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Current Treatment Options for Cerebral Arteriovenous Malformations in Pregnancy: A Review of the Literature
Abstract
Background:
Cerebral arteriovenous malformations (AVMs), though relatively rare, have the propensity to cause potentially fatal conditions, such as intracranial hemorrhage.
Methods:
Online databases were utilized to select and review references to convey recommended treatment options for cerebral AVMs in pregnancy.
Results:
The presentation of a hemorrhage from an AVM in a pregnant woman warrants the initiation of treatments.
Conclusion:
An individualized, multimodal therapeutic strategy should be employed for endovascular treatment, such as presurgical embolization.
... The prevalence of cerebral arteriovenous malformation (AVM) is estimated at approximately 0.01% of the general population [1], and the yearly hemorrhage rates of cerebral AVMs at 2-4% [2]. Most available studies suggest that the risk of hemorrhage from a cerebral AVM is unaltered in pregnancy, but this is controversial due to the inconsistency among the rates reported in literatures [2,3]. ...
... Most available studies suggest that the risk of hemorrhage from a cerebral AVM is unaltered in pregnancy, but this is controversial due to the inconsistency among the rates reported in literatures [2,3]. Studies that suggest an increased risk of rupture in pregnancy postulate that it may be due to maternal hemodynamic changes and the influence of hormonal changes during pregnancy, affecting the structure of these vessels and rendering them more prone to rupture [1,3,4]. ...
... The typical presentation of a ruptured cerebral AVM includes headaches, seizures, muscle weakness, paralysis, vertigo, aphasia, and numbness [1], which may be mistaken for other disorders associated with pregnancy, such as migraine, pre-eclampsia, eclampsia, posterior reversible encephalopathy syndrome and cerebral venous thrombosis [5]. ...
We present a case of a woman at 31 weeks and 3 days of gestation, who developed a sudden and severe headache and loss of vision in her left eye. Magnetic resonance imaging (MRI) of the brain revealed a subarachnoid bleed secondary to a right parieto-occipital arteriovenous malformation (AVM). She was conservatively managed and subsequently transferred to our institution for multidisciplinary care. The patient underwent a cesarean section at 34 weeks and 5 days of gestation followed by gamma knife surgery 6 days after. Cerebral AVMs, although relatively rare, have the propensity to cause potentially fatal outcomes. Neurological symptoms in a pregnant woman warrant investigations for early diagnosis and management, due to its associated morbidity and mortality. The management of cerebral AVMs in pregnancy is decided after weighing the benefits of treatment against the risk of bleeding. A multidisciplinary approach should be adopted due to the complexity of the condition.
... AVMs are responsible for 1-2% of all strokes. Approximately a half of all patients with AVMs have at least one episode of hemorrhage during their life [4]. Hemorrhage from an AVM is rare in pregnant females [1,2]. ...
... Some studies showed that the incidence of hemorrhages from AVMs during pregnancy is 8.1%, which is higher than the overall incidence of hemorrhages from AVMs in females, 3.5% [1,2]. According to other reports [2,4], the risk of hemorrhage from previously asymptomatic AVM during pregnancy is 3.5%, and pregnancy and labor do not increase this risk. The risk of recurrent hemorrhage during the same pregnancy is 27-30%, which is significantly higher compared to that in non-pregnant females during the first year after the primary hemorrhage from an AVM, amounting to 6%. ...
... The risk of recurrent hemorrhage during the same pregnancy is 27-30%, which is significantly higher compared to that in non-pregnant females during the first year after the primary hemorrhage from an AVM, amounting to 6%. AVM hemorrhage in pregnancy results in maternal mortality of 28% and infantile mortality of 14% [1,4]. ...
Hemorrhages from arteriovenous malformations (AVMs) in pregnant females are rare, but they are known to lead to high maternal and infant mortality. There are no standards for AVM treatment in pregnant females. Many authors believe that AVM resection before delivery improves the prognosis for life and health of the mother and fetus. In this paper, we present a case of successful surgical treatment of a female patient with AVM hemorrhage at 20 weeks and address management issues of these patients.
... Brain Arteriovenous malformations (AVM) are abnormal communication between parts of cranial arterial and venous systems with the lack of a true nutritive and absorptive capillary bed [1]. The universal prevalence of AVM is relatively uncommon, with a prevalence ranging from 0.01-0.5%, ...
... AVM commonly presents with hemorrhage in more than one half of the cases even during pregnancy [4,8,[10][11][12][13][14][15][16][17]. Microsurgery, endovascular embolization and stereotactic radiosurgery are the well-established lines of management, applied on integrated and -sometimes-on individualized bases [1]. With the exception of ARUBA trial, evidence is limited to case series and case studies for natural history and management [18,19]. ...
... Overall, AVM-induced hemorrhage represents 2% of all hemorrhagic strokes in the general population [10]. Among known risk factors for hemorrhage in AVM (previous hemorrhage history, deep location, deep venous drainage and high feeding artery pressure) [17,24-46], pregnancy still remains a debatable risk factor for first rupture of AVM during pregnancy [1,25]. Although Swain and others report increased risk of 1st hemorrhage in unruptured AVM during pregnancy (87% in 24 pregnancies with AVM by Robinson [51]. ...
Abstract
Background: Cerebral arteriovenous malformations (AVMs) are relatively uncommon lesions in general population and rare among pregnant females, meanwhile they carry a relatively higher morbidity and mortality. In view of limited data for optimal management, we try to address dilemmas commonly encountered in pregnant females with cranial AVM and propose multidisciplinary algorithms for safe management.
Methods: Five cases of cerebral AVM pregnant females (ruptured during pregnancy) were followed up for 2 years after diagnosis. Endovascular embolization was performed in 3 cases and the other cases underwent expectant management. Natural history regarding rebleeding, time at bleeding, pregnancy and obstetric management as well as the endovascular management and teratogenicity issues were the primary outcome measures. Besides, we conducted a review of literature (Pubmed, Sciencedirect and other databases) during the years 1972 to 2013.
Results: We categorized the obtained data into key issues. The effect of pregnancy as a risk for AVM rupture appeared to be ill defined. The best time for AVM intervention during pregnancy and puerperium as well as the best mode for AVM management were decided based upon maternal counselling and multidisciplinary opinion. The myths of embolization teratogenicity and vaginal delivery risk during pregnancy appeared true due to lack of congenital anomalies over 2 years follow up. Although our cases underwent caesarean section, there is no apparent risk in normal vaginal delivery.
Conclusion: Cranial AVM during pregnancy is an uncommon, yet a challenging topic. Small sample size and relatively limited period of follow-up were our major obstacles. Further prospective studies are needed to elucidate the safety of endovascular versus microsurgical management during pregnancy over a longer follow up periods, especially in context of embolization with non-adhesive embolic agents, such as Onyx.
Keywords: Arteriovenous malformations; Cranial arteriovenous malformations; Arteriovenous malformations in pregnancy; AVM rupture; Aneurysmal haemorrhage; AVM haemorrhage
... Brain Arteriovenous malformations (AVM) are abnormal communication between parts of cranial arterial and venous systems with the lack of a true nutritive and absorptive capillary bed [1]. The universal prevalence of AVM is relatively uncommon, with a prevalence ranging from 0.01-0.5%, ...
... AVM commonly presents with hemorrhage in more than one half of the cases even during pregnancy [4,8,[10][11][12][13][14][15][16][17]. Microsurgery, endovascular embolization and stereotactic radiosurgery are the well-established lines of management, applied on integrated and -sometimes-on individualized bases [1]. With the exception of ARUBA trial, evidence is limited to case series and case studies for natural history and management [18,19]. ...
... Overall, AVM-induced hemorrhage represents 2% of all hemorrhagic strokes in the general population [10]. Among known risk factors for hemorrhage in AVM (previous hemorrhage history, deep location, deep venous drainage and high feeding artery pressure) [17,24-46], pregnancy still remains a debatable risk factor for first rupture of AVM during pregnancy [1,25]. Although Swain and others report increased risk of 1st hemorrhage in unruptured AVM during pregnancy (87% in 24 pregnancies with AVM by Robinson [51]. ...
... Another 1993 review reported a 9.3% rate of hemorrhage during pregnancy compared with 4.5% during the remainder of childbearing years [79]. Overall, there is no clear evidence to recommend women with unruptured AVMs to avoid pregnancy [80]. ...
... The maternal mortality rate was 23% in cases where women required surgical intervention, and there were no reports of fetal death [64]. Microsurgical excision is the standard for treating symptomatic AVM, often with presurgical embolization, but endovascular embolization with coiling should also be considered [80]. Untreated vascular malformations are prone to re-bleeding. ...
... Currently, the main treatment options involving aggressive intervention include microsurgery, radiosurgery and endovascular embolization techniques. [11] To treat cAVM while maintaining pregnancy as the goal, it is necessary to avoid exposure to radioactive materials and contrast materials as much as possible; therefore, microsurgery is the first choice of treatment. If the craniotomy is determined, the next issue is to determine the timing of the operation. ...
Rationale:
There is no clear consensus guidance for anesthesiologists on how to manage patients with cerebral arteriovenous malformation (cAVM) rupture and hemorrhage during pregnancy who need craniotomy. Our objective was to review the anesthesia management of pregnant women who underwent resection of cAVM at our institution and to provide opinions and suggestions.
Patient concerns:
Herein, we report of 3 patients with cAVM rupture and hemorrhage during pregnancy who underwent neurosurgery at the 22nd, 28th, and 20th weeks of pregnancy.
Diagnoses:
All 3 patients were admitted to the emergency department of our hospital due to sudden symptoms. Subsequently, their head imaging results confirmed the rupture and hemorrhage of cAVM. The rupture and hemorrhage of cAVM during pregnancy has a low incidence and high mortality, which seriously endangers the safety of the mother and fetus. For this emergency condition, craniotomy for removing intracranial lesions and clear hematoma can result in a chance of a successful delivery. Especially in the second and third trimesters of pregnancy, the management goal of anesthesia is to ensure the maternofetal safety and to maintain continuous pregnancy.
Interventions:
This article describes the process of intraoperative anesthesia management and maternal-fetal outcomes and discusses the key issues for the anesthesia management of cAVM rupture during pregnancy, including considerations of physiological changes during pregnancy and anesthesia medication, intraoperative monitoring, the maintenance of hemodynamic stability, and the control of intracranial pressure, among other considerations. Resection of intracranial lesions should be performed whenever possible while maintaining the pregnancy for better maternal and infant outcomes.
