Aneurysmal subarachnoid haemorrhage in pregnancy

Hormonal influences on cerebral aneurysms: unraveling the complex connections

INTRODUCTION

Intracranial aneurysms (IAs) occur in 3-5% of the general population and are characterized by localized structural deterioration of the arterial wall with loss of internal elastic lamina and disruption of the media. The risk of incidence and rupture of aneurysms depends on age, sex, ethnicity, and other different factors, indicating the influence of genetic and environmental factors. When an aneurysm ruptures, there is an estimated 20% mortality rate, along with an added 30-40% morbidity in survivors. The alterations in hormonal levels can influence IAs, while the rupture of an aneurysm can have various impacts on endocrine pathways and affect their outcome.

AREA COVERED

This review explores the reciprocal relationship between endocrinological changes (estrogen, growth hormone, and thyroid hormones) and IAs, as well as the effects of aneurysm ruptures on endocrine fluctuations.

EXPERT OPINION

Based on the data presented in this paper, we recommend further exploration into the influence of hormones on aneurysm formation and rupture. Additionally, we propose conducting endocrine assessments for patients who have experienced a rupture of IAs. Monitoring hormonal changes in patients with IAs could serve as a potential risk factor for rupture, leading to interventions in the approach to managing IAs.

Endovascular coiling versus neurosurgical clipping for treatment of ruptured and unruptured intracranial aneurysms during pregnancy and postpartum period

BACKGROUND

Selection of appropriate surgical strategy for the treatment of intracranial aneurysms (IA) during pregnancy requires careful consideration of the potential risks to the mother and fetus. However, limited data guide treatment decisions in these patients. We compared the safety profiles of endovascular coiling (EC) and neurosurgical clipping (NC) performed for the treatment of ruptured and unruptured IA during pregnancy and the postpartum period.

METHODS

Pregnancy-related or postpartum hospitalizations undergoing surgical intervention for IA were identified from the Nationwide Readmissions Database 2016-2018. Safety outcomes included periprocedural complications, in-hospital mortality, discharge disposition, and 30-day non-elective readmissions.

RESULTS

There were 348 pregnancy-related or postpartum hospitalizations that met the study inclusion criteria (mean±SD age 31.8±5.9 years). Among 168 patients treated for ruptured aneurysms, 115 (68.5%) underwent EC and 53 (31.5%) underwent NC; whereas among 180 patients treated for unruptured aneurysms, 140 (77.8%) underwent EC and 40 (22.2%) underwent NC. There were no statistically significant differences in the baseline characteristics between patients undergoing EC versus NC for either ruptured or unruptured aneurysm groups. The outcomes were statistically comparable between EC and NC for both ruptured and unruptured IA, except for a lower incidence of ischemic stroke in patients undergoing EC for ruptured aneurysms (OR 0.12, 95% CI 0.02 to 0.84).

CONCLUSIONS

Most pregnant and postpartum patients are treated with EC for both ruptured and unruptured IA. For treatment of ruptured IA, EC is independently associated with a lower risk of perioperative ischemic stroke, but other in-hospital complications and mortality are comparable between EC and NC.

Awake endovascular coiling of a dissected intracranial aneurysm in a third-trimester twin pregnancy: A case report

RATIONALE

Subarachnoid hemorrhages (SAHs) from ruptured intracranial aneurysms are very rare during pregnancy. Management of ruptured intracranial aneurysms with SAH in pregnancy is often challenging because of the risks to the fetus and the mother. We present the first successful awake endovascular coiling of a dissected intracranial aneurysm in a third trimester twin pregnancy.

PATIENT CONCERNS

A 28 years' old pregnant woman was admitted at the obstetric department of our hospital on account of very severe headaches associated with nausea and vomiting.

DIAGNOSIS

Emergency obstetric ultrasound scan done confirmed 32 weeks' twin gestation, whereas magnetic resonance imaging established hemorrhage in the suprasellar cistern and the subarachnoid space. Magnetic resonance angiography revealed a dissected aneurysm in the ophthalmic segment of the left internal carotid artery.

