Hemorrhage Risk of Brain Arteriovenous Malformations During Pregnancy and Puerperium in a North American Cohort

Porras, Jose L.; Yang, Wuyang; Philadelphia, Eunice; Law, Jody; Garzón-Muvdi, Tomás; Caplan, Justin M.; Colby, Geoffrey P.; Coon, Alexander L.; Tamargo, Rafael J.; Huang, Judy

doi:10.1161/strokeaha.117.016828

Cited by 67 publications

(46 citation statements)

References 29 publications

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“…Subarachnoid and intracerebral hemorrhage in preeclampsia.-Hemorrhagic stroke, comprising ICH and SAH, can occur either spontaneously or secondary to rupture of vascular lesions such as aneurysms, arteriovenous malformations (AVMs), or moyamoya vasculopathy. Data conflict regarding whether pregnancy increases the risk of aneurysm or AVM rupture, [91][92][93] and no studies have evaluated the effect of PE on risk of rupture. Interestingly, VEGF is increased in brain AVMs, and VEGF inhibition with sFlt-1 decreased brain AVM severity in animal studies.…”

Section: Immediate Cerebrovascular Complications Of Preeclampsiamentioning

confidence: 99%

Preeclampsia and Cerebrovascular Disease

Miller

2019

Hypertension

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Preeclampsia (PE), a hypertensive disease affecting 5-8% of pregnancies, 1 is a multisystem disorder, with vascular dysfunction being central to the disease. The heterogeneity of PE's signs and symptoms has generated controversy regarding whether the cause of PE is mainly related to maternal or placental factors (Supplemental Tables S1, S2). 2 Most researchers agree that placental hypoxia and/or oxidative stress plays an important role in the pathophysiology of PE, leading to a cascade of downstream effects. 3-5 The maternal cerebral vasculature is highly vulnerable to adverse effects of PE. Short-and long-term cerebrovascular complications of PE include posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), hemorrhagic and ischemic stroke, cerebral small vessel disease, and vascular dementia. 6-10 This review summarizes current evidence and recent advances in our understanding of the effects of PE on cerebrovascular disease in women, and outlines gaps in knowledge and directions for future research. Epidemiology of preeclampsia-associated cerebrovascular disease. PE is a leading cause of maternal morbidity and mortality worldwide. 11 In African-Americans, PE has a higher prevalence and is more likely to be associated with maternal complications, including 3-fold higher mortality rates. 12,13 Cerebrovascular disease is the leading cause of maternal mortality in women with PE, with the majority of deaths due to intracerebral hemorrhage (ICH). 14-17 In the United States (US), maternal stroke accounted for 7.4 percent of maternal deaths from 2011-2014. 18 Rates of antepartum and postpartum stroke, highly associated with PE, increased 47 and 83 percent, respectively, from 1994-1995 to 2006-2007 in the US. 19 This has been directly attributed to increasing rates of PE. 19,20 PE increases the risk of maternal stroke up to 6-fold. 7,21 Risk factors for peripartum stroke in women with PE include older age, African American race, chronic preexisting hypertension, underlying prothrombotic or inflammatory disorders, and infections. 22

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Section: Immediate Cerebrovascular Complications Of Preeclampsiamentioning

confidence: 99%

Preeclampsia and Cerebrovascular Disease

Miller

2019

Hypertension

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“…The radiation is considered very low in both CT scan and DSA, which is equivalent to 0.17-2.8 mGy to the fetus. The accepted limit is below 50 mGy [33,34].…”

Section: Discussionmentioning

confidence: 99%

Intracerebral Hemorrhage of Brainstem in triple pregnancy after in vitro fertilization by receiving Ovum Donation: A case report and review

Winarno¹,

Schloesser²,

Dietzel³

et al. 2019

Clin J Obstet Gynaecol

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Deliveries prior to 28 weeks' gestation (extreme preterm birth) pose a global health concern, according to the World Health Organization (WHO). Extreme preterm birth is associated with several complications in the newborn and management in neonatal intensive care unit would incur high expenses. In parallel, advancements in in vitro fertilization will give an opportunity for women to conceive in cases of ovarian failure. At the same time, health providers also encourage patients to receive more than one embryo simultaneously during an embryo transfer. Here we report a case of a patient in coma condition of triplet pregnancy, post ovum donation with threeembryo transfer. Following stabilization, cranial computed tomography (CCT) was performed. The result showed bleeding in the brainstem and into intraventricular spaces at 25+4 gestation weeks. Furthermore, ICH during pregnancy is considered as a rare case in obstetrical fi eld, especially involving the brainstem. This could lead to life-threatening conditions and serious disability in the future. On the fi fth day of hospitalization, she suffered from pneumonia and pulmonary edema. On the eight day (26+5 gestations weeks), an emergency caesarean section was performed due to fully dilated of the cervix with breech presentation of all fetuses. Mother and the children survived with some non-life-threatening disabilities. This is the very fi rst case reported of intracerebral hemorrhage in the brainstem in triplet pregnancy after receiving ovum donation. Heterologous conception could be an iceberg phenomenon of gestational complications among the population. Reproductive tourism could still become greater in the future.

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“…Zhu et al found in their single-centre case series a haemorrhage risk of 5.59% during pregnancy and puerperium and a 2.52% risk in the non-pregnant period 4. Looking specifically at the North American population, Porras et al and Gross et al found an increased cAVM haemorrhage risk in pregnancy: 5.7% versus 1.3% and 8.1% versus 1.1%, respectively 4 13 14. cAVMs are typically identified by CT/CTA head or MRI brain as these studies are more readily available and are non-invasive in comparison with catheter-based cerebral angiogram.…”

Section: Discussionmentioning

confidence: 99%

Cerebral arteriovenous malformation rupture in pregnancy

Sappenfield¹,

Jha

Agazzi

et al. 2019

BMJ Case Rep

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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.

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Hemorrhage Risk of Brain Arteriovenous Malformations During Pregnancy and Puerperium in a North American Cohort

Abstract: Our results conflict with those from a recent study describing no increased rate of rupture during pregnancy. This difference may reflect unique population attributes influencing brain AVM hemorrhage during pregnancy.

Cited by 67 publications

References 29 publications

Preeclampsia and Cerebrovascular Disease

Preeclampsia and Cerebrovascular Disease

Intracerebral Hemorrhage of Brainstem in triple pregnancy after in vitro fertilization by receiving Ovum Donation: A case report and review

Cerebral arteriovenous malformation rupture in pregnancy

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