Outcomes:
The operations of the 3 pregnant women were successfully completed under our detailed anesthesia planning and careful anesthesia management. All the patients recovered well after the operation, and underwent cesarean section to give birth smoothly.
Lessons:
The preservation of pregnancy under cAVM resection is a complex challenge for anesthesiologists, and these 3 cases provide an extensive amount of experience for anesthesia management in similar situations. Detailed anesthesia planning and careful anesthesia management by anesthesiologists are important guarantees for good maternal and fetal outcomes.
... Several imaging methods are being used for the diagnosis of cerebral AVMs. These modes include digital subtraction angiography (DSA), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) [18]. ...
Cerebral arteriovenous malformations (AVM) are fistulous connections between arterial and venous blood flow, consisting of an abnormal tangle of dysplastic arteries and veins, without capillary vessels or interposed functional brain parenchyma. Management of pregnant patients with unruptured AVMs remain a dilemma for both obstetricians and neurosurgeons, due to the scarcity of data about this condition. Decisions are made weighting the risk of bleeding during pregnancy and the neurological status of the patient against the risks associated with a neurosurgical intervention. Most studies suggest that the bleeding risk does increase slightly during pregnancy, but further large prospective studies are needed. This article selects and reviews literature data to convey recommended management strategies for unruptured cerebral vascular malformations during pregnancy, childbirth and puerperium.
... Arteriovenous malformation of the brain (bAVM) presents maldevelopment of the vessels with a consequent direct connection between cerebral arteries and veins (1). The prevalence rate of 0.01-0.5% equally affecting men and women mostly in early adulthood (2). The annual risk of hemorrhage in adults is reported for 2-3 % (3) while pediatric population carries 61-68 % risk with possible worse neurological outcomes. ...
Background:
Arteriovenous malformation (bAVM) presents maldevelopment of the brain's vessels with a direct connection between cerebral arteries and veins. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable.
Objective:
Arteriovenous malformation presents maldevelopment of the brain's vessels with a consequent direct connection between cerebral arteries and veins. The annual risk of hemorrhage in adults is reported for 2-3 %. They usually present with unilateral headaches seizures and intracranial hemorrhage. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable.
Methods:
The study included a cohort of bAVM patients referred to Fujita Health University Bantane Hotokukai Hospital, Nagoya, Aichi, Japan where the main author (AA) has completed an international cerebrovascular fellowship under the mentorship of Professor Yoko Kato. Japanese Stroke Guidelines (JSG) were used for the treatment decision. Patients were graded according to the Spetzler Ponce (SP) system. Considering American Heart Association criteria (AHA), embolization was used as a part of multimodal treatment. Intraoperative microscopic video tools included Indocyanine green ICG, FLOW 800 and dual image video angiography DIVA. Clinical outcomes were measured using Modified Ranking Score (mRs).
Results:
A total of eleven patients with brain bAVM were studied with a median age of 32 years [IQR = 22-52]. There were ten patients presented with supratentorial and a single patient with infratentorial AVM. Patients were graded according to the Spetzler Ponce (SP) system. There were eight patients in SP A (72,7%), one in group B (9 %) while the rest of them were in C (18 %). Two patients had associated aneurysms that required treatment. The median size of the AVM nidus was 3,50 cm [IQR= 2-5]. Deep venous drainage was found in six patients while three were located in eloquent zones. Clinical outcomes were considered good by mRs <2 in eight patients, seven from the surgically treated group (72,7 % respectively). Surgery median length time was 427, 5 minutes; [IQR =320 - 463] with complete AVM resection in all patients and no mortality recorded in this cohort with the median follow up of 39,5 months [IQR = 19-59].
Conclusion:
Ideal management of bAVM is still controversial. Those complex vascular lesions require multimodal treatment in a majority of cases in highly specialized centers. In SP A patients, surgery provides the best results with a positive outcome and a small number of complications. With the improvement of endovascular feeder occlusion SP B patients become prone to a more positive outcome. Nowadays, intraoperative microscopic tools such as FLOW 800, ICG and DIVA are irreplaceable while improving safety to deal with bAVM. For SP C patients, a combination of endovascular and stereotactic radiosurgery was found to be a good option in the present time.
... The natural history of asymptomatic cerebral AVMs remains poorly understood as many may remain undiagnosed and only present with the development of symptoms or complications: for example, intracranial hemorrhage, seizures, headaches, and long-term disability [7,8]. It is thought that the physiological changes in the cardiovascular system that occur during pregnancy might influence the likelihood for AVM hemorrhage in pregnancy [9]. ...
Background
Vascular brain lesions (VBL) occur in up to 4.0% of the general population. With the increasing availability and use of sophisticated imaging techniques, there are more patients being diagnosed with asymptomatic intracranial AVMs and cavernous hemangiomas.
Objectives
Here we evaluate the association between VBL in pregnancy and the maternal and fetal outcomes.
Study design
The study cohort was identified by isolating all pregnancies from the nationwide inpatient sample (NIS), from the healthcare cost and utilization project (HCUP) over a five-year period. Within this cohort, cases with an arteriovenous malformation (AVM) or cerebral vascular malformations (CVM) were identified and their prevalence was calculated. Baseline demographic characteristics were compared and the odds ratios for various complications and outcomes were calculated.
Results
Amongst 4,012,396 deliveries, VBL were identified in 214 cases: a prevalence of 5.33 cases per 100,000 deliveries. Majority of VBL cases were identified in women between 25 and 35 years of age, but the proportion of women aged 35 and older was greater amongst those patients with VBL. 74% of cases were of Caucasian race and more cases with VBL had a private insurance payer (62.1%). Seizure disorders were present in 63.6% of the cases with VBL. Whilst VBL are not associated with unfavorable obstetrical complications, they are more likely to be delivered by caesarean section (CS) − 79% of VBL cases were delivered by CS compared to 33% of the patients without VBL (OR 7.03 CI 95% 4.98–9.92). Instrumental delivery was performed in 10.3% of the vaginal deliveries for index cases. Index cases were less prone to fetal growth restriction. VBL accounted for 8.4% of 166 cases of intracranial bleeding occurring during the antepartum period within the entire pregnant population.
Conclusions
Presence of VBL does not appear to carry additional risk to mother or fetus during pregnancy
... Precautions such as epidural analgesia for better pain control and instrumentation assisted vaginal delivery to shorten duration of second stage are strongly recommended. 18 We prefer elective CS in favor of feasibility in controlling hemodynamic stability, timing and duration of delivery. ...
Cerebral arteriovenous malformation (AVM) is a rare entity with an estimated prevalence of 0.01-0.05% in the general population. We reviewed hospital obstetric records during 2010-2017 and reported a case series of six patients with cerebral AVM in pregnancy, of which five patients had successful pregnancy, and one maternal mortality.
... 6 Some common signs and symptoms seen in a patient with cAVM include headache, seizure, confusion, muscle weakness, aphasia, vertigo and hallucinations. 7 In one study, headache, vomiting, limb dysfunction and altered consciousness were the main clinical manifestations in 12 patients with a cAVM bleed during pregnancy and the postpartum period. 6 These symptoms may be mistaken for other conditions associated with pregnancy such as migraine, preeclampsia, eclampsia and cerebral venous sinus thrombosis. ...
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.
... There have been a number of proposed hypothetical explanations for why a bAVM may be more prone to cause ICH during pregnancy. [23][24][25][26] However, the physiological changes associated with a normal healthy pregnancy do not accord with any known explanation for ICH in bAVM in the absence of pregnancy. [27][28][29] Although there is the potential for venous obstruction associated with pregnancy, 30,31 there were no reports of pregnancy associated bAVM ICH implicating a higher than usual presence of venous occlusion compared with nonpregnancy associated bAVM ICH. ...
BACKGROUND: Recommendations on the management of brain arteriovenous malforma-tions (bAVM) with respect to pregnancy are based upon conflicting literature.
OBJECTIVE: To systematically review the reported risk and annualized rate of first intracranial hemorrhage (ICH) from bAVM during pregnancy and puerperium.
METHODS: MEDLINE, EMBASE, and Scopus databases were searched for relevant articles in English published before April 2018. Studies providing a quantitative risk of ICH in bAVM during pregnancy were eligible.
RESULTS: From 7 initially eligible studies, 3 studies met the criteria for providing quantitative risk of first ICH bAVM during pregnancy. Data from 47 bAVM ICH during pregnancy across 4 cohorts were extracted for analysis. Due to differences in methodology and definitions of exposure period, it was not appropriate to combine the cases. The annualized risk of first ICH during pregnancy for these 4 cohorts was 3.0% (95% confidence interval [CI]: 1.7-5.2%); 3.5% (95% CI: 2.4-4.5%); 8.6% (95% CI: 1.8-25%); and 30% (95% CI: 18-49%). Only the last result from the last cohort could be considered significantly increased in comparison with the nonpregnant period (relative rate 6.8, 95% CI: 3.6-13). The limited number of eligible studies and variability in results highlighted the need for enhanced rigor of future research.
CONCLUSION: There is no conclusive evidence of an increased risk of first hemorrhage during pregnancy from bAVM. Because advice to women with bAVM may influence the management of pregnancy or bAVM with significant consequences, we believe that a retrospective multicenter, case crossover study is urgently required.
... It has been estimated that 1.8% of women of childbearing age (16-44 years) develop intracranial aneurysms; [1] whereas cerebral arteriovenous malformation (AVM) has prevalence rate of 0.01%-0.5% and generally presents symptoms at 20-40 years of age. [2] Pregnant women with such neurovascular lesions pose great challenges to anesthesiologists because ruptured cerebral AVM and aneurysm are associated with significant maternal as well as fetal morbidities and mortalities. To date, there is no clear guideline in literature regarding the mode of anesthesia for these high-risk parturients presenting for nonneurosurgical intervention. ...
... [11] Endovascular therapy was reported to be effective as a presurgical strategy even in pregnant women. [1,2] However, the safety of using contrast media remains uncertain during pregnancy. [16] Potts et al. [14] reported 48 deeply located AVMs which were classified into three groups based on their locations: the basal ganglia, thalamus, or insula. ...
