Anesthetic Management of Emergency Craniotomy for Intracerebral Hemorrhage in a Pregnant Patient: A Case Report

Abstract The anesthetic management of pregnant patients undergoing emergency neurosurgery presents significant clinical challenges due to the competing priorities of maternal neurological preservation and fetal safety. This case report describes the successful perioperative care of a pregnant woman in her second trimester who underwent emergency decompressive craniotomy for intracerebral hemorrhage. A multidisciplinary team approach involving anesthesia, neurosurgery, and obstetrics enabled prompt intervention and tailored anesthetic planning. Total intravenous anesthesia was employed to optimize cerebral perfusion while maintaining maternal hemodynamic stability. Key considerations included rapid-sequence induction, careful hemodynamics control during laryngoscopy, and the use of neuroprotective agents such as propofol and fentanyl. Dexmedetomidine and remifentanil were cautiously utilized for their sedative and analgesic properties, acknowledging emerging safety data and existing concerns regarding uterine tone and fetal bradycardia. Postoperative care was guided by the GHOST-CAP framework, focusing on the regulation of glycemia, hemodynamics, oxygenation, serum sodium, temperature, and ventilation parameters. The patient recovered without neurological sequelae, and fetal well-being was preserved throughout the perioperative period. This case highlights the critical importance of individualized, interdisciplinary management strategies in high-risk pregnant patients requiring emergency neurosurgical intervention. It also underscores the need for context-sensitive anesthetic decisions in the absence of clear evidence-based guidelines. Our report adds to the limited literature on anesthetic care in such complex scenarios and may assist clinicians facing similar challenges in resource-constrained or urgent care settings.