INTERVENTIONS

Awake cerebral angiography as well as embolization of the aneurysm with coils was done via the transarterial route and the twins were delivered via caesarean section at 37 weeks' gestation.

OUTCOMES

Two years' follow-up indicated no complications and children as well as their mother are healthy.

LESIONS

Awake endovascular coiling was very beneficial in our case because we avoided general anesthesia and the use of osmotic diuretics which are potentially hazardous during pregnancy.

Aneurysmal subarachnoid hemorrhage during pregnancy: a comprehensive and systematic review of the literature

Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent condition requiring rapid intervention and prolonged monitoring. There are few recommendations regarding the management of aSAH in pregnancy. We identified all available literature and compiled management decisions as well as reported outcomes through a systematic literature review without meta-analysis to provide recommendations for management of aSAH during pregnancy. We included a total of 23 articles containing 54 cases of pregnancy-related aSAH in our review. From these reports and other literature, we evaluated information on aSAH pathophysiology, diagnosis, and management with respect to pregnancy. Early transfer to an appropriate facility with neurocritical care, a high-risk obstetric service, and a neurosurgery team available is crucial for the management of aSAH in pregnancy. Intensive monitoring and a multidisciplinary approach remain fundamental to ensure maternal and fetal health.

A Systematic Review of Intracranial Aneurysms in the Pregnant Patient - A Clinical Conundrum

Hemodynamic and hormonal changes during pregnancy can increase rates of formation, growth, and rupture of intracranial aneurysms (IA), and the increased incidence of subarachnoid hemorrhage (SA) in pregnant patients represents a risk to both mother and fetus. Despite this, management and treatment guidelines have not been defined for this patient population. In most instances, treatment decisions are made on a case-by-case basis with varying degrees of input from subspecialists. Important considerations, such as aneurysm location, morphology, size, growth pattern, and patient characteristics have not been presented in a management algorithm in the context of the pregnant patient. Given limited and controversial literature describing management of IAs in pregnant patients, we performed a systematic literature review. We then describe our multidisciplinary team approach and provide analysis of existing literature to provide guidelines for the management of the pregnant patient with an IA. A systematic review was undertaken to identify studies describing the management of IAs in the pregnant patient using the PubMed database. Overall maternal and fetal morbidity and mortality rates were determined. Data was analyzed for 1537 patients, including 1115 (73%) pregnant with ruptured intracranial aneurysms. In most cases, these aneurysms were managed conservatively (77%; 781/1013); however, when treatment was provided, surgical clipping was the most common modality (15%; 149/1013). Overall maternal outcomes were reported for 934 cases with morbidity and mortality rates of 5% (42/934) and 21% (194/934), respectively. Overall fetal outcomes were reported for 114 cases with morbidity and mortality rates of 10% (12/119) and 8% (9/119), respectively. Pregnancy-associated physiological changes likely elevate the risk of intracranial aneurysm formation, growth, and rupture. Treatment for aneurysms and SAs is safe and effective during pregnancy when risks are properly mitigated. Due to the complexity of care, such patients should be treated using a collaborative, interdisciplinary approach by a multidisciplinary team.

A Pregnant Woman with Cranial Aneurysm Rupture in the Second Trimester of Pregnancy

BACKGROUND

Reports of cerebral aneurysm and aneurysm rupture during pregnancy are rare in the literature. Aneurysms might rupture and cause intracranial hemorrhage during or after pregnancy. Aneurysmal subarachnoid hemorrhage during pregnancy presents a challenge regarding treatment and management. No institution has reported a large patient population or experience in managing this condition during pregnancy in the literature. Owing to the limited number of cases, there are no available treatment guidelines, and treatment is usually based on a case-by-case approach.

