Case Report: "Damage control" in obstetric neurosurgery: staged management of ruptured arteriovenous malformation...

Catastrophic arteriovenous malformation (AVM) rupture during the second trimester presents a formidable clinical dilemma, necessitating a delicate balance between maternal resuscitation and fetal preservation. This challenge is acute when uncal herniation precludes extensive diagnostic workup.

We report a staged "damage control" strategy in a 27-year-old gravida (26 weeks) who presented with acute neurologic collapse, anisocoria, and coma. In advance of definitive angiographic characterization, we proceeded directly to emergency decompressive craniectomy to reverse impending herniation. Postpartum angiography revealed a small, eloquent Spetzler-Martin Grade II AVM. Definitive embolization (Onyx-18) was deferred until two months postpartum to ensure hemodynamic stability.

The emergency decompression successfully stabilized the patient. Following 12 weeks of supportive care, the pregnancy culminated in a successful term delivery. The patient achieved a full neurological recovery (modified Rankin Scale (mRS) score of 0), and the infant remained healthy.

This case substantiates that in the context of pregnancy complicated by herniation, neurosurgical intervention must decouple acute decompression from vascular treatment. A staged approach may facilitate maternal neurological recovery while preserving fetal viability.