Use of endovascular embolization to treat a ruptured arteriovenous malformation in a pregnant woman: a case report

<p>Abstract</p> <p>Introduction</p> <p>Pregnancy has been linked to increased rates of arteriovenous malformation rupture. This link remains a matter of debate and very few studies have addressed the management of arteriovenous malformation in pregnancy. Unruptured arteriovenous malformations in pregnant woman generally warrant conservative management due to the low rupture risk. When pregnant women present with ruptured arteriovenous malformation, however, surgery is often indicated due to the increased risk of re-rupture and associated mortality. Endovascular embolization is widely accepted as an important component of contemporary, multimodal therapy for arteriovenous malformations. Although rarely curative, embolization can facilitate subsequent surgical resection or radiosurgery. No previous reports have been devoted to the endovascular management of an arteriovenous malformation in a pregnant woman.</p> <p>Case presentation</p> <p>A 23-year-old Caucasian woman presented with headache and visual disturbance after the rupture of a left parieto-occipital arteriovenous malformation in the 22nd week of her pregnancy. After involving high-risk obstetric consultants and taking precautions to shield the fetus from ionizing radiation, we proceeded with a single stage of endovascular embolization followed soon after by open surgical resection of the arteriovenous malformation. There were several goals for the angiography in this patient: to better understand the anatomy of the arteriovenous malformation, including the number and orientation of feeding arteries and draining veins; to look for associated pre-nidal or intra-nidal aneurysms; and to partially embolize the arteriovenous malformation via safely-accessible feeders to facilitate surgical resection and minimize blood loss and operative morbidity.</p> <p>Conclusion</p> <p>From our experience and review of the literature, we maintain that ruptured arteriovenous malformations in pregnancy may be managed in a similar manner to those in non-gravid women. Precautions should be taken to reduce the operative time and exposure of the fetus to ionizing radiation and contrast agents.</p

Gross Total Resection of a Ruptured Micro-arteriovenous Malformation within the Cerebellar Peduncle: A Case Report and Qualitative Review of the Literature

AbstractDeep-seated micro-arteriovenous malformations (micro-AVMs) may pose a challenge for complete yet safe resection. We propose the strategic placement of two to three microaneurysm clips throughout the hemorrhage cavity to successfully localize the micro-AVM nidus via digital subtraction angiography (DSA). We successfully demonstrate this novel method in a 15-year-old adolescent boy with cerebellar intraparenchymal hemorrhage who underwent hematoma evacuation and expansile duraplasty. He was found to have a 1-cm nidus of a micro-AVM with early venous drainage located in the right middle cerebellar peduncle. Five days later, we proceeded to resect the micro-AVM; however, a clear nidus or bleeding source was unable to be localized intraoperatively despite the use of stereotactic neuronavigation. In turn, we placed two mini-aneurysm clips superiorly and inferiorly within the hematoma cavity, which led to successful localization via DSA and complete resection. No surgical complications occurred. The patient completely recovered from right-sided weakness and dysarthria 6 to 12 months postoperatively. Our technique allows for the rapid localization and complete resection of micro-AVM nidi when stereotactic neuronavigation is inadequate.</jats:p