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

Brain Arteriovenous malformations (AVM) are abnormal communication between parts of cranial arterial and venous systems with the lack of a true nutritive and absorptive capillary bed [1]. The universal prevalence of AVM is relatively uncommon, with a prevalence ranging from 0.01-0.5%, 10/100000 to 140500/100000 specifically [2-7] clustering between 3rd and 5th decade i.e. presenting usually before 40 years old of age [4,8,9]. AVM commonly presents with hemorrhage in more than one half of the cases even during pregnancy [4,8,10-17]. Microsurgery, endovascular embolization and stereotactic radiosurgery are the well-established lines of management, applied on integrated and -sometimeson individualized bases [1]. With the exception of ARUBA trial, evidence is limited to case series and case studies for natural history and management [18,19]. Moreover, 2 problems arise in the context of AVM management during pregnancy: first is the significant morbidity and mortality of intracerebral hemorrhage due to AVM or aneurysm during pregnancy and puerperium [20], with estimated 4.4% [21] or 5-12% [22] of all maternal deaths rendering it-one timethe third non-obstetric cause of maternal deaths [21], second is the poorly defined natural history of AVM during pregnancy [3,23], which hinders development of definite guidelines for management of AVM during pregnancy [3,4]. In this case-series study along with a literature review, we try to establish a practical algorithmic management in addition to answering the frequently asked questions in obstetric and endovascular management. Volume 4 Issue 2 2016