Cranial Arteriovenous Malformations During Pregnancy: A Multidisciplinary Algorithm for Safe Management. Case Series and Review of the Literature

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.