Arteriovenous Malformations in Pregnancy—Report of Two Patients

Abstract

Background

Cerebral arteriovenous malformations (AVMs) during pregnancy pose significant risks of hemorrhage, requiring careful multidisciplinary management. The optimal anesthetic and obstetric strategies remain unclear due to limited data.

Methods

We report two cases of pregnant women with cerebral AVMs managed by a multidisciplinary team. Both patients underwent close neurological and fetal monitoring and elective cesarean deliveries under spinal anesthesia combined with norepinephrine infusion to maintain hemodynamic stability.

Results

The first case involved a primigravida with a large, unruptured right parietal AVM presenting with headache and transient visual symptoms. The second was a secundigravida presenting with seizures and subacute hemorrhages. Both deliveries were uneventful, with stable mean arterial pressures maintained intraoperatively, no hypertensive surges, and favorable maternal and neonatal outcomes. Postpartum plans included further neurovascular evaluation.

Conclusion

These cases highlight the importance of individualized, multidisciplinary care in managing cerebral AVMs during pregnancy. Spinal anesthesia with norepinephrine infusion provided stable hemodynamic control and allowed continuous neurological monitoring, potentially reducing rupture risk. Further research is needed to establish standardized protocols.

Keywords

AVM rupture in pregnancy - cerebral arteriovenous malformation - multidisciplinary management

Background

Hemorrhagic stroke during pregnancy and puerperium is a serious complication, with maternal mortality rates of 35 to 83% and accounting for 5 to12% of maternal deaths.[1] Intracranial arteriovenous malformations (AVMs), though rare (∼0.01% prevalence), are a significant cause of hemorrhagic stroke, affecting both sexes equally, usually between ages 20 and 40 years.[2] Pregnancy causes major cardiovascular changes: blood volume and cardiac output increase substantially, while systemic blood pressure decreases due to lowered peripheral resistance. Despite increased cardiac output during labor, AVM rupture is rare, indicating factors beyond blood pressure may influence rupture risk.[3] [4]

Most AVMs remain undiagnosed until symptomatic, presenting as headache, seizures, neurological deficits, or intracranial hemorrhage, which pose high risks to mother and fetus. Given physiological changes in pregnancy that may elevate rupture risk, early recognition of symptoms by obstetricians is critical for timely multidisciplinary management and patient counseling. Mortality related to AVM rupture in pregnancy remains significant.[1] [2] [5]

The risk of AVM rupture during pregnancy is debated: some studies suggest increased risk later in gestation,[6] others report early ruptures or no significant difference compared to nonpregnant individuals.[7] [8] With an estimated 5.7% annual rupture risk during pregnancy,[9] managing unruptured AVMs demands individualized care. We present two contrasting cases illustrating this complexity and the importance of tailored management.

Materials and Methods

Two pregnant patients with cerebral AVMs were managed using standardized protocols involving neuroimaging, seizure prophylaxis, fetal monitoring, and elective cesarean delivery under spinal anesthesia. Multidisciplinary teams (MDTs) coordinated care. Vasopressors were used intraoperatively as needed to maintain hemodynamic stability. Postoperative pain was managed with multimodal analgesia.

Results

Case 1: A Primigravida with a Complex, Unruptured AVM

A 19-year-old female presented with a 1-day history of generalized headache, neck pain, and transient left eye blurring lasting 30 minutes, accompanied by vomiting and loss of appetite but no fever or aura. Neurological exam was normal (Glasgow Coma Scale [GCS] 15/15), and symptoms improved with analgesics. Blood tests, including white blood cell (WBC) count 7,500/mm³, C-reactive protein (CRP) < 3 mg/L, and electrolytes, were normal. Initial noncontrast computed tomography (CT) showed an isodense lesion in the right parietal region, prompting further imaging. CT angiogram and digital subtraction angiography (DSA) revealed a diffuse AVM nidus (5.1 × 4.8 × 4.0 cm) in the right parietal lobe, with feeding vessels from the right middle cerebral artery, both anterior cerebral arteries, and right posterior cerebral artery, draining into the right transverse sinus. Multiple dilated vessels extended toward the vein of Galen and straight sinus. Embolization was offered, but the patient was lost to follow-up.

