Clinical Report: Staged Management Approach in Obstetric Neurosurgery
Overview
This report details a staged management strategy for a pregnant patient with a ruptured arteriovenous malformation (AVM) and impending herniation. The approach successfully prioritized maternal resuscitation and fetal preservation, resulting in a healthy delivery and full neurological recovery.
Background
Ruptured AVMs during pregnancy pose significant risks, contributing to maternal mortality rates between 5% and 12%. The management of such cases requires careful consideration of both maternal and fetal health, particularly when complications like herniation arise. A staged 'damage control' approach may offer a viable solution to balance these competing priorities.
Data Highlights
Event
Date
Details
Emergency Decompressive Craniectomy
Day 1
Performed to reverse herniation
Cesarean Delivery
39 weeks
Healthy infant delivered
Postpartum Angiography
76 days post-delivery
Diagnostic workup for AVM
Cranioplasty
75 days post-embolization
Final surgical intervention
Key Findings
The patient presented with severe symptoms including coma and anisocoria due to uncal herniation.
Emergency decompressive craniectomy was performed to stabilize the patient before definitive vascular treatment.
Postpartum angiography revealed a Spetzler–Martin Grade II AVM.
The patient achieved a full neurological recovery with a modified Rankin Scale score of 0.
The infant was delivered healthy at term, demonstrating the effectiveness of the staged approach.
Clinical Implications
This case highlights the importance of prioritizing maternal stabilization in obstetric neurosurgery, particularly in emergencies involving AVM rupture. A staged approach allows for timely intervention while minimizing risks to both mother and fetus.
Conclusion
The successful management of this case underscores the potential benefits of a staged 'damage control' strategy in obstetric neurosurgery for ruptured AVMs, balancing the need for immediate intervention with the preservation of fetal health.
Aviva Abosch, M.D., Ph.D., a neurosurgeon at Baptist Health Miami Neuroscience Institute, part of Baptist Health Brain and Spine Care, was installed as the Esernia Endowed Chair in Surgical Treatment of Adult Epilepsy and Movement Disorders.
