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.

Keywords: headache (including migraines); neurosurgery; obstetrics and gynaecology.

Figure 1

CT head of right frontal intraparenchymal haematoma with intraventricular extension.

Figure 2

(A,B) Initial coronal and sagittal CT angiography (CTA) at the time of patient’s presentation demonstrating a large intraparenchymal haematoma with an underlying vascular lesion concerning a cerebral arteriovenous malformation (cAVM). (A) Coronal view demonstrating frontal basal interhemispheric cAVM with a nidus measuring 3.5 cm. (B) Sagittal view demonstrating superficial cortical veins draining the cAVM via the superior sagittal sinus. (C,D) Three-dimensional reconstruction of the CTA demonstrating on coronal and sagittal views that the cAVM appears to be supplied by the right anterior cerebral artery.

Figure 3

(A,B) Preoperative right internal carotid artery (ICA) cerebral angiogram. (A) Anteriorposterior (A/P) projection demonstrating a compact cerebral arteriovenous malformation (cAVM) nidus measuring 3.5 cm in maximal diameter that is supplied by the right anterior cerebral artery. (B) Lateral projection demonstrating the superficial drainage pattern of the cAVM via the superior sagittal sinus. A venous varix is clearly seen. (C,D) Right ICA cerebral angiogram A/P and lateral projections following stage 1 microcatheter embolisation of cAVM. This reduced the nidus volume by approximately 50%–75%.

Figure 4

Axial, sagittal and coronal MRI T2 sequence following embolisation of cerebral arteriovenous malformation (cAVM). Approximately 50% of the cAVM remains and is supplied by the right anterior cerebral artery. The venous drainage is via the superior sagittal sinus. There is T2 hyperintensity demonstrating oedema surrounding the intraparenchymal haematoma.

Figure 5

(A,B) Coronal and sagittal CT angiography following microsurgical resection of cerebral arteriovenous malformation (cAVM). Clips are visualised adjacent to the right anterior cerebral artery where feeders to the cAVM were divided and resected. The venous drainage via the superior sagittal sinus is no longer present.