Ruptured Thoracolumbar Perimedullary Arteriovenous Fistula during Pregnancy Complicated by Cerebral Subarachnoid Hemorrhage and Brainstem Hematoma: A Case Report

Abstract

Intradural spinal arteriovenous fistulas (sAVF) are spinal vascular lesions that usually manifest due to myelopathy or local symptoms caused by venous congestion and ischemia. In addition, perimedullary arteriovenous fistulas (PMAVF) in particular may rupture and cause subarachnoid or intramedullary hemorrhage along with relevant symptoms. Subarachnoid hemorrhage (SAH) can propagate into cranial space with clinically dominant symptoms and signs of typical aneurysmal intracranial SAH. The standard workup for cerebral SAH, after excluding an intracranial source of hemorrhage, is usually limited to a cervical spine MRI; therefore, thoracolumbar sources of hemorrhage can be missed, or their diagnosis may be delayed. Here we present a case of a pregnant patient who presented with cerebral SAH. The source of hemorrhage was not initially identified, leading to a presumptive diagnosis of benign pretruncal non-aneurysmal SAH. The correct diagnosis of spinal thoracolumbar PMAVF was revealed 2.5 months later due to the progression of local symptoms. While the diagnosis was being refined and endovascular treatment was being planned (but delayed due to pregnancy), there was a recurrence of intraconal hemorrhage followed by brainstem hemorrhage. This led to significant clinical deterioration. The PMAVF was then treated microsurgically and the patient experienced partial recovery.

Not All Subarachnoid Hemorrhages in Pregnancy Are Intracranial in Origin: A Case Report

“…[7][8][9][10][11] In one case report of SAH during pregnancy from a thoracolumbar AV malformation, its source was not identified until 2.5 months following initial presentation when the patient showed signs of cord compression. 12 In this patient, the epicenter of the bleed was primarily the AVM localized in a subdural, extramedullary location along the cervicothoracic spine. Blood from the AVM rupture migrated via the foramen magnum and subsequently through breaches in the subarachnoid membrane into the cerebral ventricles to give the initial impression of intracranial SAH.…”

“…7–11 In one case report of SAH during pregnancy from a thoracolumbar AV malformation, its source was not identified until 2.5 months following initial presentation when the patient showed signs of cord compression. 12…”