Background:
A tailor-made treatment is often required in arteriovenous malformations (AVMs) depending on the individual situation. In most cases, treatment strategy is usually determined according to the patient's Spetzler-Martin grade. However, in the present case, we were not able to treat the patient following the usual guidelines because of neurological symptoms and pregnancy.
Case description:
We describe a rare case of a 31-year-old woman in the 15th week of gestation who presented with an AVM in the anterior perforated substance (APS). She suffered a sudden coma and hemiplegia. A computed tomographic scan showed an enhanced mass and a huge hematoma in the basal ganglia and temporal lobe. The hematoma was successfully evacuated in an endoscopic procedure. Angiography showed that a 25-mm nidus in the APS was fed by the anterior choroidal arteries (AChAs) and the lenticulostriate arteries (LSAs). Therefore, we attempted to remove the nidus because the patient became alert with mild aphasia and hemiparesis 10 days after hemorrhage. The feeding arteries were cut under motor evoked potential (MEP) monitoring, and the nidus was totally resected leaving two of four AChAs and a single artery with several LSAs. The postoperative course was uneventful, and she gave birth to a healthy baby by caesarian delivery 122 days after the hemorrhage with only minor sequelae.
Conclusions:
Surgical strategy with a device-administered anesthesia are suitable for removing large AVMs even in pregnant women and for the successful outcome of their pregnancies. Even after recovering from a coma and hemiplegia, MEP monitoring is effective for removing large AVMs even when located in the APS.
... If urgent endovascular treatment of such AVMs is required, the radiation exposure may pose potential risk to the fetus. Lead shielding is considered important for decreasing the risk of radiation exposure [5]. ...
Acute neurovascular events, though rare, can complicate pregnancy and postpartum period. It is important to be aware of these clinical conditions for reducing maternal and fetal morbidity and mortality. In this review, we present a few important neurovascular emergencies and their imaging manifestations by various imaging modalities—computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA)—which presented at our institution in the peripartum period.
... Cerebral arteriovenous malformations (AVM) have a prevalence of 0.01-0.5% and in 18% of cases they are associated with aneurysms [46]. While CS may prevent the cerebral hemodynamic alteration associated with vaginal delivery, there is no evidence suggesting that VD may increase the risk of AVM hemorrhage and that CS may prevent this rare complication [47]. ...
Purpose:
To propose an evidence-based review on the most frequent indications for Cesarean section (CS) given by specialists in disciplines other than Obstetrics and Gynecology, with the aim of increasing consciousness about the available data in the literature and the guidelines recommendations about topics that are not frequently managed by obstetricians and gynecologists.
Methods:
We analyzed hospital discharge data regarding deliveries occurred in a 10-year study period in our department to obtain the prevalence and the list of the most recurrent non-obstetrical indications for CS. A search was performed in PubMed, the Cochrane Library, SCOPUS, Web of Science and Ovid MEDLINE and only studies published in English from 1950 to 2017 were included. For indications for which no systematic reviews existed, we included the best available evidence, including guidelines of non-obstetrics scientific societies or organizations, RCTs, non-randomized controlled clinical trials, case-control studies, cohort studies, and case series.
Results:
The rising rate of CS registered in the recent years is not justified by reduction in maternal--fetal risk or perinatal outcomes and often reflects inappropriate clinical behaviour and a wrong tendency that assimilates CS as a defensive practice. In a relevant percentage of cases, the indication to CS is given by specialists in other disciplines, even when specific guidelines do not give clear recommendation about the route of delivery.
Conclusions:
To refuse non-obstetrical indications for CS, when scientific support is lacking, could be a useful and safe strategy to further reduce the rate of unnecessary CS.
... 4,19 Two narrative reviews were excluded. 20,21 The most recent International Journal of Stroke, 12 (7) case-series-using a self-controlled method in large hospital-based, retrospective Chinese cohort-showed a decreased hemorrhage risk associated with preg- nancy, delivery, and puerperium. 19 Another retrospect- ive study concluded that the hemorrhage risk during pregnancy was not increased, 11 whereas two studies showed an increased risk of BAVM hemorrhage during pregnancy 9 or during the second trimester only. ...
Background
It is unclear whether the risk of bleeding from brain arteriovenous malformations is higher during pregnancy, delivery, or puerperium. We compared occurrence of brain arteriovenous malformation hemorrhage in women during this period with occurrence of hemorrhage outside this period during their fertile years.
Methods
We included all women with ruptured brain arteriovenous malformations (16–41 years) from a retrospective database of patients with brain arteriovenous malformations in four Dutch university hospitals (n = 95) and from the population-based Scottish Audit of Intracranial Vascular Malformations (n = 44). We estimated the relative rate of brain arteriovenous malformation rupture (before any treatment) during exposed time (pregnancy, delivery, puerperium) versus non-exposed time during fertile years, using the case-crossover design as primary analysis, and the self-controlled case-series design as secondary analysis.
Results
In 17 of 95 Dutch women and in 3 of 44 Scottish women, hemorrhages occurred while pregnant; none occurred during delivery or puerperium. In Dutch women, the relative rate of brain arteriovenous malformation rupture during pregnancy, delivery, or puerperium was 6.8 (95% confidence interval 3.6–13) according to the case-crossover method and 7.1 (95% confidence interval 3.4–13) using the self-controlled case-series method. In Scottish women, the relative rate was 1.3 (95% confidence interval 0.39–4.1) using the case-crossover method and 1.7 (95% confidence interval 0.0–4.4) according to the self-controlled case-series method. Because of limited overlap of confidence intervals, we refrained from pooling the cohorts.
Conclusions
Case-crossover and self-controlled case series analyses reveal an increase in relative rate of brain arteriovenous malformation rupture during pregnancy in the Dutch cohort but not in the Scottish cohort. Since point estimates varied between both cohorts and numbers are relatively small, the clinical implications of our findings are uncertain.
... Even with the hormonal and hyperdynamic circulatory changes that occur during pregnancy, it is not yet clear whether pregnancy specifically influences the incidence of bleeding with intracranial AVMs. The results of more recent retrospective and prospective studies have shown that nonruptured AVMs are not associated with an increased risk of rupture during pregnancy (47,48). There is, however, a higher risk for repeat AVM rupture during pregnancy owing to the hemodynamic changes that occur. ...
A number of physiologic, hormonal, immunologic, and hemodynamic changes take place in the maternal body during pregnancy. The majority of these changes are essential for maintaining the normal course of pregnancy. However, these changes may also cause acute or chronic conditions that affect various biologic systems in the mother. In addition, conditions of the central and peripheral nervous systems can cause a variety of neurologic symptoms and complications. Neurologic signs and symptoms in pregnant and postpartum women may be due to the exacerbation of a preexisting medical condition, the initial manifestation of a primary central nervous system–related problem, or a neurologic problem unique to pregnancy and the postpartum period. Because the symptoms of these conditions are either nonspecific or overlapping, it can be challenging to pinpoint the diagnosis clinically. These conditions can be classified into more commonly seen conditions such as headache, venous thrombosis, preeclampsia, subarachnoid hemorrhage, posterior reversible encephalopathy syndrome, and certain pituitary disorders; and less commonly seen entities such as aneurysm, arteriovenous malformation, primary or secondary neoplasm, Sheehan syndrome, and Wernicke encephalopathy. Imaging has an important role in the differentiation and exclusion of various neurologic conditions, and most of the time, imaging findings can point the clinician to a specific diagnosis. The imaging appearances of common and uncommon neurologic conditions that can occur during pregnancy and the early postpartum period are highlighted in this article.
AIM: The aim of this study was to investigate the features of the course of pregnancy, childbirth and the postpartum period in women with cerebrovascular pathology and to assess the choice of the optimal method of delivery and perinatal outcomes. MATERIALS AND METHODS: This study assessed ten cases of pregnancy and delivery in women with cerebrovascular pathology (arteriovenous malformation (50%), cavernous malformation (30%), and arterial aneurysms (20%)). All women were followed up, treated and delivered at the Obstetrics and Gynecology Clinic (Academician I.P. Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia) between 2018 and 2019. RESULTS: In eight out of ten women with cerebrovascular pathology, the course of pregnancy was complicated by the threat of premature birth, chronic placental insufficiency, and severe preeclampsia. In one case, the pathology of the cerebral blood vessels (cavernous malformation) manifested itself as a general hemorrhagic disturbance of the cerebral blood circulation during this pregnancy; in all other cases, cerebrovascular pathology was diagnosed before pregnancy. When analyzing the timing of delivery, it should be noted that only in one case with severe preeclampsia, the pregnancy was completed at 34 weeks and 1 day (emergency childbirth). The average delivery time for the remaining patients was 38 weeks 3 days (planned childbirth). The analysis of delivery methods showed that in 90% of cases (n = 9), pregnant women were delivered by caesarean section. Vaginal delivery occurred in one patient with a history of arteriovenous malformation of the left frontal lobe after subtotal embolization. The course of the postpartum period in all the patients was uneventful. During the next year, a planned consultation with a neurologist took place in three cases. CONCLUSIONS: It is required that a multidisciplinary team should develop tactics for pregravid preparation, pregnancy and postpartum management, with an assessment of long-term consequences in pregnant women with cerebrovascular disease, which will improve the efficiency of medical care and will contribute to the further implementation of reproductive functions in such patients. It is necessary to develop rehabilitation plans with the selection of personalized rehabilitation methods aimed at reducing complications associated with pregnancy and childbirth.
Objective
Acute hemorrhage due to cerebral arteriovenous malformation (cAVM) during pregnancy is uncommon but life-threatening for both the mother and the fetus, and presents a great challenge to clinical management. However, there is still no consensus on the treatment strategy and the treatment timing of acute hemorrhage from cAVM during pregnancy. The aim of this study was to amalgamate published case series and our cases regarding the clinical management of pregnant patients under this special condition.
Methods
We illustrated a case series of three pregnant patients with acute hemorrhage due to cAVM in our hospital. And a systematic PubMed search of
English-language literature published between 1970 and 2020 was carried out. Clinical information including patients’ age, gestational age, imaging studies, treatment strategy, treatment timing, delivery mode and outcomes, were collected and analyzed.
