Cerebrovascular Disease and Pregnancy

Lim

et al. 2014

Anaesth Intensive Care

Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.

Section: Discussionmentioning

confidence: 99%

Pituitary Apoplexy with Reversible Cerebral Vasoconstrictive Syndrome after Spinal Anaesthesia for Emergency Caesarean Section: An Uncommon Cause for Postpartum Headache

Lim

et al. 2014

Anaesth Intensive Care

“…The effect of pregnancy on the risk of rupture is controversial; some report increased risk [ 33 , 50 , 71 ], while others have no increased risk [ 30 , 40 , 72 - 74 ]. Thus, firm recommendations cannot be made, and the general trend is to avoid vaginal delivery where possible, delay radiosurgery until after delivery, manage ruptured bAVM as per considerations above while maintaining obstetric principles such as the risk of anti-epileptic medications, positioning to avoid aortocaval compression, and risks of radiation with imaging [ 3 ].…”

Section: Reviewmentioning

confidence: 99%

Management of Brain Arteriovenous Malformations: A Review

Naranbhai¹,

Pérez²

2023

Cureus

Brain arteriovenous malformations (bAVM) are vascular malformations of the brain affecting all ages. The optimum management strategy is essentially devoid of high-quality evidence and is highly nuanced and embedded in local customs. This study summarizes the frequently employed management strategies, drawing conclusions on the utility of each method of treatment and delving into controversies surrounding them. A literature search on PubMed and Medline was done on January 3 rd , 2022. 11,767 articles were found, and abstracts were reviewed. Full-text review of 153 articles led to chapters from three books and 71 articles incorporated into a summative discussion. Spetzler-Ponce (S-P) Class A patients may be offered surgery if they are good surgical candidates and have a good number of high-quality years of life left. The exception is diffuse Spetzler-Martin (S-M) grade 2 in a patient older than 40 years: radiosurgery for unruptured and embolization for ruptured. S-P Class B may be offered surgery if a compact nidus or if younger than 40 years. If diffuse or age greater than 40, radiosurgery may be preferred if the Pollock-Flickinger score is less than 2.5. For the remainder of S-P Class B, conservative management may be preferred. S-P Class C is generally not treated unless young or those patients with poorly controlled seizures affecting their quality of life are willing to risk permanent neurological deficits. While the quality of studies is generally high, the level of evidence is concerning with only one randomized controlled trial (RCT). Most research output hails from high-income countries, i.e., perhaps not universally applicable to all settings owing to possible genetic, environmental, and resource differences. More research is needed: large volume studies in the pregnant population, validation of scoring systems in pediatric age groups, clinical trials focused on combination multi-staged treatment modalities, and studies originating from the developing world.

J Cereb Blood Flow Metab

“…In addition, remodeling of cerebral arteries during gestation could impact the integrity of the vascular wall, a consequence that is also important to consider, especially in the presence of comorbidities such as diabetes or hypertension that are known to increase the risk of hemorrhagic stroke. 36,37 The majority of studies during pregnancy has been on the PCA, mostly because of the propensity for edema to form in the posterior cortex during conditions such as early-onset preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and eclampsia. 26,27 Late-pregnancy has been particularly studied because this is when neurologic symptoms occur most often.…”

Section: Adaptation Of the Cerebral Circulation During Normal Pregnancymentioning

confidence: 99%

The Adaptation of the Cerebral Circulation to Pregnancy: Mechanisms and Consequences

Cipolla

2013

The adaptation of the cerebral circulation to pregnancy is unique from other vascular beds. Most notably, the growth and vasodilatory response to high levels of circulating growth factors and cytokines that promote substantial hemodynamic changes in other vascular beds is limited in the cerebral circulation. This is accomplished through several mechanisms, including downregulation of key receptors and transcription factors, and production of circulating factors that counteract the vasodilatory effects of vascular endothelial growth factor (VEGF) and placental growth factor. Pregnancy both prevents and reverses hypertensive inward remodeling of cerebral arteries, possibly through downregulation of the angiotensin type 1 receptor. The blood-brain barrier (BBB) importantly adapts to pregnancy by preventing the passage of seizure provoking serum into the brain and limiting the permeability effects of VEGF that is more highly expressed in cerebral vasculature during pregnancy. While the adaptation of the cerebral circulation to pregnancy provides for relatively normal cerebral blood flow and BBB properties in the face of substantial cardiovascular changes and high levels of circulating factors, under pathologic conditions, these adaptations appear to promote greater brain injury, including edema formation during acute hypertension, and greater sensitivity to bacterial endotoxin.