CASE DESCRIPTION

A 31-year-old woman presented in the 27th week of pregnancy with sudden-onset headache, which was diagnosed as subarachnoid hemorrhage. The diagnosis of subarachnoid hemorrhage with an aneurysm located on the anterior communicating artery was made with magnetic resonance imaging and digital subtraction angiography. The aneurysm was treated by surgical clipping. The pregnancy continued successfully until the 35th gestational week, when the infant was successfully delivered by planned cesarean section owing to preeclampsia and fetal growth retardation. Postoperative follow-up was uneventful.

CONCLUSIONS

We present our experience in the management of aneurysmal subarachnoid hemorrhage during pregnancy and maternal and fetal outcomes of this rare disease. More cases and multicenter studies are needed to develop standardized management of this disease.

Intracranial hemorrhage from giant aneurysm in pregnancy: A rare association

We report a case of giant aneurysm causing subarachnoid hemorrhage in a pregnant female. A 25-year-old female presented with sudden onset of severe headache and vomiting with altered sensorium and right hemiplegia. On investigation, she had a giant supraclinoid segment internal carotid artery (ICA) aneurysm. She was planned for digital substraction angiography, but during the procedure she deteriorated neurologically and went into spontaneous labor. The baby was a male child with weight of 1.1 kg. She was taken up for surgery and aneurysm was clipped. We discuss the rare occurrence of intracranial hemorrhage in pregnancy due to a giant ICA aneurysm.

Dissecting intracranial aneurysm in pregnancy: A rare association

We report a case of dissecting aneurysm of the right posterior cerebral artery presenting with sudden onset headache and altered behavior during labor. A 26-year-old P1001 with uncomplicated antenatal period, except history of headache off and on since 32 weeks of pregnancy, developed sudden onset headache and altered behavior during 3^rd stage of labor. She had vaginal delivery and a live born male baby was delivered with good Apgar score. The CT was suggestive of subarachnoid hemorrhage and DSA was suggestive of dissecting aneurysm of the right P2 segment with hypoplasia of right P1 segment and A1 segment of posterior and anterior cerebral artery, respectively. The patient was managed conservatively. At 4-month follow-up, the patient was doing well. We discuss about the rare association of a dissecting aneurysm and pregnancy, especially dissection of the posterior cerebral artery.

Diagnosis of Acute Neurologic Emergencies in Pregnant and Postpartum Women

Acute neurologic symptoms in pregnant and postpartum women may be caused by exacerbation of a preexisting neurologic condition, the initial presentation of a non-pregnancy-related problem, or a new neurologic problem. Pregnant and postpartum patients with headache and neurologic symptoms are often diagnosed with preeclampsia or eclampsia; however, other etiologies must also be considered. A team approach with close communication between emergency physicians, neurologists, maternal-fetal medicine specialists, and radiologists is the key to obtaining best outcomes. This article reviews the clinical features and differential diagnosis of acute serious neurologic conditions in pregnancy and the puerperium, focusing on diagnosis.

Aneurysmal Subarachnoid Hemorrhage in Pregnancy-Case Series, Review, and Pooled Data Analysis

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy represents an important cause of maternal and fetal morbidity and mortality. Approaches to diagnostics and treatment are still controversial, and there are only a limited number of cases described in the literature. Our study examines the management of aSAH in pregnant patients, creating a case series by combining patients from our hospital records with those from the limited available literature.

METHODS

Data collected from Addenbrooke's Hospital records and cases published between January 1995 and January 2015 were studied. Chi-square test, exact Fisher's test, and chi-square test for trend were used for analyzing categorical data, while the t-test and Mann-Whitney-Wilcoxon test were used for continuous data.

RESULTS

Fifty-two patients were included. The mean age was 31.47 ± 5.80, and most patients were in their third trimester. A univariate pooled data analysis suggested that the maternal outcome may depend on the mother's age, mother's Hunt and Hess scale score, Glasgow Coma Scale at arrival, treatment modality for the aneurysm, mode, and timing of delivery. However, at the multivariate analysis only the presence of general complications resulted in a significant impact on maternal outcome.