One year later, the patient presented at 12 weeks' period of amenorrhea with an unplanned pregnancy. A MDT including obstetrics, neurology, neurosurgery, anesthesiology, and neonatology devised a management plan. Levetiracetam was started for seizure prevention, with close neurological and obstetric monitoring. Weekly growth ultrasounds and Doppler studies assessed fetal well-being. Urgent magnetic resonance imaging (MRI) was planned if neurological status worsened. An elective lower segment cesarean section (LSCS) under spinal anesthesia was scheduled at 37 weeks. Mean arterial pressure (MAP) was maintained between 80 and 95 mm Hg during delivery, using norepinephrine infusion (0.05–0.1 mcg/kg/min) to manage spinal anesthesia-induced hypotension. No hypertensive surges above 140 mm Hg or hemodynamic instability occurred. Delivery was uneventful, with good maternal and neonatal outcomes. The patient, however, did not return for follow-up.

Case 2: A Gravida II with Acute Seizures and Subacute Hemorrhages

A previously healthy 30-year-old woman, gravida 2 para 1, presented at 26 weeks and 2 days gestation with three generalized tonic-clonic seizures preceded by high-grade fever. Examination was normal, with no focal deficits and a GCS of 15. Blood tests showed WBC 8,200/mm³ and CRP 4.1 mg/dL. Lumbar puncture ruled out meningitis. Without acute mass effect or deterioration, neurosurgical intervention was deferred. Initial management focused on stabilization, and levetiracetam was started promptly, effectively controlling seizures. Her fever resolved with treatment.

The patient's fever resolved within 3 days, suspected as viral. Brain CT showed superficial patchy intraparenchymal hemorrhages in the left frontoparietal region, suggesting AVM bleed. A MDT decided on contrast MRI after discussing risks with the patient and family. MRI revealed an abnormal left frontal-parietal area with a T1 intermediate signal, low fluid-attenuated inversion recovery, and blooming on susceptibility-weighted imaging, indicating patchy hemorrhages of varying ages. Multiple tortuous vessels suggested a vascular malformation with venous drainage into the superior sagittal sinus. Postcontrast imaging showed a “caput medusae” pattern consistent with a developmental venous anomaly, with diffuse AVM as a differential. No mass effect, midline shift, subarachnoid or intraventricular hemorrhage, or signs of encephalitis or meningitis were seen. Major intracranial vessels were normal.

Antiepileptic treatment with levetiracetam controlled seizures; fever resolved. The MDT planned close monitoring until 34 weeks with weekly fetal biophysical profiles. At 34 weeks, an elective LSCS under spinal anesthesia was performed. MAP was maintained at 85 to 100 mm Hg intraoperatively with norepinephrine infusion (0.05–0.1 mcg/kg/min) to avoid cerebral hypoperfusion. Delivery was uneventful, with favorable maternal and neonatal outcomes. Postpartum DSA was planned after recovery.

Both patients received preemptive analgesia using hyperbaric bupivacaine and intrathecal fentanyl to achieve sensory block to T6. Our patients did not experience any discomfort, such as retching or vomiting, during uterine manipulation despite the sensory block being targeted only up to T6 rather than T4. Low-dose norepinephrine countered spinal anesthesia-induced hypotension while patients were positioned left laterally. Multimodal analgesics such as subcutaneous morphine, diclofenac, and paracetamol, were used postoperatively. Multidisciplinary coordination and strict blood pressure control were maintained throughout.

Key clinical characteristics, management details, and outcomes from our cases, along with a comparison to select published reports, are summarized in [Table 1].

Table 1 Comparison of current study cases with published reports on cerebral AVMs in pregnancy

