The management of intracranial aneurysms during pregnancy: a systematic review

Abstract

It has been estimated that 1.8% of women of childbearing age (16 to 44 years) develop intracranial aneurysms, however the incidence of unruptured intracranial aneurysms during pregnancy is not well established in the literature (25). Rupture of intracranial aneurysms occurs in the range of 1 to 10 per 100,000 pregnancies (1, 33). Case fatality from subarachnoid hemorrhage during pregnancy is reported as high as 83%, but outcomes have improved with better medical care (10, 12). Cerebrovascular management of aneurysms during pregnancy is complicated by the nature of maternal hemodynamics and their intimate relationship to the developing child. Given the dependence of the fetus on its mother, and the importance of a stable environment during fetal development, risk reduction from an intracranial aneurysm must clearly focus on both the mother and the child (39,40,42). Whether these aneurysms █ INTRODUCTIONAlthough intracranial aneurysms are uncommon during pregnancy, normal hemodynamic changes in pregnant women may increase vascular stress and the risk of aneurysm formation, progression and rupture (35,44,47). Systemically, maternal adaptations to pregnancy include increases in cardiac output (CO) and plasma volume (PV), and a redistribution of the CO between various organs (43). Cerebrovascular changes are thought to result from hormones that increase during pregnancy, such as estrogen, progesterone, and vascular endothelial growth factor (36). Other reported factors that may potentiate aneurysm progression during pregnancy include high levels of relaxin and increased wall tension from intraparenchymal artery hypoplasia (6, 51).Hemodynamic changes during pregnancy may favor the formation and rupture of intracranial aneurysms. Despite this risk, guidelines for managing intracranial aneurysms during pregnancy have not been clearly defined. The objective of this review is to describe the treatment options for pregnant women with intracranial aneurysms, and to report the maternal and fetal outcomes associated with different treatment strategies. A search of the literature was conducted using the PubMed database for the period January 1991 through June 2015. Aneurysm characteristics and management, pregnancy management, and maternal and fetal outcomes were evaluated. The most recent search was performed in June 2015. In total, 50 aneurysms (44 patients) were evaluated. Rupture was confirmed upon imaging in 36 aneurysms (72%), and most aneurysms ruptured during the third trimester (77.8%). Coil embolization was associated with a lower complication rate than clipping in patients with ruptured aneurysms (9.5% vs 23.1%). For patients with unruptured aneurysms, surgical management was associated with 31.9% fewer complications compared to no treatment. Most patients underwent Cesarean delivery (84%), and a combined neurosurgical-obstetrical procedure was used for 8 patients with ruptured aneurysms near term. Adverse outcomes were reported in 11.9% of children. Treatment of intracranial aneurysms during pregnancy is sa...

About an Intracranial Aneurysm Rupture During Delivery

“…It can also be dangerous for the baby because of radiations during the procedure if delivery has not yet been performed. 3 Diagnosis of aneurysm rupture was suspected during delivery for our patient, which allowed the obstetrician to extract the child and begin studies to underpin the diagnosis. It is true that the baby is on the safe side if delivery occurs before aneurysm treatment because of anesthesia risk, maternal hemodynamic variations due to aneurysm rupture such as vasospasm and hypoxia, dehydration, and acidosis due to low uterine perfusion.…”

“…The differential diagnosis is eclampsia crisis which can delay proper care. 2 In their literature review, Barbarite et al 3 reported that endovascular approach was mostly compared with clipping, respectively 47.7% against 36.4%. Endovascular treatment is harmless and allows a short hospitalization, but can be dangerous because of the heparin therapy that follows if a cesarian section is planned after.…”

Neurosurgical Issues in Pregnancy

“…36 In a recent systematic review on the management of intracranial aneurysms in pregnant women, the authors showed that coil embolization was performed more often than surgical clipping, probably due to the less invasive nature of coiling and shorter operating times. 38 However, coil embolization during pregnancy exposes the developing fetus to potential radiation-related risks. These risks depend on the dose and the stage of pregnancy at the time of radiation, varying from death of the embryo (embryogenesis during the first 2 weeks) to congenital abnormalities (organogenesis during week 2 to 7) to growth retardation and childhood cancer (fetal period from week 8 until birth).…”

Manejo clínico de hemorragia subaracnoidea por aneurisma intracraneal en una mujer embarazada en Quito, Ecuador: reporte de caso

“…Por otro lado, la incidencia de HSA se incrementa durante la gestación, y su frecuencia aumenta con la edad de la madre y la paridad (1). Una revisión de la literatura sobre hemorragia intracraneal en el embrazo indica que la HSA representa el 34,8 % de los eventos hemorrágicos intracraneales durante el embarazo, y que de estos, el 26,7 % tienen desenlaces fatales para la madre (6), mientras que se reporta una mortalidad entre 7 a 25 % para el feto (7,8).…”

“…Los cambios hemodinámicos normales asociados al embarazo podrían generar estrés vascular importante, e incrementarían el riesgo en la formación de aneurismas, su progresión y consecuente ruptura (7). En el embarazo se evidencian aumentos del 50 al 60 % en el gasto cardiaco, volumen plasmático, hipercoagulabilidad y cambios del sistema endócrino (9, 10).…”