Results
The rebleed rate is about 7.1% and the mortality of rebleeding is up to 25%. Treatment modalities included radical surgery, endovascular embolization, radiosurgery/stereotactic radiosurgery, palliative surgery, and conservative treatment. There were no maternal death in both of the intrapartum intervention group and the postpartum intervention subgroup of gestational age < 34 weeks.
Conclusions
High rebleed rate and high mortality of rebleeding prompt that the intervention of ruptured cAVM should not be delayed. Intervention of ruptured cAVM within two weeks after initial hemorrhage is advisable in patients at gestational age < 34 weeks, while termination of pregnancy as soon as possible followed by timely intervention of ruptured cAVM is practicable in patients at gestational age ≥ 34 weeks.
Purpose:
Intradural spinal cord arteriovenous shunts (IDSCAVS) are rare and constitute a challenging situation if symptoms occur during pregnancy. We present a series of ten such cases referred to our center: five cervical, four thoracic and one lumbar.
Methods:
We retrospectively reviewed our global series of 215 IDSCAVSs between 2002 and March 2020 and found ten patients who had presented during pregnancy. Clinical, radiological and therapeutic data were studied.
Results:
Seven shunts were AVM type niduses and three were micro AV-fistulae. All were associated with pial venous reflux and six hemorrhagic cases had pseudo aneurysms. Symptoms occurred mainly during the third trimester, 80% of patients presented with hemorrhage and spinal cord dysfunction. We embolized seven patients and proposed surgery in one, always after delivery: all recovered well. One woman declined treatment; one other was operated in emergency but did not improve. Mean follow-up was 3.9 years (0.5-19 years).
Conclusions:
Despite this small group of patients, our initial experience of IDSCAVSs diagnosed during pregnancy indicates that embolization is an effective management strategy if performed after delivery and a recovery period. Results indicate that IDSCAVSs seem to have a low risk of early rebleedings after the ictal event and may be closely followed up until delivery. The results obtained show good clinical outcome without long-term rebleeds. Women with known IDSCAVSs should not be discouraged from becoming pregnant, however it seems wise to embolize them before pregnancy in order to offer protection against risks during pregnancy.
The term “neuro-obstetrics” refers to a multidisciplinary approach to the care of pregnant women with neurologic comorbidities, both preconceptionally and throughout pregnancy. General preconception care should be offered to all women, including women with neurologic disease. Women with neurologic comorbidities should also be offered specialist preconception care by an obstetrician who consults with a neurologist, anesthesiologist, and if indicated clinical geneticist and/or other specialists.
In women with neurologic comorbidities, neurologic sequelae may influence the course of the pregnancy and delivery. Also, pregnancy may influence the severity of the neurologic condition, depending on the type of disease. Physiologic adaptations during pregnancy and altered pharmacokinetics may cause altered blood serum levels of drugs, leading to decreased or increased drug effects. When administering drugs to a woman who wishes to conceive, it is important to consider possible teratogenic effects and possible secretion in breast milk. Tailoring medication regimens should be considered, preferably preconceptionally. In this chapter, we review general principles of neuro-obstetric care, as well as some specific considerations for neurologists, obstetricians, and anesthesiologists caring for pregnant women with common neurologic conditions.
Arteriovenous malformations (AVMs) are vascular anomalies where dilated arterioles are connected directly to venules without an intervening capillary bed. This tangle of blood vessels is often called a nidus. AVMs may exist in any part of the body, but those in the brain and spinal cord are associated with the greatest morbidity and mortality. The cause remains unknown but may be multifactorial involving genetic polymorphisms and possible environmental triggers. Treatment is with surgery, embolization, or stereotactic radiosurgery.
Stroke is a rare event during pregnancy (10/100,000) and can be ischemic (24%), hemorrhagic (74%) or both (2%). Pregnancy probably increases the risk even if it is discussed for arteriovenous malformation (AVM), aneurismal subarachnoid hemorrhage (SAH) and cavernomas. Between 2010 and 2012, 31 maternal deaths were associated with stroke. In 22 cases, stroke was the direct cause of death giving a maternal mortality ratio of 0,9/100,000 witch is not different from the former report (2007-2009). There were 2 cerebral thrombophlebitis, 2 ischemic strokes and 18 hemorrhagic strokes (4 SAH, 2 AVM). These deaths occurred during ongoing pregnancy in 5 cases (25%), after miscarriage in 1 case (5%) and in the post-partum period in 14 cases (70%). In this last situation, stroke occurred before delivery in 4 cases and during the post-partum period in 9 cases (1 to 9 days) (1 unknown). There were 7 vaginal deliveries (50%) and 6 emergency cesarean sections (43%) (1 unknown). Most of those deaths were considered to be unavoidable (13/17, 76%). Four deaths were considered by the experts as being possibly avoidable (delay diagnosis, diagnostic error, inadequate treatment, lake of interruption of the pregnancy). Analyzing those deaths remind that any sudden, severe and unusual headache must be explored and that pregnancy does not contraindicate any of the diagnostic examinations (TDM, angio-TDM, MRI) or invasive treatments (surgery, arterio-embolization, fibrinolysis) necessary for its management. Furthermore, the diagnosis of postdural puncture headache should not be establishedwithout imaging when the symptomatology is not absolutely typical.
Copyright © 2017 Elsevier Masson SAS. All rights reserved.
For the period 2010-2012, 256 maternal deaths were identified, representing 85 women who died each year in France from a cause related to pregnancy, childbirth or their
consequences. This figure corresponds to a maternal mortality ratio (MMR) of 10.3 per
100,000 live births, which is stable compared to the previous period of 2007-2009, and
averages the rate observed in European countries. However, 56 % of these deaths are
considered "avoidable" or "potentially avoidable", and in 60 % of cases the care provided
was not optimal, indicating room for improvement.
A major result of this report is one third reduction of direct maternal mortality over the last
10 years, mainly due to the statistically significant decline observed for the first time in
mortality due to obstetric hemorrhage, whose frequency was divided by 2 in 10 years.
However, almost all of the remaining hemorrhage-related deaths are considered preventable, and this is still the leading cause of maternal mortality in France (11% of deaths). Some inequalities in maternal mortality remain unchanged and are a source of great concern. These are territorial disparities: 1 maternal death out of 7 occurs in the oversea departments, and the maternal mortality ratio in these territories is 4 times that of mainland France; and social disparities: the mortality of migrant women remains 2.5 times higher than that of women born in France, and this excess is particularly marked for women born in sub-Saharan Africa whose MMR is 3.5 times that of native women.
Beyond these figures, the authors identified 22 key messages from the analysis of all
maternal deaths in France in 2010-2012. According to the general principle of the survey,
"better understanding for more effective prevention", they target aspects of the content or of the organization of health care which are involved in the avoidability of these deaths and can be improved, and that have been repeatedly identified in this series of stories both unique and exemplary.
ECR 2017: Voice of EPOS: Winner of Magnum Cum Laude
Stroke is a neurological emergency and one of the most common causes of long-term disability and death. Although stroke is rare at a younger age, the normal physiologic changes associated with pregnancy, combined with some of the pathophysiological processes unique to pregnancy, predispose women to develop stroke during pregnancy and the puerperium. This chapter reviews the mechanisms and risk factors for cerebrovascular disease related to pregnancy, the presenting features, diagnosis and management of these disorders, and their implications for pregnancy and delivery.
Cerebral arteriovenous malformation (AVM) in pregnancy is a complex situation and there is no agreement on its hemorrhage risk and treatment. Although studies on bleeding risk of cerebral AVMs in pregnancy are very few, and they provide different results, pregnancy will increase the hemorrhagic risk of AVM and ruptured cerebral AVM in pregnancy should be actively treated. After intracranial hemorrhage, cerebral angiography should be performed for pregnant women shielded correctly. Cerebral angiography could clearly demonstrate the characteristics of cerebral AVM. Results from the literature show that the radiation dose of endovascular and stereotactic radiotherapy for cerebral AVM in pregnancy was below the safety value and was safe. For an unruptured AVM in pregnancy, if there are no bleeding factors, e.g. no coexisting aneurysm, smooth venous drainage, no venous ectasia, or high risk of treatment, then it should be observed conservatively.
© The Author(s) 2015.
PURPOSE: Over the past few decades maternal mortality has progressively declined because of improved management of the major obstetric problems of hemorrhage, infection, and toxemia. As a result, the relative incidence of deaths resulting from non obstetric causes has increased. Chief among nonobstetric causes are neurologic disorders. Those most common during pregnancy are low back pain, intracranial tumors, subarachnoid hemorrhage, and neurotrauma. The management of the neurosurgical pathologies during pregnancy needs some specifications for both the mother and the fetus. METHODS: We performed a retrospective study evaluating the clinical, radiological, and surgical characteristics of 9 patients who have cranial neuropathologies and have undergone neurosurgical intervention. RESULTS: Most of the patients in this study had vaginal delivery. Prominent neurosurgical disease related to cerebral damage. Every patient underwent a laboratory and radiological evaluation. All except one survived the neurosurgical pathology. Neither baby nor mother had significant problem during delivery and neurosurgical intervention. CONCLUSION: Pregnant women may face to every kind of neurosurgical pathology that nonpregnant women have faced. In addition, pregnancy itself, gives rise some metabolic changes in the women and those changes may cause some neurologic pathologies to be symptomatic or to aggravate the present symptomatology. Because of those reasons, close neurologic follow up of a pregnant woman is of vital importance. At the end of a pregnancy having experienced some neurologic interventions including diagnostic evaluation or surgical intervention does not necessitates the cesarean section for a neurologically intact infant and mother.