Study	Our study		Liu et al, 2014	Agarwal et al, 2012		Amias, 1970	Guerrero-Domínguez et al, 2015	Santos et al, 2020
No. of cases	1	1	979	2		19 angioma (total), 10 during pregnancy	1	1
Maternal age (in years)	19	30	Mean 26.1 ± 12.4 years	27	26	17–37 years (pregnancy group)	32	20
Gravida/Para	G1P0	G2P1	Mixed	G1P0	G4P2	Mixed	G1P1	G1P0
Gestational age at presentation	12 weeks	26 + 2 weeks	Mostly 2nd/3rd trimester	11.5 Weeks	Not mentioned	Mostly 2nd/3rd trimester	22 weeks	38 + 1 weeks
AVM status	Unruptured	Ruptured	393 ruptured	Ruptured	Unruptured	All ruptured	Ruptured	Ruptured (3 years prior)
AVM location/size	Rt parietal, 5.1 × 4.8 × 4.0 cm	Lt frontoparietal, diffuse	Frontal, temporal, parietal, basal ganglia, cerebellum	The right lentiform nucleus and right thalamus	Left posterior parietal cortex	Frontoparietal, temporal, brainstem	Left temporo-occipital region	Cervicomedullary junction (right side predominant)
Initial presentation	Headache, visual symptoms	Seizures, subacute bleed	Headache, vomiting, limb dysfunction, altered consciousness	With post-coital sudden onset headache accompanied by numbness/tingling in left upper extremity.	Severe migraines with concomitant vomiting, dizziness, and right-sided weakness	Headache, coma, seizures, deficits	Severe headache associated with nausea and vomiting.	History of right-sided weakness, headache, vomiting (3 years prior)
Imaging modality	CT, DSA (pre-pregnancy)	CT, MRI (no gadolinium)	Emergency CT for all; 9 had emergency DSA	CT	CT	Angiography (all), LP, CT (in some)	CT and CT angiography	CT head (acute hemorrhage), MRI brain/spine, CT angiogram, cerebral angiogram
Maternal comorbidities	None	None	Not specified	None	History of stage 2 embolization of a left parietal AVM	Rare hypertension, otherwise none noted	None	None
Mode of delivery	Cesarean (37 wk)	Cesarean (34 wk)	Cesarean common; some abortions due to radiation concerns	Cesarean	Cesarean	Mix: cesarean, forceps, vaginal	Not specified	Urgent cesarean section
Anesthesia type	Spinal + NE infusion	Spinal + NE infusion	Not specified	Not specified	Not specified	Regional (forceps), GA (surgery)	General anesthesia	Combined spinal (fentanyl) + continuous lumbar epidural (lidocaine)
Vasopressor use	Yes	Yes	Not specified	Not specified	Not specified	Not specified	A regimen of corticoids was begun 5 days prior to surgery	Not specified
Maternal outcome	Good	Good	No maternal deaths in surgical group; 1 death in conservative group	Good	Good	Most survived, some deaths	Good	Uneventful perioperative and postoperative course; neurologically intact at discharge and follow-up
Neonatal outcome	Good	Good	4 fetal deaths (abortions) in surgical group	Good	Good	Most infants survived, some preterm/deaths	Not specified	Healthy neonate delivered
Intervention timing/follow-up	Conservative, defaulted postpartum f/u	Postpartum DSA planned	Emergency surgery in 6, elective surgery in 1, gamma knife in 1, multidisciplinary care	Postponed intervention	Postpartum embolization	Surgical or conservative	Craniotomy for surgical resection of the AVM	Conservative during pregnancy; neurosurgical reevaluation postpartum

Abbreviations: AVM, arteriovenous malformation; CT, computed tomography; DSA, digital subtraction angiography; GA, general anesthesia; LP, lumbar puncture; MRI, magnetic resonance imaging; NE, norepinephrine.

Discussion

Cerebral AVMs in pregnancy require careful management due to potential hemorrhage risk, though this risk is still debated.[3] These two cases highlight the importance of individualized, multidisciplinary care during pregnancy, given the physiological changes involved. AVMs often present with intracranial hemorrhage (50%), seizures, or headaches.[2] In our cases, the first patient had nonhemorrhagic symptoms like headache and transient visual disturbances, while the second had seizures and subacute hemorrhages, reflecting the varied clinical spectrum of AVM in pregnancy.[2] [3]

The risk of AVM rupture rises as pregnancy progresses, peaking in the third trimester, labor, and early postpartum period. This is due to pregnancy-related hemodynamic changes such as increased blood volume and cardiac output that stress AVMs. Strict blood pressure control is vital to lower rupture risk. Thus, close monitoring and multidisciplinary care are essential during the peripartum period to protect both mother and child.[1] [3]

Prompt diagnosis is vital. Noncontrast CT is the first-line imaging for detecting acute hemorrhage due to rapid availability and sensitivity.[7] CT angiography or DSA remains the gold standard for detailed AVM evaluation. Studies show fetal radiation exposure from brain DSA is extremely low, especially with abdominal lead shielding, which is also recommended during brain CT scans. Although fetal exposure during mid-to-late pregnancy is minimal with shielding, further data are needed.[1] [5]

Radiation effects vary by gestational age, with the highest risk during early pregnancy, especially the first trimester, causing embryo death, malformations, or neurodevelopmental issues. The fetus is most vulnerable during organogenesis (2–8 weeks), requiring careful imaging choices and minimal exposure. In mid and late pregnancy, fetal tissues are less sensitive, and with proper shielding, diagnostic radiation is generally safe but should be used cautiously.[10]

Therefore, minimizing fetal radiation through careful imaging selection, shielding, and alternatives like MRI without gadolinium is essential, as demonstrated in case 2. When angiography is required, dose reduction and careful planning help balance maternal diagnostic needs with fetal safety.