CONCLUSIONS

Ruptured aneurysms in pregnant patients with aSAH may be safely secured in a timely manner. The diagnostic and treatment strategy for each of these patients should consider peculiar maternal and obstetric factors and requires a multidisciplinary assessment involving obstetrics, neurosurgeons, and intensivists. Considering the observed statistical power of our series, our findings should be taken with caution and should be supported by further systematic data collection.

Diagnosing and managing peripartum headache

A 38-year-old gravida 7 para 5 Hispanic woman at 36 weeks and 4 days gestation presented with a postpartum headache following vaginal delivery complicated by an unintentional dural puncture for epidural analgesia. Due to the positional nature of the headache and its frontal and occipital origin, a postdural puncture headache was diagnosed. After failure of conservative treatment, an epidural blood patch was used, which offered immediate relief. However, shortly following the procedure, the parturient's neurological condition deteriorated due to an unrecognized intraparenchymal and subarachnoid hemorrhage requiring an emergent craniectomy. This case highlights the importance of diligence when evaluating and treating postpartum headache despite a classic presentation.

[Emergency cesarean section and craniectomy in a patient with rupture of a cerebral arteriovenous malformation]

The intracerebral hemorrhage in pregnancy is a rare event, but can have catastrophic consequences for both mother and fetus. The management of non-ruptured arteriovenous malformations in pregnancy is not free of controversy in the current literature, as there is the possibility of spontaneous bleeding and becoming a true emergency. We report the case of a pregnant patient of 35 weeks with a diagnosis of a cerebral arteriovenous malformation, who developed a sudden onset of headache, generalized tonic-clonic seizures, loss of consciousness, and hemiparesis with radiological images of an intracranial hematoma with a mass effect, and signs of herniation. The multidisciplinary management is discussed, emphasizing perioperative cesarean approach plus craniotomy and drainage of the hematoma, and subsequent management in intensive care, and definitive management by neuroradiology, with a successful outcome.

The Risk of Aneurysmal Subarachnoid Hemorrhage During Pregnancy, Delivery, and the Puerperium in the Utrecht Population

Background and Purpose— It is unclear whether the risk of aneurysmal subarachnoid hemorrhage (aSAH) is increased during pregnancy, labor, and the puerperium. We compared the risk of aSAH during this period with the risk outside this period.

Methods— We included women with aSAH between 18 and 42 years of age (n=244) from our prospectively collected database of patients with subarachnoid hemorrhage treated in the University Medical Center Utrecht, the provincial referral center, between January 1987 and April 2006. We estimated the relative risk of aSAH during pregnancy, delivery, or the puerperium by a case-crossover design and calculated a standardized incidence ratio, dividing the observed number of patients with aSAH during pregnancy, delivery, or puerperium by the expected number based on the incidence in the general population of women of the same age during the study period.

Results— Of the 244 women, 4 were pregnant, 3 in the puerperium and none in labor. The relative risk of aSAH during pregnancy, delivery, or the puerperium was 0.4 (95% CI, 0.2 to 0.9). Based on the number of women aged 18 to 42 years within the catchment area of our hospital and the number of pregnancies within the study period, the expected number of patients with aSAH during pregnancy, delivery, or the puerperium was 12, resulting in a standardized incidence ratio of 0.6 (95% CI, 0.2 to 1.1).

Conclusions— The risk of aSAH is not increased during pregnancy, labor, and the puerperium. There is no need to advise against pregnancy in women with an increased risk of subarachnoid hemorrhage and no evidence to advise against vaginal delivery in such women.

Occurrence of perimesencephalic subarachnoid hemorrhage during pregnancy

BACKGROUND

Perimesencephalic subarachnoid hemorrhage (P-SAH) is a benign subset of subarachnoid hemorrhage with a favorable prognosis and low rate of re-bleeding. Risk factors may include hypertension and tobacco use, but it has not previously been reported during pregnancy.

METHODS

We report two cases of P-SAH in pregnant women, a 40-year-old female, 8-weeks pregnant and a 37-year-old female at 35 weeks gestational age.

