Relative risk of hemorrhage during pregnancy in patients with brain arteriovenous malformations

Abstract

Background It is unclear whether the risk of bleeding from brain arteriovenous malformations is higher during pregnancy, delivery, or puerperium. We compared occurrence of brain arteriovenous malformation hemorrhage in women during this period with occurrence of hemorrhage outside this period during their fertile years. Methods We included all women with ruptured brain arteriovenous malformations (16-41 years) from a retrospective database of patients with brain arteriovenous malformations in four Dutch university hospitals (n = 95) and from the population-based Scottish Audit of Intracranial Vascular Malformations (n = 44). We estimated the relative rate of brain arteriovenous malformation rupture (before any treatment) during exposed time (pregnancy, delivery, puerperium) versus non-exposed time during fertile years, using the case-crossover design as primary analysis, and the self-controlled case-series design as secondary analysis. Results In 17 of 95 Dutch women and in 3 of 44 Scottish women, hemorrhages occurred while pregnant; none occurred during delivery or puerperium. In Dutch women, the relative rate of brain arteriovenous malformation rupture during pregnancy, delivery, or puerperium was 6.8 (95% confidence interval 3.6-13) according to the case-crossover method and 7.1 (95% confidence interval 3.4-13) using the self-controlled case-series method. In Scottish women, the relative rate was 1.3 (95% confidence interval 0.39-4.1) using the case-crossover method and 1.7 (95% confidence interval 0.0-4.4) according to the self-controlled case-series method. Because of limited overlap of confidence intervals, we refrained from pooling the cohorts. Conclusions Case-crossover and self-controlled case series analyses reveal an increase in relative rate of brain arteriovenous malformation rupture during pregnancy in the Dutch cohort but not in the Scottish cohort. Since point estimates varied between both cohorts and numbers are relatively small, the clinical implications of our findings are uncertain.

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

“…This is lower than numbers in prior reports using the same ICD-9 code and could be the result of inclusion of all intracranial hemorrhages (ie, subarachnoid hemorrhage) rather than solely ICH. 7,30,31 Although it is possible that arteriovenous malformation was underdiagnosed, our data suggest that it is unlikely that arteriovenous malformation rupture significantly contributes to ICH incidence reported here. Similarly, we identified fewer than 10 patients with cerebral venous sinus thrombosis and no cases of sickle cell anemia in our analysis cohort.…”

Arteriovenous Malformation Hemorrhage in Pregnancy: A Systematic Review and Meta-Analysis

“…The total number of patients involved in this study was 2578, with a total number of pregnancies of 1,962 and a total number of hemorrhages during pregnancy of 158. The included studies were published from 1974 to 2021 in three regions: Europe, which involved the United Kingdom [ 9 , 20 ] and Scotland [ 21 ]; America, which involved the United States [ 10 , 22 , 23 , 24 ] and North America [ 25 ]; and Asia, which involved China [ 26 , 27 , 28 ] and Japan [ 12 ].…”

“…These studies applied three types of study design: retrospective review [ 9 , 10 , 12 , 20 , 22 , 23 , 24 , 25 , 27 , 28 ], case-cross-over design [ 26 ] and a combination of self-controlled case-series and case-crossover design [ 21 ]. The study with the combination of case series and case-crossover designs was treated as a case-crossover design in the meta-analysis.…”

Maternal Stroke: an Update

“…Intravascular volume expands during pregnancy from 30-50%, with a consequent 45% increase in cardiac output (55). These changes may have an impact on enlargement of brain arteriovenous malformations and cerebral aneurysms, although evidence is sparse and this is debated (19,(56)(57)(58)(59). Hemodynamic changes may exacerbate other conditions such as preexisting cardiomyopathies and valvular heart disease, contributing to increased risk of cardioembolic events, including stroke (60)(61)(62).…”