Successful perinatal management of a ruptured brain arteriovenous malformation in a pregnant patient by endovascular embolization followed by elective cesarean section: a single-case experience

Abstract

BackgroundAlthough brain arteriovenous malformations (AVM) usually remain asymptomatic during pregnancy, they can cause intracranial hemorrhage and lead to serious neurological deficits. Nowadays, it is accepted that treatment of a ruptured brain AVM during pregnancy should be based on neurologic, not obstetric, indications.Recently, endovascular treatment has been recognized as a treatment option associated in pregnant patients with brain AVMs.Case presentationA 34-year-old woman presented at 25 weeks of gestation with a history of severe headache followed by severe consciousness disturbance. Brain CT showed a subcortical hematoma in the right occipital lobe along with bilateral intraventricular hematomas. A cerebral angiogram was performed to confirm the diagnosis, which revealed right occipital AVM. At 27 weeks of gestation, endovascular embolization of the AVM was attempted under general anesthesia. The feeding artery and the nidus were simultaneously obliterated by injection of 50 % n-butyl-cyanoacrylate. As a result, the blood flow into the nidus was drastically decreased and the risk of re-bleeding was substantially reduced. At 38 weeks of gestation, elective cesarean section was performed to deliver the baby under combined spinal-epidural anesthesia (CSEA). An infant weighing 3665 g was delivered, with Apgar scores of 8 and 9 at 1 and 5 min, respectively.Postoperative analgesia was provided by a continuous infusion of ropivacaine via the epidural catheter. The infant was confirmed as not having any congenital anomalies.On POD 5, both of the patient and the infant were discharged home without any medical problems. The mother has shown no evidence of re-bleeding from the intracranial lesion since, and the infant is thriving well.ConclusionsEndovascular treatment in pregnant women is associated with various unique concerns. However, it can be carried out safely and effectively and is useful not only for saving the mother’s life but also for allowing the pregnancy to continue to term.

Endovascular Treatment and Peri-interventional Management of Ruptured Cerebrovascular Lesions During Pregnancy

“…Considering that the fetus is not in the directly irradiated area and shield protection is used, it is only exposed to scattered radiation. Our calculated fetal radiation dose of 0.02 mGy during diagnostic angiography and therapeutic endovascular procedure, confirmed the relatively low dose to the fetus under appropriate shielding protection of the uterus and is similar to fetal radiation doses previously calculated by other interventionalists [ 22 , 23 ]. Assuming that the cumulative fetal radiation dose should never exceed 100 mGy [ 20 ], endovascular procedures can be performed safely in pregnant patients.…”

Embolization of Ruptured Infratentorial Pial AVM in Pregnancy

“…Extremely limited information on the dose of fetal radiation during embolization is available in the literature. Asano et al reported an exposure level of the uterus of 0.14 mGy [63]. Although three feeding branches were embolized in our case in one session to achieve complete occlusion of the AVM, the dose in the uterus was less than 1 µSv.…”

Cerebral arteriovenous malformations during pregnancy: a management dilemma

“…However, the majority of large epidemiological studies of intracerebral haemorrhage in pregnancy have not been differentiated by mechanism. Risk of re-bleeding in the same pregnancy is 27%–30% which is much higher than women who are not pregnant within a year 1 3 4 8 9…”

“…Ruptured AVM has been successfully being treated by surgical resection 3 15. Direct open surgery is considered to be associated with a lower rate of feto-maternal mortality when compared with conservative management alone, however, it is associated with an elevated risk of intraoperative bleeding which causes a decrease in uterine and placental blood supply and hence risk to fetus 4. Non-surgical options like endovascular embolisation have shown promising results in many case reports 1 4 15…”

“…It is essential to share all information, including treatment options, their possible side effects and feto-maternal outcome with the patient and the family. It is difficult to come up with an ideal treatment plan, as there are no definitive guidelines due to limited data and also because natural history of disease in pregnancy is not well understood 3–5…”