RESULTS

CT scan confirmed P-SAH in both cases. CT angiography in one case and cerebral angiogram in the other did not reveal aneurysm or other potential bleeding source. The patients underwent transcranial Doppler ultrasound monitoring without evidence of vasospasm.

CONCLUSION

P-SAH hemorrhage may occur during early or late pregnancy. We do not propose an increased risk of P-SAH during pregnancy. The clinical course appears favorable and CT angiography alone may be considered the preferred diagnostic test to assess for aneurysm in first trimester pregnancy.

Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

Anesthetic considerations for intraoperative management of cerebrovascular disease in neurovascular surgical procedures

Despite new surgical methods and interventions a considerable number of patients who undergo neurovascular procedures emergently or electively have substantial mortality, morbidity, and disability. Sound knowledge of pathophysiology of cerebral hypoperfusion, reliable and timely information from monitoring devices, and appropriate choice of therapeutic intervention is essential for successful anesthetic management of these patients. The management of perioperative vasospasm and temporary ischemia during aneurysm clipping require an understanding of cerebral vascular pathophysiology and neuroprotective measures.

Postpartum dissecting aneurysm of the posterior cerebral artery

Intracranial dissecting aneurysm may cause subarachnoid hemorrhage (SAH) or infarction, and postpartum dissecting aneurysm is rare. A 30-year-old 6 days postpartum woman presented with posterior cerebral artery (PCA) dissection evolving dramatically over a short period. She had been well until 6 days after delivery when she suffered sudden onset of headache, vomiting, and unconsciousness. CT scan demonstrated SAH and digital subtraction angiography (DSA) revealed a fusiform dilatation of the left PCA (P3/P4 segment). The initial diagnosis was ruptured dissecting aneurysm, and conservative management was recommended in the acute period. DSA showed smoothening of the vascular wall 6 days after onset, and obliteration of the left P3/P4 segment was observed 13 days after onset. She was discharged without neurological deficits 26 days after onset. Postpartum SAH due to dissecting aneurysm of the PCA is rare, but should be considered in the differential diagnosis of postpartum headache.

The implications of ISAT and ISUIA for the management of cerebral aneurysms during pregnancy

Both the International Subarachnoid Aneurysm Trial (ISAT) and the International Study on Unruptured Intracranial Aneurysms (ISUIA) have been widely extrapolated to influence the management of actual or anticipated aneurysmal subarachnoid hemorrhage (SAH). However, it remains possible that sub-groups exist for which such extrapolation might subsequently prove premature. In this review, we discuss the implications that such extrapolation may potentially have for one such SAH sub-group: the clinically rare scenario of SAH in pregnancy.

Aneurysmal subarachnoid haemorrhage in a patient with thyrotoxicosis

A case of subarachnoid haemorrhage secondary to rupture of an intracranial aneurysm occurring in a patient with new-onset, frank thyrotoxicosis is described. This unusual case highlights the dilemma of whether to continue beta-blockers such as propanolol for frank thyrotoxicosis, or whether to assign higher priority to maintaining adequate cerebral perfusion pressure in established ischaemic deficit due to vasospasm. In a complicated case such as this, the Maudsley Mentation Test score and perfusion CT scanning are two useful adjuncts for the early detection and evaluation of the course of ischaemic deficit.

Labor analgesia for the parturient with neurological disease: what does an obstetrician need to know?

Several neurological disorders including multiple sclerosis, myasthenia gravis, epilepsy, spinal cord injury, and subarachnoid hemorrhage are encountered with increasing frequency in pregnant women worldwide. Although there is absence of uniform anesthetic guidelines for pregnant patients with most of these (and other) neurological disorders, and the decision whether or not to administer regional anesthesia is based on an individual risk-to-benefit ratio on a case-by-case basis, few of these disorders contraindicate the use of neuraxial anesthesia. This article attempts to review the specific concerns for administration of labor analgesia posed by multiple sclerosis, myasthenia gravis, epilepsy, paraplegia and subarachnoid hemorrhage.