Stereotactic radiosurgery successfully obliterates carefully selected arteriovenous malformations (AVM's) of the brain. In an initial 3-year experience using the 201-source cobalt-60 gamma knife at the University of Pittsburgh, 227 patients with AVM's were treated. Symptoms at presentation included prior hemorrhage in 143 patients (63%), headache in 104 (46%), and seizures in 70 (31%). Neurological deficits were present in 102 patients (45%). Prior surgical resection (resulting in subtotal removal) had been performed in 36 patients (16%). In 47 selected patients (21%), embolization procedures were performed in an attempt to reduce the AVM size prior to radiosurgery. The lesions were classified according to the Spetzler grading system: 64 (28%) were Grade VI (inoperable), 22 (10%) were Grade IV, 90 (40%) were Grade III, 43 (19%) were Grade II, and eight (4%) were Grade I. With the aid of computer imaging-integrated isodose plans for single-treatment irradiation, total coverage of the AVM nidus was possible in 216 patients (95%). The location and volume of the AVM were the most important factors for the selection of radiation dose. Magnetic resonance (MR) imaging was performed at 6-month intervals in 161 patients. Seventeen patients who had MR evidence of complete obliteration underwent angiography within 3 months of imaging: in 14 (82%) complete obliteration was confirmation being 4 months (mean 17 months) after radiosurgery. The 2-year obliteration rates according to volume were: all eight (100%) AVM's less than 1 cu cm; 22 (85%) of 26 AVM's of 1 to 4 cu cm; and seven (58%) of 12 AVM's greater than 4 cu cm. Magnetic resonance imaging revealed postirradiation changes in 38 (24%) of 161 patients at a mean interval of 10.2 months after radiosurgery; only 10 (26%) of those 38 patients were symptomatic. In the entire series, two patients developed permanent new neurological deficits believed to be treatment-related. Two patients died of repeat hemorrhage at 6 and 23 months after treatment during the latency interval prior to obliteration. Stereotactic radiosurgery is an important method to obliterate AVM's, especially those previously considered inoperable. Success and complication risks are related to the AVM location and the volume treated.
Two-hundred and seventeen patients from a total population of 343 patients with arteriovenous malformations, were managed without surgery. Follow up was for a mean of 10.4 years. Using life survival analyses, there was a 42% risk of haemorrhage, 29% risk of death, 18% risk of epilepsy and a 27% risk of having a neurological handicap by 20 years after diagnosis in unoperated patients.
Six patients with ruptured supratentorial arteriovenous malformation (AVM) and an associated venous aneurysm (ectasia, dilatation, varix, pouch) are described.
At presentation, patients ranged in age from 16 to 61 years and were equally distributed according to sex. Maximal AVM diameter was between 2.5 and 5.0 cm at presentation while the maximal size of the venous aneurysm ranged between 0.75 and 3.0 cm. One patient had multiple venous pouches while 5 patients had a single venous aneurysm. Three patients had a single bleed; 1 patient had 2 bleeds; and 2 patients had 3 bleeds. Hemorrhage around the venous aneurysm was seen in 4 of 5 patients who underwent magnetic resonance imaging of the brain. One patient, who suffered 3 bleeds over a several year period, had both an increase in the size of the venous aneurysm as well as enlargement of the AVM. The following features did not appear to influence hemorrhage: AVM size or location; venous aneurysm size or location; age; sex; pattern; location or number of draining veins; or external circulation feeders.
These observations suggest that a venous aneurysm may increase the risk of hemorrhage from a supratentorial AVM and may be an ominous feature.
✓ An important factor in making a recommendation for treatment of a patient with arteriovenous malformation (AVM) is to estimate the risk of surgery for that patient. A simple, broadly applicable grading system that is designed to predict the risk of morbidity and mortality attending the operative treatment of specific AVM's is proposed. The lesion is graded on the basis of size, pattern of venous drainage, and neurological eloquence of adjacent brain. All AVM's fall into one of six grades. Grade I malformations are small, superficial, and located in non-eloquent cortex; Grade V lesions are large, deep, and situated in neurologically critical areas; and Grade VI lesions are essentially inoperable AVM's. Retrospective application of this grading scheme to a series of surgically excised AVM's has demonstrated its correlation with the incidence of postoperative neurological complications. The application of a standardized grading scheme will enable a comparison of results between various clinical series and ...
Pregnancy is said to increase the risk of acute cerebrovascular disease. Both internal carotid (ICA) and middle cerebral artery (MCA) velocimetry were carried out in 17 healthy nonpregnant women, 159 pregnant women with uncomplicated pregnancies, and 14 normal postpartum women, to establish normal reference values of the cerebral circulation. The apparatus used was a transcranial Doppler, TC2-64B (EME, Uberlingen, Germany), with 4 and 2 MHz transducers for the ICA and MCA, respectively. The mean velocity of the ICA and MCA tended to decrease toward term: at 36 to 40 weeks of gestation 28.6 ± 4.5 and 53.2 ± 8.9 cm/s, or 24.9% (p < 0.001) and 16.4% (p < 0.01) less than the values of nonpregnant women (38.1 ± 6.3 and 63.6 ± 11.9 cm/s), respectively. By Day 7 postpartum, pregnant values returned to those of normal, nonpregnant women. Unlike the velocity in the ICA, a transient increase in the mean velocity of the MCA was observed at 12 to 15 weeks of gestation. There was a transient increase in peak systolic velocity in the MCA at 8 to 27 weeks of gestation, as compared with nonpregnant values. Pulsatility indices were significantly higher than those in nonpregnant women at 4 to 35 weeks of gestation in the ICA and throughout pregnancy in the MCA. Both pulsatility indices returned to nonpregnant values in the postpartum period. Our results may be useful in the study of cerebrovascular diseases which frequently become manifest in pregnancy and the postpartum period.
SYNOPSISThe relationships between migraine and A-V Malformations is a subject of controversy and the arguments are mainly based on case reports and retrospective data. To clarify this subject a structured inquiry and classification of headaches in large samples of patients with intracranial vascular malformations (IVM) is essential. The authors studied the prevalence of headaches in 51 patients with IVM admitted to our Department, between 1984 and 1992. The methods used were a review of medical records followed by a self-administered headache questionnaire and clinical interview using the IHS criteria for the diagnostic classification of headaches. The relative frequency of the different types of headaches was calculated and compared with the general population data. A correlative study of the headache characteristics with the type and location of the IVM was made. A high prevalence (47%) of migraine type headaches and a strong positive correlation (88.8%) between the site of AVM and side of the pain was found. This is highly suggestive but not conclusive of a pathophysiologic relationship between these entities. The conclusion drawn is that a prospective study of headaches by questionnaire or semi-structured clinical interview in patients with IVM is essential to discover the effective prevalence and characteristics of headaches associated with IVM and their relationships.
To correct the historical notion that permeates throughout the neurointerventional surgical literature that Dr Barney Brooks was the founder of the specialty.
Both articles written by Dr B Brooks and all pertinent literature dealing with neurointerventional treatment of the carotid-cavernous sinus fistula (CCSF) were reviewed.
The notion that Dr B Brooks was the first to use the embolization method to treat the CCSF was based on misinterpretation of his papers published in 1930 and on 'second generation' references used by subsequent authors.
Dr B Brooks never described embolization of the CCSF by a 'free' piece of muscle introduced into the internal carotid artery (ICA).
To identify clinical and angiographic factors of cerebral arteriovenous malformations (AVMs) associated with hemorrhage to improve the estimation of the risks and help guide management in clinical decision making.
We conducted a retrospective analysis of 100 consecutive adults who have presented during the past 3 years to our institution with cerebral AVMs. Angiographic and clinical parameters were evaluated using multivariate logistic regression analysis to analyze factors associated with hemorrhagic presentation.
The group had a mean age of 37.8 years; 53% were men, 48% presented with intracranial hemorrhage, and 40% presented with seizures. All 10 patients with cerebellar AVMs presented with hemorrhage. The following factors were independently associated with AVM hemorrhage: history of hypertension (P = 0.019; odds ratio [OR] = 5.36), nidal diameter <3 cm (P = 0.023: OR = 4.60), and deep venous drainage (P = 0.009: OR = 5.77). Dural arterial supply (P = 0.008; OR = 0.15) was independently associated with decreased risk of bleed. Location, nidal aneurysms, patient age, and smoking were not associated with increased or decreased bleeding risk.
In this study, we found small AVM size and deep venous drainage to be positively associated with AVM hemorrhage. Dural supply was associated with a decreased likelihood of hemorrhagic presentation. Hypertension was found to be the only clinical factor positively associated with hemorrhage, a finding not previously reported. Smoking, although associated with increased risk of aneurysmal subarachnoid hemorrhage, was not associated with a higher risk of AVM hemorrhage.
Twenty-one patients with an intracranial AVM were subjected to 2 separate serial carotid angiograms. The median time between examinations was 44 months. The volumes of the malformations were calculated using an ellipsoid volume approximation. The median volume in the first angiogram was 5.8 cm3 and in the second angiogram 7.1 cm3. With a ±20% limit chosen to bracket a range of “non-verified” change in size, it was found that 12 cases showed increase in size, 8 were unchanged and 1 had reduced. The smallest AVMs had a tendency to increase in size, those of moderate volume to remain unchanged and the largest AVMs to reduce in size. The relative annual change was also calculated: small malformations showed a rapid increase in size, while the moderate and large volume AVMs showed no change and a slight decrease, respectively. When the logarithm of the coefficient of annual change was plotted over the logarithm of the figure for initial size, a fairly close linear relationship was suggested.From the AVM dimensions reported by Höök and Johanson (1958) in their cases, values were calculated which are thought to be approximately comparable with the volumes of the present material. The changes as such and in terms of annual change were in rough agreement with the present findings.
The effect of radiation on the fetus has been derived primarily from animal studies and human exposures to diagnostic and therapeutic radiation as well as atomic bomb exposure. Given the variety of sources, there is controversy over the dose of radiation in addition to the other environmental conditions that surrounded these events and their relationship to exposure today.
The effects of ionizing radiation on the fetus, the prenatal period, parental exposure, the pregnant clinician, and the pregnant patient are discussed in the context of their exposure to radiation.
The fetus is most sensitive to radiation effects between 8 and 15 weeks of pregnancy. Stepping away from the table and using movable shields help reduce the exposure by a factor of four for every doubling of the distance between the operator and the radiation source.
Proposed guidelines for pregnancy during vascular residency training involving fluoroscopic procedures can help bring about awareness, clarify maximal exposure, and better delineate the role of the pregnant resident.
Cerebral arteriovenous lesions are in general considered to be congenital in nature despite the fact that there is no evidence that the AV shunts diagnosed in adults are present at birth in a similar format.
Construction of a vascular structure is the result of complex biological influences starting in the embryo, and continuing in the foetus, the neonate and the young infant. This vascular tree has to be maintained, repaired and modified according to metabolic demands, requiring over time the renewal of the entire structure. This is also genetically programmed and controlled.
Both construction and maintenance involve repetitive steps and feedback towards the vascular tree according to the demands. Alterations in the programme or in the cellular logistics to achieve it, will create a different construction of the blood vessel wall.
