Anaesthetic Management of a Spontaneous Haemorrhagic Stroke Following Severe Preeclampsia: A Case Report

Haemorrhagic stroke (HS) during pregnancy, especially in the context of preeclampsia, is a rare but critical emergency that poses significant health risks to both the mother and the foetus. Even so, rapid recognition and appropriate management are of utmost importance to minimise unfavourable outcomes. We present a case of the management of HS in a pregnant woman with severe preeclampsia, resulting in favourable outcomes for both mother and neonate. A 39-year-old female (gravida 8, para 4) at 32 weeks and six days of gestation was admitted with sudden-onset severe headache, vomiting, hypertension (200/100 mmHg), inability to speak, right-sided hemiplegia, and proteinuria. Given a depressed level of consciousness (Glasgow Coma Scale 9), she was intubated following rapid sequence induction. Neuroimaging showed a left cerebellar vermis and hemisphere haemorrhage with marked mass effect and transtentorial and tonsillar herniation. Emergency decompressive craniotomy with haematoma evacuation was performed under total intravenous anaesthesia (TIVA), with intracranial pressure and severe hypertension managed accordingly. Intraoperative deterioration of foetal cardiotocography prompted an emergency caesarean section in the same theatre, without patient transfer. The neonate was delivered with Apgar scores of 6, 8, and 9; transient respiratory depression required supplemental oxygen and a three-day neonatal unit admission, with no mechanical ventilation. The mother was extubated on day three and discharged two weeks after admission with residual ataxic gait and dysarthria. Throughout the case, continuous foetal monitoring was essential to guide the timing of delivery, underlining the importance of early recognition of foetal distress and immediate delivery without delay. This case emphasises the crucial role of the obstetric anaesthesiologist as the central coordinator in a complex multidisciplinary scenario involving simultaneous neurosurgical and obstetric emergencies.