Graded Epidural Anaesthesia for Caesarean Section in the Presence of an Untreated Spetzler-Martin Grade V Cerebral Arteriovenous Malformation With Radiological Progression Over Six Years: A Case Report

Cerebral arteriovenous malformations (AVMs) are rare during pregnancy, when the haemodynamic and hormonal changes of gestation may increase the risk of rupture. Lesions that are large, located in eloquent regions, and drained by deep venous channels represent a surgically high-risk subtype, carry substantial surgical morbidity, and are frequently managed conservatively when unruptured. We describe a 33-year-old G3P1L1A1 parturient at 36 weeks and six days of gestation with an untreated right parieto-temporo-occipital AVM, who declined intervention across three encounters and underwent an elective lower-segment Caesarean section (LSCS) with bilateral tubal ligation. The anaesthetic approach chosen was a graded epidural technique: fractionated bupivacaine boluses with real-time haemodynamic monitoring between increments. This allowed the rate of sympathectomy to be controlled, avoiding the abrupt sympathectomy associated with a subarachnoid block. Carbetocin was used as the uterotonic agent. Levetiracetam was continued perioperatively. A healthy male infant was delivered, and the mother was discharged neurologically intact on day seven, with no AVM rupture, seizure, or new deficit.