 (ACM-1) in parturients is a topic of ongoing discussion between obstetricians and anesthesiologists. The primary unanswered question remains; How should the anesthesia provider proceed with labor analgesia and anesthesia for cesarean section when confronted with an advanced, asymptomatic, or minimally symptomatic case of ACM-1 during labor?
  
  
  METHODS
  A 24-year-old, ASA II, G1P0 full-term parturient presented to Labor and Delivery for vaginal delivery. A diagnosis of ACM-1 was made 12 years ago when a brain magnetic resonance imaging (MRI) was performed for right-sided numbness following a rear-end motor vehicle collision. The patient had been asymptomatic since then and had been seen by an outside neurologist frequently for the past 10 years. During the anesthesia evaluation, it was noted that she had an exaggerated patellar reflex, and a questionable left-sided Babinski; subsequently, an MRI study was requested. Review of a brain MRI demonstrated an advanced form of ACM with a 1.7 cm transtonsillar herniation and a large syrinx extending from C1 down to C5. Following a discussion with the patient, family, and primary OB team, a plan for elective cesarean section was made per neurosurgical recommendations. This was conducted uneventfully under general anesthesia. The patient had no complaints in the post-anesthesia care unit.
  
  
  CONCLUSIONS
  Unfamiliarity of health care providers with regards to ACM-1 parturients can be countered by increasing awareness of this condition throughout medical specialties involved in their care. The Ghaly Obstetric Guide to Arnold-Chiari malformation Type 1, along with proper training of anesthesia care providers regarding the specificities of ACM-1 parturients aids in better management and understanding of this complex condition.
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; Department of Anesthesiology, JHS Hospital of Cook County, Chicago, Illinois, USA; Ghaly Neurosurgical Associates, Aurora, Chicago, Illinois, USA; Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA.
authors.forename: Ramsis F
authors.initials: RF
authors.lastname: Ghaly
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Tverdohleb
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA.
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Candido
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA.
authors.forename: Nebojsa Nick
authors.initials: NN
authors.lastname: Knezevic
keywords: ACM-1; anesthesia; delivery; multidisciplinary; parturient