Anesthetic management for Cesarean section in term parturient with a ruptured intracranial AV malformation
Linda T Le, MD and A Wendling, MD
Department of Anesthesiology, University of Florida, Gainesville, Florida
Rupture of an arterio-venous malformation (AVM) during pregnancy is a
rare (5:10,000 parturients) but potentially fatal occurrence with a
mortality rate that exceeds 30%. Ruptures have been documented in the second
and third trimester of pregnancy with a 30% rate of re-bleeding. For a
parturient with an AVM, both the delivery and the attendant anesthesia need
to be managed with the goal of minimizing transmural pressure changes in the
AVM.
A parturient with a subarachnoid hemorrhage secondary to a left cerebellar
AVM presented at 38 weeks gestational age for cesarean section prior to
definitive neurosurgical treatment of the AVM. The patient presented one day
prior with headaches, nausea and vomiting. CT angiogram revealed a left
inferior cerebellar intraparenchymal hemorrhage with moderate hydrocephalus.
The patient’s past medical history was remarkable for depression and a
previous cesarean section for uterine fibroids. A joint decision by the
anesthesia, neurosurgical and obstetric department was made to proceed with
cesarean section prior to embolization versus surgical resection of the AVM.
We utilized a combined spinal epidural technique for the delivery of the
fetus to avoid the potential swings in blood pressure with emergence and to
allow for awake neurologic monitoring. Surgery proceeded uneventfully and a
healthy baby boy was delivered. The patient fully recovered neurologic
function of her lower extremities and subsequently underwent successful AVM
resection 3 days after cesarean section.
In the patient with an untreated AV malformation, anesthetic management is
complicated by the risk of rebleeding and its associated mortality. Whether
regional or general anesthesia is utilized, the anesthesiologist needs to
consider the risks, benefits and limitations of each. We review the
associated cerebral and systemic hemodynamic changes associated with both
techniques.
