Brain arteriovenous malformations (bAVMs) during pregnancy: An Italian survey and literature review

Brain arteriovenous malformations (bAVMs) occur in approximately 0.001% to 0.5% of the general population. During pregnancy, bAVMs remain uncommon vascular lesions, with an estimated incidence of about 1 per 100,000 per year in unselected populations. Maternal physiological changes, such as the increase in cardiac output and increased estrogen levels during pregnancy make the structure of the vessels more prone to rupture. Our study investigates the management of bAVM in pregnant patients, reporting data from an Italian survey and literature review. On behalf of an ad hoc task force of the Neuro-Vascular Committee of SINch (Società Italiana di Neurochirurgia), a survey on the treatment options and management of vascular brain lesions during pregnancy was conducted to analyze the management of pregnant patients diagnosed with bAVM between January 2011 and September 2021. We also conducted a literature search in MEDLINE (PubMed) according to PRISMA guidelines published between 1967 and 2022. A total of 18 neurosurgical centers participate in the survey. 15 pregnant women with bAVM were included in this retrospective study. Seizures occurred in 20% of cases, headache in 33.3%, hemiparesis in 13.4%. Emergency surgical intervention was required in 46.7% of cases, of which neurosurgical treatment (haematoma evacuation + bAVM exclusion) was performed in 85% of cases; endovascular treatment was required in one case. The Cesarian Section (C-section) was performed in nine cases (60%, 9/15), of which 8 (88.9%) were emergency and 1 (12.1%) elective. Conclusion The association between pregnancy and bAVM is a rare event that threatens the lives of mother and child, posing neurosurgical, obstetric and ethical challenges. A multidisciplinary approach should be pursued. In case of rupture of bAVM, the best treatment should be decided on a case-by-case basis. C-section appears to be safer than vaginal delivery. In the future, a multicenter study will hopefully provide overarching recommendations for the management of bAVM patients during pregnancy.