A multidisciplinary approach is essential, as shown in both cases. Case 1 was managed conservatively with levetiracetam and close monitoring,[6] while case 2 required acute stabilization and seizure control, with embolization deferred postpartum unless urgent.[3] Both cases had elective cesarean delivery at 34 to 37 weeks to minimize hemodynamic stress and rupture risk.[1] [11]

Anesthetic management balances maternal hemodynamics and fetal safety. Spinal anesthesia with norepinephrine infusion (0.05–0.1 mcg/kg/min) maintained MAP at 80 to 100 mm Hg, supporting stable cardiovascular status to reduce rupture risk. Both general and regional anesthesia have been used successfully for cesarean in AVM patients, but no clear guidelines exist due to rarity.[12] [13] Regional anesthesia, especially epidural or combined spinal-epidural, allows awake neurological monitoring and avoids hypertensive surges seen with general anesthesia.[12] Spinal anesthesia may cause hypotension from sympathetic blockade, requiring vasopressors to preserve cerebral and uteroplacental perfusion.[1] [11] In these cases, norepinephrine effectively prevented hypotension without hypertension.

In patients with intracranial AVMs, especially with hemorrhage, general anesthesia is often safer due to controlled ventilation and intracranial pressure management. Neuraxial blockade can be used safely if raised intracranial pressure is excluded and neurological stability is ensured. This avoids airway manipulation that may cause hypertensive surges and increase rupture risk.[12] [14]

General anesthesia is an option, especially in emergencies or when neurosurgical intervention is planned, offering controlled ventilation and intracranial pressure management but risking hypertensive surges during airway manipulation that may increase AVM rupture risk.[12] [13] Spinal anesthesia, used in our cases, avoided these risks, maintaining stable hemodynamics with systolic blood pressure under 140 mm Hg and allowing continuous neurological monitoring via GCS assessment for early detection of changes.[3] [5]

Our anesthetic approach ensured cardiovascular stability and real-time neurological assessment, consistent with reports of favorable maternal and neonatal outcomes using individualized, multidisciplinary care.[1] [5] Cesarean sections were performed in neurosurgical theaters to enable immediate intervention, such as decompressive craniectomy, if AVM rupture occurred.[12] The anesthesia team was prepared for rapid conversion to general anesthesia if needed for airway control or neurological deterioration.[3]

Timing of AVM surgery depends on gestation, rupture status, and maternal-fetal condition. Delivery is prioritized to reduce fetal risks, with AVM resection deferred postpartum to avoid fetal anesthesia and radiation exposure.[3] [12] However, ruptured or high-risk AVMs may require combined cesarean and neurosurgery under general anesthesia for better ventilation and intracranial pressure control.[12] [14]

Surgical and anesthetic plans should be individualized by a MDT. With such care, outcomes for unruptured or stabilized AVMs are generally favorable, though hemorrhage remains the leading cause of morbidity and mortality.[9] Postpartum DSA, as in case 2, enables definitive assessment. Untreated AVMs carry a 2 to 4% annual hemorrhage risk.[8]

Limitations

This report is limited by the small sample size and observational design, which reduce generalizability and the ability to prove the superiority of spinal anesthesia with norepinephrine. Lack of long-term maternal and neonatal follow-up and postoperative imaging restrict safety and progression assessments. Follow-up challenges due to socioeconomic and health care access issues affect data completeness. Existing literature suffers from small samples, heterogeneous designs, and no randomized trials, underscoring the need for multicenter registries and prospective studies. The impact of pregnancy-related physiological changes on AVM rupture risk remains unclear, warranting future research to improve maternal-fetal outcomes.

Conclusion

Managing cerebral AVMs during pregnancy requires individualized risk assessment and multidisciplinary coordination. Hemodynamic changes in pregnancy increase the risk of AVM rupture, necessitating close monitoring and proactive anesthetic planning. Mode and timing of delivery should be tailored to minimize maternal neurological risk, with cesarean delivery often preferred. Our cases highlight that spinal anesthesia combined with norepinephrine infusion effectively maintains stable hemodynamics and allows continuous neurological monitoring, reducing rupture risk. These findings emphasize the importance of balancing maternal and fetal safety through personalized, collaborative care.

Conflict of Interest

None declared.

• References

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Publication History

Article published online:
12 December 2025