Optimal intervention for ruptured cerebral arteriovenous malformation during pregnancy

Cerebral arteriovenous malformation (AVM) is a significant cause of hemorrhagic stroke in pregnant women. The risk of rebleeding after an initial hemorrhage during pregnancy is high, necessitating aggressive intervention and careful management. However, the optimal timing and method of intervention remain unclear. In particular, there has been little discussion regarding cases in which rebleeding occurred despite aggressive intervention. We present a case of cerebral AVM with intraventricular hemorrhage during pregnancy, which subsequently rebled after a cesarean section.

A 30-year-old primigravida at 27 weeks of gestation presented with a sudden headache and was diagnosed with intraventricular hemorrhage. Magnetic resonance imaging revealed a flow void in the left fusiform gyrus, confirming a Spetzler-Martin Grade 2 AVM. Due to the deep location and limited safety data on Onyx use during pregnancy, surgery was postponed until after delivery. Cesarean section was planned at 32 weeks to ensure fetal viability. No rebleeding occurred preoperatively. At 32 weeks and 2 days, a cesarean section was performed under spinal anesthesia, delivering a male infant weighing 1,567 g. Postoperative computed tomography revealed intraventricular rebleeding, although no neurological deterioration occurred. Emergency transarterial embolization (TAE) with Onyx was performed the following day, followed by another TAE and AVM resection. Angiography confirmed complete lesion removal, and both the mother and child recovered favorably.

Considering the high rates of rebleeding and the significant maternal and fetal mortality, prioritizing rebleeding prevention may be a key component of the intervention strategy for ruptured AVMs during pregnancy.