Analysis of the origin of the cerebrofacial endothelial cell would suggest that, the earlier a causative event occurs the larger the area of impact, and the higher the chances of apparent multifocality will be. The later the trigger occurs the more focal the defect and the smaller the lesion. If so, growth of an AVM as such should not occur; large nidi will not result from the growth of smaller ones.
The impact of Rendu-Osler-Weber (ROW) disease on the venous endothelial cells and the polymorphism observed in cerebral arteriovenous shunts in ROW patients may outline the role played by the veins as the primary target in the development of cerebral AVMs.
The venous and arterial angiopathy related to chronic high flow (or flow changes beyond normal equilibrium) impact a normally reacting vasculature which has been “abnormally” triggered by an AVM. This intraluminal trigger represents a “stress trigger” which can be flow, pressure or “other” related factors.
This interpretation identifies the so-called AVMs to be the expression of various diseases rather than the disease itself. They are the result and negative impact of biological dysfunction of the remodelling process at the capillarovenous junction.
Patient age, hemorrhagic presentation, nidal diffuseness, and deep perforating artery supply are important factors when selecting patients with brain arteriovenous malformations (AVMs) for surgery.
We hypothesized that these factors outside of the Spetzler-Martin grading system could be combined into a simple, supplementary grading system that would accurately predict neurologic outcome and refine patient selection.
A consecutive, single-surgeon series of 300 patients with AVMs treated microsurgically was analyzed in terms of change between preoperative and final postoperative modified Rankin Scale scores. Three different multivariable logistic models (full, Spetzler-Martin, and supplementary models) were constructed to test the association of combined predictor variables with the change in modified Rankin Scale score. A simplified supplementary grading system was developed from the data with points assigned according to each variable and added together for a supplementary AVM grade.
Predictive accuracy was highest for the full multivariable model (receiver operating characteristic curve area, 0.78), followed by the supplementary model (0.73), and least for the Spetzler-Martin model (0.66). Predictive accuracy of the simplified supplementary grade was significantly better than that of the Spetzler-Martin grade (P = .042), with receiver operating characteristic curve areas of 0.73 and 0.65, respectively.
This new AVM grading system supplements rather than replaces the well-established Spetzler-Martin grading system and is a better predictor of neurologic outcomes after AVM surgery. The supplementary grading scale has high predictive accuracy on its own and stratifies surgical risk more evenly. The supplementary grading system is easily applicable at the bedside, where it is intended to improve preoperative risk prediction and patient selection for surgery.
The first haemodynamic change during pregnancy seems to be a rise in heart rate. Starting between two and five weeks this continues well into the third trimester. Stroke volume increases slightly later than the heart rate and continues throughout the second trimester after an augmentation of venous return and a fall of systemic vascular resistance and afterload. Myocardial contractility is probably slightly increased. During the third trimester there is relatively little change in these cardiac indices. After delivery there is a very early and dramatic reduction in volume loading followed by a return towards normal cardiac output. Structural changes within the heart reflect the volume loading of pregnancy and include dilatation of the valve ring and increase in myocardial thickness. Post partum resolution of the ventricular hypertrophy seems to take longer than the rest of the post partum changes. The resemblance to the cardiovascular changes associated with training and exercise are fascinating and worthy of further study.
The relationship between the size of an arteriovenous malformation (AVM) and its propensity to hemorrhage is unclear. Although nidus volume increases geometrically with respect to AVM diameter, hemorrhages are at least as common, in small AVM's compared to large AVM's. The authors prospectively evaluated 92 AVM's for nidus size, hematoma size, and arterial feeding pressure to determine if these variables influence the tendency to hemorrhage.
Small AVM's (diameter ≤ 3 cm) presented with hemorrhage significantly more often (p < 0.001) than large AVM's (diameter > 6 cm), the incidence being 82% versus 21%. Intraoperative arterial pressures were recorded from the main feeding vessel(s) in 24 of the 92 patients in this series: 10 presented with hemorrhage and 14 presented with other neurological symptoms. In the AVM's that had hemorrhaged, the mean difference between mean arterial blood pressure and the feeding artery pressure was 6.5 mm Hg (range 2 to 15 mm Hg). In the AVM's that did not rupture, this difference was 40 mm Hg (range 17 to 63 mm Hg). Smaller AVM's had significantly higher feeding artery pressures (p < 0.05) than did larger AVM's, and they were associated with large hemorrhages. It is suggested that differences in arterial feeding pressure may be responsible for the observed relationship between the size of AVM's and the frequency and severity of hemorrhage.
The clinical outcomes are described for 247 consecutive cases of arteriovenous malformation (AVM) treated with the gamma knife between April, 1970, and December 31, 1983. Headache resolved in 65 (66.3%) of the 98 patients presenting with this symptom and improved in an additional nine (9.2%). Of 59 patients admitted with seizures, 11 (18.6%) became seizure-free without anticonvulsant medication and an additional 30 patients (50.8%) became seizure-free with anticonvulsant medication. Pre-existing neurological deficits improved or totally disappeared following radiosurgery in 56.7% of affected cases. This improvement presumably occurred within the frame of the natural history.
The protective effect of the ionizing beams against hemorrhage in incompletely obliterated AVM's is analyzed. To assess the rate of rebleeding, probability estimates were calculated using both the person-year method and the Kaplan-Meier life table. With the person-year method the actual rebleed rate is not too different from the values observed in the natural history of the disease (2% to 3%/yr). Analysis by Kaplan-Meier life-table estimates demonstrated a risk of nearly 3.7%/yr until 60 months after radiosurgery. Five years following treatment, the life table ends in a plateau which could be interpreted as an indication of decrease in the risk of hemorrhage. However, long flat regions at the right end of the life table do not imply that the real risk of rebleeding is negligible unless a large number of patients have been followed well into or beyond the flat region.
Vascular musculature was studied in cerebral arteriovenous malformations using a monoclonal antibody against the muscle protein actin in 20 cases. The more typical vessels (arterial and venous types) and a number of abnormalities of the muscular layer were identified. The latter included (1) partially developed media; (2) two layers of the media separated by a well-formed internal elastic membrane; (3) total or partial disarray of the muscle coat; and (4) partial absence of the media. Previously described large capillaries proved to be postcapillary venules by virtue of having a distinct muscular layer. Serial sectioning indicated that the previously described "polypoid projections" of the media are mostly artifacts and the concept of "arterialization of veins in arteriovenous malformations" could not be substantiated. The actin method proved to be a useful adjunct to the conventional stains for accurate and selective detection of smooth-muscle cells.
Among 91 patients with unruptured intracranial arteriovenous malformations (AVM's), 16 patients had 26 unruptured intracranial saccular aneurysms. An actuarial analysis showed the risk of intracranial hemorrhage among patients with coexisting aneurysm and AVM to be 7% per year at 5 years following diagnosis compared to 1.7% for patients with AVM alone. The difference in length of survival free of hemorrhage was significant (log-rank, p less than 0.0007). Several angiographic and clinical parameters were investigated to better understand the relationship of these lesions. The aneurysms occurred in similar percentages in patients with small, medium, and large AVM's. Twenty-five aneurysms were on arteries feeding the malformation system, almost equally distributed proximally and distally. Eleven aneurysms were atypical in location, and all arose from primary or secondary branch feeders to the malformation; 24 were on enlarged feeding arteries. Eleven (16%) of the 67 patients with high-flow AVM's had associated aneurysms, compared with five (21%) of the 24 patients with low-flow AVM's. Four (16%) of 25 low-shunt malformations and 12 (18%) of 65 high-shunt malformations had associated aneurysms. All five aneurysms associated with low-shunt malformations were on a direct arterial feeder of the malformation. These data suggest that the intracranial AVM's predispose to aneurysm formation within AVM feeding systems and that the mechanism is not simply based upon the high blood flow or high arteriovenous shunt in these systems.
We conducted a retrospective analysis of 451 women with an arteriovenous malformation (AVM) of the brain to determine whether pregnancy is a risk factor for cerebral hemorrhages. A total of 540 pregnancies occurred among our patient population, resulting in 438 live births and 102 abortions. There were 17 pregnancies complicated by a cerebral hemorrhage. The hemorrhage rate during pregnancy for women with an unruptured AVM was 0.035 +/- 0.005 per person-year. The hemorrhage rate for nonpregnant women of childbearing age with an unruptured AVM was 0.031 +/- 0.002 per person-year. Pregnancy did not increase significantly the rate of first cerebral hemorrhage from an AVM (P = 0.35). We found that women with an AVM face a 3.5% risk of hemorrhage during pregnancy. Pregnancy is not a risk factor for hemorrhage in women without a previous hemorrhage. This conclusion assumes no selection bias exists in our study population; a bias would be introduced if the risk of fatal outcome after a hemorrhage were greater in pregnant women than in nonpregnant women.
Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.
Between January 1975 and June 1989, 240 patients with cerebral vascular malformations were treated at Henry Ford Hospital. In 16 of the patients, the treatment was influenced by pregnancy. Eleven of the patients presented with hemorrhage, four with seizures, and one with hydrocephalus. There were no maternal or fetal deaths in the patients presenting with seizure or hydrocephalus. There were two maternal deaths and one fetal death among the cases presenting with hemorrhage. In the patients with seizure or hydrocephalus, the pregnancy was brought to term and obstetric indications used to determine the time and method of delivery. Hydrocephalus was treated by shunting, and seizures with medication. Antiepileptic drug levels fluctuate in pregnancy and hence were closely monitored to ensure therapeutic levels. Vascular malformations are the most common cause of subarachnoid hemorrhage in pregnancy. The risk of rebleed in the same pregnancy is about 27%. If an arteriovenous malformation ruptures during pregnancy and the patient's condition deteriorates, appropriate emergency surgery should be done. In stable patients, our policy has been to bring the pregnancy to term and then electively perform a craniotomy to excise the arteriovenous malformation.
The authors have updated a series of 166 prospectively followed unoperated symptomatic patients with arteriovenous malformations (AVM's) of the brain. Follow-up data were obtained for 160 (96%) of the original population, with a mean follow-up period of 23.7 years. The rate of major rebleeding was 4.0% per year, and the mortality rate was 1.0% per year. At follow-up review, 23% of the series were dead from AVM hemorrhage. The combined rate of major morbidity and mortality was 2.7% per year. These annual rates remained essentially constant over the entire period of the study. There was no difference in the incidence of rebleeding or death regardless of presentation with or without evidence of hemorrhage. The mean interval between initial presentation and subsequent hemorrhage was 7.7 years.
