Current Treatment Options for Cerebral Arteriovenous Malformations in Pregnancy: A Review of the Literature

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“…Recurrence usually occurs in the 1 st year from previous hemorrhage [53], or even can recur in the same pregnancy [54]. A number of mechanisms can explain such phenomenona, well illustrated in a review by Nitin et al [1], which are categorized under structural (high velocity feeder, lack of smooth muscles at nidus leading to loss of autoregulation and low nidal resistance, together with occasionally incomplete venous elastic lamina), hemodynamic (turbulence, shear stress, high pressure feeder effect) cardiologic and endocrinologic (vasoactive estrogen and progesterone) hypotheses, though no definite associations yet exist. Of course, we have been anticipating results from ARUBA trial [18,56], till it was recently halted by NINDS organization due to preliminary results showing superiority of conservative AVM management to interventional therapy, as the event rate was found to be 3 times higher in the intervention group than conservative arm [57].…”

“…Overall, AVM-induced hemorrhage represents 2% of all hemorrhagic strokes in the general population [10]. Among known risk factors for hemorrhage in AVM (previous hemorrhage history, deep location, deep venous drainage and high feeding artery pressure) [17,, pregnancy still remains a debatable risk factor for first rupture of AVM during pregnancy [1,25]. Although Swain and others report increased risk of 1st hemorrhage in unruptured AVM during pregnancy (87% in 24 pregnancies with AVM by Robinson et al, 9.3% by Forster et al [47]) Horton et al [48] estimate prevalence of first AVM hemorrhage as 0.035 +/-0.005/person-year in 451 pregnant females with unruptured AVM, which didn't significantly differ from that of nonpregnant females during childbearing period (0.035 +/-0.005/person-year).…”

“…However, the anaesthesia, patient positioning and approach considerations (vide infra) made the sole reliance on surgical management a real challenge. Advances in microsurgery as well as adjuvant endovascular AVM intervention are rather options of choice nowadays [62], especially Spetzler-Martin IV and V lesions, which need a multidisciplinary management [1].…”

“…Brain Arteriovenous malformations (AVM) are abnormal communication between parts of cranial arterial and venous systems with the lack of a true nutritive and absorptive capillary bed [1]. The universal prevalence of AVM is relatively uncommon, with a prevalence ranging from 0.01-0.5%, 10/100000 to 140-500/100000 specifically [2][3][4][5][6][7] clustering between 3 rd and 5 th decade i.e.…”

“…AVM commonly presents with hemorrhage in more than one half of the cases even during pregnancy [4,8,[10][11][12][13][14][15][16][17]. Microsurgery, endovascular embolization and stereotactic radiosurgery are the well-established lines of management, applied on integrated and -sometimes-on individualized bases [1]. With the exception of ARUBA trial, evidence is limited to case series and case studies for natural history and management [18,19].…”