Simultaneous cesarean delivery and posterior fossa decompression for ruptured cerebellar AVM hemorrhage at term: A case report

Background Intracerebral hemorrhage (ICH) in pregnancy is rare but carries high maternal-fetal morbidity and mortality. Posterior fossa hemorrhage is uniquely dangerous because of rapid brainstem compression and obstructive hydrocephalus, often necessitating emergent neurosurgical decompression. Case A 31-year-old gravida 2 para 1 patient at 38–39 weeks' gestation developed abrupt, severe headache followed by dysarthria and progressive left-sided weakness, rapidly declining to obtundation. Non-contrast head CT at a community hospital demonstrated a large cerebellar ICH with fourth ventricle obstruction and herniation physiology. She was intubated, treated with hyperosmolar therapy, and transferred to a tertiary neurocritical care center on blood pressure control. On arrival she was comatose with impaired brainstem reflexes but preserved motor withdrawal. Given imminent maternal neurologic deterioration and the need for prone posterior fossa surgery, a multidisciplinary team performed urgent cesarean delivery with immediate neurosurgical intervention consisting of external ventricular drain placement and suboccipital decompression with hematoma evacuation in the same operative episode. Postoperatively, she transiently required vasopressor support and blood transfusion, then improved quickly: by postoperative day 1 she was awake, following commands, and subsequently extubated, with mild residual ocular and facial weakness. The neonate required brief resuscitation and short NICU monitoring before reuniting with the mother. Months later, diagnostic cerebral angiography identified a small cerebellar arteriovenous malformation (AVM), and staged definitive AVM resection with confirmatory angiography was completed postpartum. Conclusion This case highlights a time-critical operative strategy-coordinated cesarean delivery and posterior fossa decompression-to optimize maternal and fetal outcomes in term pregnancy complicated by catastrophic cerebellar hemorrhage.