The most serious and frequent complication of intracranial arteriovenous malformations (AVMs) is intracranial hemorrhage. Identification of patients at greatest risk for intracranial bleeding would be beneficial. Detailed analysis of vascular architecture was performed in 65 patients with intracranial AVMs to identify the vascular characteristics that correlated with hemorrhage. Fifteen characteristics were assessed. Hemorrhage was present in 45 patients (69%). The following characteristics correlated positively with hemorrhage (Fisher-Irwin exact test): central venous drainage (P less than .0001), periventricular or intraventricular location of the AVM (P = .0002), and intranidal aneurysm (P = .028). The following characteristics correlated negatively with hemorrhage: angiomatous change (P = .0005), peripheral venous drainage (P = .005), and mixed venous drainage (P = .021). Multivariate linear discriminant analysis demonstrated that central venous drainage, angiomatous change (negatively predictive), intranidal aneurysm, and periventricular or intraventricular location of the AVM were the most discriminating or predictive characteristics of hemorrhage. Detailed analysis of the vascular architecture of intracranial AVMs helped identify features that strongly correlate with clinical hemorrhage and have important prognostic implications for the treatment of patients with these lesions.
The clinical course of 50 patients with conservatively treated intracranial arteriovenous malformations (AVM's) was followed, most of them for more than 5 years. The average follow-up period was 13.4 years. The initial symptom was intracranial bleeding in 29 patients (58%) and seizure in 15 patients (30%). Small and deep-seated AVM's were associated with a high incidence of bleeding; however, repeated hemorrhages were not necessarily indicative of a poor prognosis. Children younger than 15 years had a better prognosis than adults. There was no correlation between pregnancy and bleeding. In the hemorrhage group, the incidence of rebleeding was 6.9% in the 1st year after initial rupture, 1.91% per year after 5 years, and 0.92% per year after 15 years. The overall incidence of rebleeding was 34.5% in the hemorrhage group. Of the 50 patients, 37 (74%) had a good clinical outcome, four (8%) had a fair outcome, and four (8%) had a poor outcome; five patients died.
To assess the magnitude and timing of cardiovascular changes in pregnancy, eight subjects were serially studied before conception and at 8, 16, and 24 weeks' gestation. With the use of M-mode echocardiography, cardiac output, ejection fraction, stroke volume, and end-diastolic volume were calculated from left ventricular dimensions with subjects in the left lateral position. Systemic vascular resistance was calculated with the use of cardiac output and simultaneously obtained measurements of arterial pressure. Cardiac output increased 1 L/min at 8 weeks' gestation, which represented greater than 50% of the total change seen. Cardiac output increased primarily because of stroke volume rather than heart rate. By 8 weeks' gestation, systemic vascular resistance had fallen to 70% of its preconceptional value. Thus when subjects are studied before conception and during the early phase of pregnancy, the majority of the pregnancy-induced changes in these parameters occur during the embryonic period.
Serial hemodynamic measurements were performed in 13 women on two occasions before conception and then at monthly intervals throughout pregnancy. Cardiac output (CO) was measured by Doppler and cross-sectional echocardiography at the aortic, pulmonary, and mitral valves. Cardiac chamber size and ventricular function were investigated by M-mode echocardiography. CO increased from a mean of 4.88 l/min before the conception to a maximum of 7.21 l/min at 32 wk, the increase being significant by 5 wk after the last menstrual period. Heart rate and left ventricular performance increased during the first trimester. Heart rate increased further during the second trimester, during which left atrial and left ventricular end-diastolic dimensions increased, suggesting an increase in venous return. Derived values of total peripheral vascular resistance fell during the first 20 wk. These changes were associated with a progressive increase in valve orifice area and left ventricular wall thickness during pregnancy.
The authors studied the charts and angiograms of 178 patients with cerebral vascular lesions. The angiographic features of these malformations could be grouped into the following categories: arterial variations, arterial aneurysms, arterial infundibulum, arterial stenosis, venous variation, venous stenosis, venous ectasia, arteriovenous fistula, transcerebral vascularization and external carotid supply. The age and sex of the patients as well as the topography and angiographic features were correlated with the incidence of hemorrhage. We found that deep and posterior fossa malformations, as well as temporal, insular and callosal localizations, were more likely to have bled. We also found that older males (40-50 years) with associated aneurysms and younger females (20-30 years) with venous stenosis were more likely to have bled.
We report a series of 101 patients with cerebral arteriovenous malformations (CAVM), in which 23 cases presented with one or several arterial aneurysm(s) (AA). Each AA could be classified into distal intra-lesional, proximal or remote. Patients with CAVM + AA tend to be older and more frequently present with epilepsy, haemorrhage events and neurological deficits. Of these 23 patients, 16 had their AVM treated partially or totally by embolization. In our series, the endovascular treatment of the arteriovenous shunt with a proximal AA on the same vessel has resulted in at least a regression, and sometimes a disappearance of the arterial ectasia. Although partial treatment of the AVM does no erase the risk of haemorrhage from the malformation itself, it may diminish the chance of developing a flow-related AA or any other expression of the high-flow angiopathy.
The authors conducted a long-term follow-up study of 168 patients to define the natural history of clinically unruptured intracranial arteriovenous malformations (AVM's). Charts of patients seen at the Mayo Clinic between 1974 and 1985 were reviewed. Follow-up information was obtained on 166 patients until death, surgery, or other intervention, or for at least 4 years after diagnosis (mean follow-up time 8.2 years). All available cerebral arteriograms and computerized tomography scans of the head were reviewed. Intracranial hemorrhage occurred in 31 patients (18%), due to AVM rupture in 29 and secondary to AVM or aneurysm rupture in two. The mean risk of hemorrhage was 2.2% per year, and the observed annual rates of hemorrhage increased over time. The risk of death from rupture was 29%, and 23% of survivors had significant long-term morbidity. The size of the AVM and the presence of treated or untreated hypertension were of no value in predicting rupture.
It is difficult to assess the natural history of intracranial vascular malformations because they are varied in nature, they are frequently silent clinically, they are often treated when they are discovered, and untreated lesions are not often followed in an organized way. Capillary telangiectasias are usually occult lesions of no clinical significance. Cavernous hemangiomas may cause seizures and may bleed, but the approximate yearly risks of bleeding and of death have not been determined. Venous angiomas seldom cause symptoms, with the exception that those in the cerebellum seem to have a propensity to bleed. Intracranial dural arteriovenous malformations (AVMs) may bleed and may cause brain injury if there is insufficient outflow into a dural venous sinus. The dural AVMs that drain into the cavernous sinus have a more benign course than those that drain into the transverse or sigmoid sinus. The aneurysm of the vein of Galen presents a different clinical picture and threat to health according to whether the patient is a neonate, an infant, or an older child. The AVM of the brain encountered in the adult usually presents with hemorrhage or seizures. An unruptured AVM has approximately a 2 to 3% risk of bleeding per year, with about a 1% risk of death per year. The mortality rate of the first hemorrhage is about 10%. Among the survivors, there is about a 6% chance of rebleeding during the 1st year and then approximately a 2 to 3% risk of bleeding per year subsequently. The mortality rate associated with a second hemorrhage is about 13%, and for subsequent hemorrhages the mortality is roughly 20%.
A case is described of a young woman with progression of a macrofistulous arteriovenous malformation during pregnancy. This resulted in severe symptoms necessitating cesarean section, following which there was a dramatic postpartum recovery. The arteriovenous malformation was confirmed by angiography. The literature related to arteriovenous malformations in pregnancy is reviewed.
The authors report a retrospective study of 146 patients to assess the extent to which aneurysms, arteriovenous malformations, and pregnancy interact. The natural history of the lesions was modified if the women became pregnant. Clinical syndromes, diagnosis, neurosurgical and obstetrical management, and treatment are discussed.
A series of women who had spontaneous subarachnoid hemorrhage during pregnancy is reviewed. These patients are more likely than the average to have an angiographically demonstrable lesion, with arteriovenous anomalies and aneurysms occurring equally. The clinical features are evaluated so that an idea of the causative lesion can be gained at the bedside in the absence of specific neurological tests. When the known cardiovascular changes of pregnancy are correlated with the clinical features in these patients, it is found that subarachnoid hemorrhage from an arteriovenous anomaly or aneurysm in pregnancy is not related to the increased cardiac output. From these data, the preferred neurosurgical and obstetrical management is defined.
✓ The quality of survival of 150 patients with arteriovenous malformations of the brain is presented. The mean period of follow-up was over 15 years. The surgically operated and conservatively managed groups are compared, a comparison that in the long run appears to favor the operated cases. The results are discussed and indications for surgery summarized.
A report on 18 patients with occlusive lesions completes a study of 70 cases of cerebral vascular disease associated with pregnancy and the puerperium.
Cortical venous thrombosis has traditionally been accepted as the chief cause of strokes during pregnancy but full neurological investigation demonstrates a high proportion of arterial lesions. In the present series there were 9 cases of arterial occlusion; 6 presenting during pregnancy and 3 in the puerperium. The nine cases of cortical venous thrombosis all occurred in the puerperium.
The presentation, clinical course and outcome differed markedly between patients with arterial and venous lesions but it would be erroneous to rely on clinical features alone to distinguish them.
Cerebral vascular occlusions may be confused with haemorrhagic lesions, intracranial infection, idiopathic epilepsy and psychosis. The occurrence of a sudden fit in the puerperium may lead to the mistaken diagnosis of postpartum eclampsia although this did not arise here.
Active treatment by operation or with anticoagulants was carried out in half the cases; the other patients being treated symptomatically. The nature and extent of the pathological process appeared to be more significant in determining the outcome than the method of treatment employed. Venous lesions carried a higher initial mortality than arterial occlusions but recovery amongst the patients who survived was more rapid and complete than that following arterial strokes.
The method of management of a stroke occurring during pregnancy should be selected chiefly on neurosurgical grounds and the obstetric requirements considered secondarily.
