Emergency craniotomy in a hypertensive pregnant patient with basal ganglia hemorrhage: A case report of neuroanesthetic and fetal-perfusion strategies.

Background: Intracranial hemorrhage (ICH) during pregnancy presents a rare but significant risk to both mother and fetus. The anesthetic management of these patients is highly complex, requiring a delicate balance between controlling intracranial pressure and ensuring adequate uteroplacental perfusion. This case report details the perioperative strategies employed for an emergent craniotomy in a hypertensive pregnant patient with a basal ganglia hemorrhage. Case Description: A 19-year-old woman, gravida 2, para 1, at 27-28 weeks of gestation, presented with acute loss of consciousness, anisocoria, and right hemiparesis after severe vomiting. Her blood pressure was 182/102 mmHg, and a computed tomography scan revealed a left basal ganglia hemorrhage (>30 mL) with significant mass effect. Following a multidisciplinary discussion, an emergency craniotomy was indicated. Preoperative optimization included oxygenation, a head-up left lateral tilt position, and dexmedetomidine sedation. Anesthesia was induced using a rapid sequence protocol with propofol, fentanyl, lidocaine, and rocuronium. Intraoperative hemodynamics and ventilation were meticulously maintained, with end-tidal CO2 targeted at 30-32 mmHg. The patient remained stable, with blood loss of 660 mL and urine output of 60 mL/h. Postoperatively, she showed gradual neurological improvement in the intensive care unit. Conclusion: This case underscores the importance of individualized anesthetic strategies in pregnant patients with life-threatening ICH. A multidisciplinary, evidence-based approach, including neuroanesthetic principles and obstetric considerations, is essential to optimizing maternal and fetal outcomes.