Cerebral arteriovenous malformation rupture in pregnancy

Abstract

A 30-year-old nulliparous woman at 38 5/7 weeks of gestation developed a sudden, severe headache at work and subsequent loss of consciousness. She underwent evaluation in the emergency department. CT and CT angiogram head revealed a large intraparenchymal haematoma with intraventricular extension secondary to ruptured cerebral arteriovenous malformation (cAVM). She was intubated and transferred to a tertiary care centre. The patient underwent caesarean section followed by partial embolisation of the cAVM with planned second embolisation and resection 1 week later. Due to drowsiness and headache, the planned repeat embolisation and cAVM resection were performed 3 days earlier. The patient had a full recovery. Emergency medicine physicians and obstetrician-gynaecologists should be familiar with differential diagnosis of sudden headache in pregnancy and signs of a ruptured cAVM to facilitate early diagnosis, multidisciplinary team approach and timely treatment. Early diagnosis and management of ruptured cAVM are important due to associated morbidity and mortality.

An Unusual Case of Cerebral Arteriovenous Malformation in Pregnancy

“…In the setting of concerns for spontaneous intracerebral hemorrhage, the American Heart Association/American Stroke Association recommends rapid non-contrast CT or MRI [ 2 ]. In pregnancy, radiological imaging other than ultrasound is usually avoided unless there is a clearly defined indication, and precautions are taken to limit fetus exposure to ionizing radiation.…”

“…It is vital for definitive treatment to be considered once an AVM hemorrhage has occurred due to the greater risk of re-bleeding after an initial AVM rupture [ 1 , 3 ]. There are several options in definitively treating cerebral AVMs, with case reports of neurosurgical treatment [ 2 , 4 ], stereotactic radiosurgery [ 4 ] and endovascular embolization [ 2 ] documented. Attributes of the AVM, stage of pregnancy, urgency for definitive treatment as well as the risks of intervention should be considered in this decision-making process.…”

“…Endovascular embolization has been increasingly used in the treatment of AVMs in the general population, either as a stand-alone treatment or used prior to surgical resection [ 2 ]. In pregnancy, the fluoroscopy component of endovascular procedures also presents a potential risk to the fetus for excessive radiation exposure and should be minimized [ 1 ].…”

“…The prevalence of cerebral arteriovenous malformation (AVM) is estimated at approximately 0.01% of the general population [ 1 ], and the yearly hemorrhage rates of cerebral AVMs at 2-4% [ 2 ]. Most available studies suggest that the risk of hemorrhage from a cerebral AVM is unaltered in pregnancy, but this is controversial due to the inconsistency among the rates reported in literatures [ 2 , 3 ].…”

“…The prevalence of cerebral arteriovenous malformation (AVM) is estimated at approximately 0.01% of the general population [ 1 ], and the yearly hemorrhage rates of cerebral AVMs at 2-4% [ 2 ]. Most available studies suggest that the risk of hemorrhage from a cerebral AVM is unaltered in pregnancy, but this is controversial due to the inconsistency among the rates reported in literatures [ 2 , 3 ]. Studies that suggest an increased risk of rupture in pregnancy postulate that it may be due to maternal hemodynamic changes and the influence of hormonal changes during pregnancy, affecting the structure of these vessels and rendering them more prone to rupture [ 1 , 3 , 4 ].…”