A series of 137 unoperated patients with arteriovenous malformation of the brain is reported upon. Median time between onset of symptoms and end of follow-up period was 8 years; median length of follow-up period from date of diagnosis was 4 years and 7 months. Frontal, temporal and occipital malformations seemed to have a better prognosis than parietal, central or infratentorial ones: one out of 52 patients in the former group and 13 out of 85 in the latter died from a haemorrhage caused by the malformation. It is pointed out that there are no reports anywhere on large, unselected series of conservatively treated patients with arteriovenous malformation of the brain, and that criteria for operation are too subjective at present with unjustified assumptions that the natural prognosis is gloomy.
The natural history of intracranial arteriovenous malformations (AVMs) was studied in 131 patients. The 83 patients managed nonsurgically and the 48 patients treated surgically were followed for an average of 8 years. Hemorrhage occurred in 61.8% of all patients. A second hemorrhage occurred in 67.4% of the survivors of the first hemorrhage. The mortality associated with recurrent hemorrhage did not increase significantly with successive episodes of hemorrhage. The rate of rebleeding was 17.9%/year initially, but declined to 3%/year after 5 years and then to 2%/year after 10 years. Among patients treated nonsurgically, the prognosis was more favorable for patients presenting with seizures than for patients presenting with hemorrhage. Patients in the seizure group had a 26.9% incidence of hemorrhage causing an 11.6% mortality; 40.5% of the patients in the hemorrhage group died. The prognosis was poor for patients with posterior fossa AVMs; the mortality was 66.7% with the first hemorrhage. Recurrent posterior fossa hemorrhage was the rule in survivors, and most of those hemorrhages were fatal. The prognosis for children with AVMs was no different from that for adults.
The case records of 191 patients with a cerebral arteriovenous malformation (AVM) were reviewed to determine bleeding characteristics of these lesions. Possible influences of age, sex, the location and size of the AVM, type of initial hemorrhage, and condition of the patients were analyzed. Of these 191 patients, 102 had a single hemorrhage, 32 had a recurrent hemorrhage, and 57 never bled. The follow-up period for patients with an unruptured AVM was a mean of 4.8 years and a maximum of 31 years; for those with a ruptured AVM, the mean was 2 years, and the maximum 37 years.
Size of the AVM was significantly related to the risk of first hemorrhage. The average yearly risk for first hemorrhage was between 2% and 3%. Bleeding occurred most frequently in the 11- to 35-year-old age group. The risk of rebleeding increased with advancing age. Among 93 patients followed after their AVM had ruptured, the risk of rebleeding was 6% in 1 year. After the first year, the average rebleeding rate was about 2% per year up to 20 years.
Focal neurological deficits (FNDs) in patients with arteriovenous malformations (AVMs) have been widely attributed to the phenomenon of "cerebral steal." The incidence of focal deficits was investigated in a large prospective sample.
Using data from patient history and examination, CT or MRI, and transcranial Doppler sonography, we studied 152 consecutive, prospective AVM patients for evidence of FNDs unrelated to a hemorrhagic event. Feeding mean arterial pressure was measured during superselective angiography.
Two (1.3%) of 152 patients met the criteria for a progressive FND. Nonprogressive FNDs were seen in 11 (7.2%) patients (stable in 4.6%, reversible in 2.6%). The median observation time period was 17 months (range, 1 to 60 months). There were no differences in transcranial Doppler mean velocities in feeding arteries in FND versus non-FND groups (118 +/- 44 versus 112 +/- 37 cm/s, P > .05) or pulsatility indexes (0.53 +/- 0.20 versus 0.55 +/- 0.15, P > .05). Feeding artery pressure was similar in FND (n = 10) and non-FND (n = 96) groups (39 +/- 16 versus 39 +/- 16 mm Hg at a systemic pressure of 82 +/- 18 versus 75 +/- 14 mm Hg, NS).
Nonhemorrhagic focal neurological syndromes in AVM patients are infrequent. Progressive deficits are especially rare. There was no relation between feeding artery pressure or flow velocities and FND. There does not appear to be sufficient evidence to assign steal as an operative pathophysiological mechanism in the vast majority of AVM patients.
The incidence, causes, and prognosis of nonhemorrhagic strokes and intraparenchymal hemorrhages occurring in association with pregnancy or puerperium are poorly understood.
We carried out a retrospective (1989 through 1991) and prospective (1992) study in 63 public maternities (348,295 deliveries) of the region of Ile de France (10,660,554 inhabitants) and in the neurology, neurosurgery, and intensive care units of the same geographic area. Records of women who suffered a cerebrovascular event during pregnancy or the first 2 weeks postpartum were reviewed by two study neurologists. Stroke was defined according to the criteria of the World Health Organization.
Thirty-one cases of strokes were identified, including 15 nonhemorrhagic strokes (including strokelike deficits associated with eclampsia) and 16 intraparenchymal hemorrhages, assessed in all cases by CT scan and/or MRI. The incidence of nonhemorrhagic strokes in women who delivered in public maternities of Ile de France was 4.3 per 100,000 deliveries (95% confidence interval, 2.4 to 7.1) and that of intraparenchymal hemorrhage was 4.6 per 100,000 deliveries (95% confidence interval, 2.6 to 7.5). Eclampsia accounted for 47% of cases of nonhemorrhagic strokes. The other causes were extracranial vertebral artery dissection, postpartum cerebral angiopathy, inherited protein S deficiency, and disseminated intravascular coagulation associated with amniotic fluid embolism. The cause remained undetermined in four cases despite extensive investigations. Eclampsia accounted for 44% of intraparenchymal hemorrhages. Another 37% were due to rupture of a vascular malformation. The cause remained undetermined in three cases. There were four maternal deaths (all associated with intraparenchymal hemorrhage), three of them in eclamptic women. Fetal mortality and prematurity were associated with eclampsia.
The incidence of nonhemorrhagic stroke does not seem to be much increased during pregnancy and early puerperium. In contrast to that in the nonpregnant state, the frequency of intraparenchymal hemorrhage in pregnancy appears to be similar to that of nonhemorrhagic strokes, suggesting that pregnancy may increase the risk of cerebral hemorrhage. Eclampsia is the main cause of both nonhemorrhagic stroke and intraparenchymal hemorrhage. Intraparenchymal hemorrhage associated with eclampsia carries a poor prognosis.
The physiological and anatomical aberrations that result in hemorrhage from cerebral arteriovenous malformations (AVMs) remain unclear. In an attempt to clarify which conditions may predispose to hemorrhage, we examined clinical and physiological indices on presentation groups of either hemorrhage or nonhemorrhage in a large cohort of patients (n = 449). Variables examined included AVM size, type of venous drainage, transcranial Doppler (TCD) velocities, feeding mean arterial pressure (FMAP), and draining vein pressure. TCD and pressure data were obtained before any treatment. Age (mean +/- standard deviation) at the time of presentation was 33 +/- 13 years and did not differ between groups. Patients with small (< or = 2.5 cm) AVMs presented more frequently with hemorrhage (90%) than did patients with medium (> 2.5 and < or = 5.0 cm; 52%) or large (> 5.0 cm; 50%) AVMs (P = 0.0001). The 48 of 94 AVMs (51%) with deep venous drainage were more likely to have hemorrhage (P = 0.0219) than were those with superficial drainage (24 of 73 [33%]). Deep drainage was a predictor of hemorrhage even in the subgroup of medium and large supratentorial AVMs (P = 0.005). There was no difference in draining vein pressure (n = 18) between groups (21 +/- 10 and 19 +/- 11 mm Hg, respectively; P = 0.7812). FMAP (n = 52) was higher in the hemorrhage than in the nonhemorrhage group (44 +/- 13 versus 34 +/- 10 mm Hg; P = 0.0007) but was only weakly related to the size of the lesion (largest dimension) (y = -0.74x + 40; r = 0.09).(ABSTRACT TRUNCATED AT 250 WORDS)
Data were obtained from 191 women with cerebral arteriovenous malformations (AVMs) referred for stereotactic radiosurgery with the Leksell Gamma Unit in Sheffield. The risk of cerebral bleeding from arteriovenous malformations during pregnancy was examined and related to the different trimesters of pregnancy in these women. Some tentative guidelines are suggested for advising women with AVMs, who become pregnant.
Our purpose was to investigate the maternal hemodynamic and cardiac structural changes that occur during pregnancy.
Eighteen women underwent serial echocardiography beginning at 8 to 11 weeks' gestation, then at monthly intervals throughout pregnancy and at 6 and 12 weeks post partum. Cardiac output was measured by pulsed- and continuous-wave Doppler at the aortic valve. Left ventricular chamber size, wall thickness, and mass were determined by M-mode echocardiography. Ventricular diastolic function was assessed by Doppler recording of mitral inflow.
Cardiac output by pulsed Doppler increased from 6.7 +/- 0.6 L/min at 8 to 11 weeks' gestation to 8.7 +/- 1.4 L/min at 36 to 39 weeks' gestation before falling to 5.7 +/- 0.7 L/min 12 weeks post partum. Heart rate increased 29%, and stroke volume increased 18%. Left ventricular mass increased because of an increase in wall thickness. Peak mitral A wave velocity increased in late pregnancy. Cardiac output by pulsed and continuous-wave Doppler was similar.
Cardiac output continues to increase even in late pregnancy. Left ventricular mass increases because of increased wall thickness. The mitral flow velocity findings suggested decreased ventricular compliance or increased preload.
The relationships between migraine and A-V Malformations is a subject of controversy and the arguments are mainly based on case reports and retrospective data. To clarify this subject a structured inquiry and classification of headaches in large samples of patients with intracranial vascular malformations (IVM) is essential. The authors studied the prevalence of headaches in 51 patients with IVM admitted to our Department, between 1984 and 1992. The methods used were a review of medical records followed by a self-administered headache questionnaire and clinical interview using the IHS criteria for the diagnostic classification of headaches. The relative frequency of the different types of headaches was calculated and compared with the general population data. A correlative study of the headache characteristics with the type and location of the IVM was made. A high prevalence (47%) of migraine type headaches and a strong positive correlation (88.8%) between the site of AVM and side of the pain was found. This is highly suggestive but not conclusive of a pathophysiologic relationship between these entities. The conclusion drawn is that a prospective study of headaches by questionnaire or semi-structured clinical interview in patients with IVM is essential to discover the effective prevalence and characteristics of headaches associated with IVM and their relationships.