Cerebrospinal fluid removal during spinal anaesthesia for caesarean delivery in a patient with idiopathic intracranial hypertension

Dear Editor,
Idiopathic intracranial hypertension (IIH), also known as pseudotumour cerebri or benign intracranial hypertension, is a neurologic condition that commonly affects obese females of child-bearing age [1]. IIH occurs when cerebrospinal fluid (CSF) accumulates abnormally in the brain, leading to elevated intracranial pressure (ICP) and symptoms such as headache, papilloedema, and vision changes. This accumulation of fluid may be due to an increase in fluid production or a decrease in fluid absorption. It is charac­terised by an increased ICP without signs of altered mental status, absence of intracranial lesions, and normal CSF composition [2, 3]. The incidence of IIH is greatest in obese females of childbearing age, with an estimated incidence of 7.9/100 000 [1].
Treatment strategies focus on redirecting or removing CSF from the subarachnoid space or decreasing the production of CSF [4]. Serial lumbar punctures may also be used to remove 20–30 mL of CSF with moderate success rates [5]. Acetazolamide is also often employed as it decreases CSF production, though the long term use of this medication is associated with acidaemia and is often discontinued in pregnancy [5]. Surgical interventions for refractory symptoms may be considered at later stages.
We present a patient with IIH who was admitted for worsening headache with vision changes and later required a caesarean delivery. She achieved symptomatic relief of IIH with low volume CSF removal during spinal anaesthesia.
A 30 year-old primigravida at 39 weeks gestation with a body mass index of 40 kg m-2 presented to labour and delivery with regular contractions and breech presentation. She had a diagnosis of IIH for several years, which had been previously well managed with acetazola­mide and occasional CSF removal with lumbar punctures. During her pregnancy she had stopped her acetazolamide and noted worsening of her IIH symptoms. She was managed during her pregnancy with occasional therapeutic lumbar punctures for CSF removal.
Upon presentation the patient complained of a pressure like headache at 7/10 intensity along with blurry vision. She was admitted to labour and delivery and evaluated for preeclampsia given her complaints and symptoms. The patient was normotensive with normal laboratory values and had reported that her symptoms had been progressively getting worse throughout her pregnancy. Given that the patient was at term gestation with regular contractions...


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