Management strategies for neoplastic and vascular brain lesions presenting during pregnancy: A series of 29 patients

Management of sporadic intracranial vascular malformations in pregnancy: a retrospective analysis

BACKGROUND

Sporadic intracranial vascular malformations can pose significant risk to parturients, and additional reports of management may inform patient care. Here we describe the peripartum management of parturients with intracranial vascular malformations.

METHODS

After Institutional Review Board approval, we performed a retrospective analysis of parturients with a known sporadic intracranial vascular malformation including cavernous malformation, developmental venous anomaly, or arteriovenous malformation who delivered at our institution between 2007 and 2020.

RESULTS

We identified 10 parturients (five cavernous malformations, three developmental venous anomalies, and two arteriovenous malformations) with 16 deliveries. Among all deliveries, 13 (81.3%) were cesarean deliveries without trial of labor; 11 of these (84.6%) received a single-shot spinal and two (15.4%) received an epidural for surgical anesthesia. Two deliveries (12.5%) began with attempted trial of labor but ultimately required cesarean delivery for failure to progress; one of these cases received epidural anesthesia and the other received combined spinal-epidural anesthesia. One delivery was via spontaneous vaginal delivery with epidural analgesia. Overall, our study's cesarean delivery rate was 93.8% and spontaneous vaginal delivery rate was 6.2%. Three of 16 pregnancies were complicated by seizure, obstructive hydrocephalus, or intracranial hemorrhage. There were no intensive care unit admissions or maternal deaths.

CONCLUSIONS

In our case series of 16 deliveries, there were no complications directly resulting from neuraxial procedures. It remains unclear whether intracranial developmental venous anomalies or unruptured arteriovenous malformations impart increased risk during pregnancy. Antepartum planning with a multidisciplinary team approach enables risk stratification and optimal management.

Management of brain tumors presenting in pregnancy: a case series and systematic review

Patients who present with brain tumors during pregnancy require unique imaging and neurosurgical, obstetrical, and anesthetic considerations. Here, we review the literature and discuss the management of patients who present with brain tumors during pregnancy. Between 2009 and 2019, 9 patients were diagnosed at our institution with brain tumors during pregnancy. Clinical information was extracted from the electronic medical records. The median age at presentation was 29 years (range, 25-38 years). The most common symptoms at presentation included headache (n=5), visual changes (n=4), hemiparesis (n=3), and seizures (n=3). The median gestational age at presentation was 20.5 weeks (range, 11-37 weeks). Of note, 8 patients (89%) delivered healthy newborns, and 1 patient terminated her pregnancy. In addition, 5 patients (56%) required neurosurgical procedures during pregnancy (gestational ages, 14-37 weeks) because of disease progression (n=2) or neurologic instability (n=3). There was 1 episode of postneurosurgery morbidity (pulmonary embolism [PE]) and no surgical maternal mortality. The median length of follow-up was 15 months (range, 6-45 months). In cases demonstrating unstable or progressive neurosurgical status past the point of fetal viability, neurosurgical intervention should be considered. The physiological and pharmacodynamic changes of pregnancy substantially affect anesthetic management. Pregnancy termination should be discussed and offered to the patient when aggressive disease necessitates immediate treatment and the fetal gestational age remains previable, although neurologically stable patients may be able to continue the pregnancy to term. Ultimately, pregnant patients with brain tumors require an individualized approach to their care under the guidance of a multidisciplinary team.

Cerebral cavernous malformation: Management and outcome during pregnancy and puerperium. A systematic review of literature

INTRODUCTION

Cerebral cavernomas malformations (CCMs) are vascular malformations that occur with an incidence of 0,4-0,8 % in general population. The most feared complication is cerebral hemorrhage. Currently there are no guidelines for pregnant women with CCMs. Some authors claimed that many physiological changes related to pregnancy could be linked to an high risk of rupture and bleeding of the cerebral cavernoma. However, more recent studies highlight that the presence of cerebral cavernomatosis is not a contraindication for pregnancy and that the risk of bleeding is similar in pregnant and in non-pregnant women.

AIM OF THE STUDY

The purpose of our work is to analyze, through the study of controversial findings in literature, all the information currently available trying to establish a common approach for management of women with cerebral cavernomatosis in pregnancy, during childbirth and in the puerperium.

FINDINGS

In accordance with existing literature, pregnancy does not appear to be a significant risk factor for the worsening of clinical manifestations associated with the presence of CCMs. Vaginal delivery is not contraindicated in patients with CCMs and there is no indication to perform cesarean section to reduce the incidence of hemorrhage. The only indication for neurosurgery of CCMs in pregnancy is the presence of rapidly progressive symptoms and should be postponed to the puerperium if arises after 30 weeks. The puerperium is a critical time for the woman with cavernomas for the possibility of bleeding and clinical observation must be continued.

CONCLUSION

The patients with a diagnosis of a CCMs can have a pregnancy without any particular risk to themselves and the fetus but should be addressed to highly specialized obstetrics center to assesses the initial individual risk related to their pathology and to follow the pregnancy.

Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature

BACKGROUND

Recommendations on the management of brain arteriovenous malformations (bAVM) with respect to pregnancy are based upon conflicting literature.

OBJECTIVE

To systematically review the reported risk and annualized rate of first intracranial hemorrhage (ICH) from bAVM during pregnancy and puerperium.

METHODS

MEDLINE, EMBASE, and Scopus databases were searched for relevant articles in English published before April 2018. Studies providing a quantitative risk of ICH in bAVM during pregnancy were eligible.

RESULTS

From 7 initially eligible studies, 3 studies met the criteria for providing quantitative risk of first ICH bAVM during pregnancy. Data from 47 bAVM ICH during pregnancy across 4 cohorts were extracted for analysis. Due to differences in methodology and definitions of exposure period, it was not appropriate to combine the cases. The annualized risk of first ICH during pregnancy for these 4 cohorts was 3.0% (95% confidence interval [CI]: 1.7-5.2%); 3.5% (95% CI: 2.4-4.5%); 8.6% (95% CI: 1.8-25%); and 30% (95% CI: 18-49%). Only the last result from the last cohort could be considered significantly increased in comparison with the nonpregnant period (relative rate 6.8, 95% CI: 3.6-13). The limited number of eligible studies and variability in results highlighted the need for enhanced rigor of future research.

CONCLUSION

There is no conclusive evidence of an increased risk of first hemorrhage during pregnancy from bAVM. Because advice to women with bAVM may influence the management of pregnancy or bAVM with significant consequences, we believe that a retrospective multicenter, case crossover study is urgently required.

Prevalence, risk factors and pregnancy outcomes of women with vascular brain lesions in pregnancy

BACKGROUND

Vascular brain lesions (VBL) occur in up to 4.0% of the general population. With the increasing availability and use of sophisticated imaging techniques, there are more patients being diagnosed with asymptomatic intracranial AVMs and cavernous hemangiomas.

OBJECTIVES

Here we evaluate the association between VBL in pregnancy and the maternal and fetal outcomes.

STUDY DESIGN

The study cohort was identified by isolating all pregnancies from the nationwide inpatient sample (NIS), from the healthcare cost and utilization project (HCUP) over a five-year period. Within this cohort, cases with an arteriovenous malformation (AVM) or cerebral vascular malformations (CVM) were identified and their prevalence was calculated. Baseline demographic characteristics were compared and the odds ratios for various complications and outcomes were calculated.

RESULTS

Amongst 4,012,396 deliveries, VBL were identified in 214 cases: a prevalence of 5.33 cases per 100,000 deliveries. Majority of VBL cases were identified in women between 25 and 35 years of age, but the proportion of women aged 35 and older was greater amongst those patients with VBL. 74% of cases were of Caucasian race and more cases with VBL had a private insurance payer (62.1%). Seizure disorders were present in 63.6% of the cases with VBL. Whilst VBL are not associated with unfavorable obstetrical complications, they are more likely to be delivered by caesarean section (CS) - 79% of VBL cases were delivered by CS compared to 33% of the patients without VBL (OR 7.03 CI 95% 4.98-9.92). Instrumental delivery was performed in 10.3% of the vaginal deliveries for index cases. Index cases were less prone to fetal growth restriction. VBL accounted for 8.4% of 166 cases of intracranial bleeding occurring during the antepartum period within the entire pregnant population.

CONCLUSIONS

Presence of VBL does not appear to carry additional risk to mother or fetus during pregnancy.

An Integrative Survival Analysis with Identification of Prognostic Factors in the Patients with Coexisting Glioma and Intracranial Aneurysm

OBJECTIVE

This study aimed to perform an integrative clinical and survival analysis for patients with coexisting glioma and intracranial aneurysm and to assess the influence of prognostic factors on overall survival (OS).

METHODS

A systematic literature search on PubMed and Web of Science was performed for literature in English published from 1951 to August 2017. Detailed information including clinical characteristics, treatments, critical events, and time to events for survival analysis was extracted from the included articles. Clinical characteristics of included patients were reviewed, and survival analysis was performed to identify prognostic factors of OS.

RESULTS

A total of 56 cases from 38 articles published in English-language journals were included in this study, and relative details were selected for integrative analysis. Univariate analysis demonstrated that age (<47/≥47 years), ruptured aneurysm (yes/no), glioma type (glioblastoma multiforme [GBM]/no GBM), World Health Organization (WHO) grade (low/high), and radiotherapy (yes/no) had a statistically significant correlation with OS (log-rank P = 0.004, P = 0.037, P = 0.004, P < 0.001, and P < 0.001, respectively). Further, multivariate analysis revealed that WHO grade (hazard ratio [HR], 22.383; 95% confidence interval [CI], 1.795-279.151; P = 0.016) and receiving radiotherapy (HR, 0.054; 95% CI, 0.009-0.333; P = 0.002) were the independent prognostic factors for OS.

CONCLUSIONS

This integrative survival analysis revealed that WHO grade and receiving radiotherapy were independent prognostic factors for OS, and patients with low-grade glioma and receiving radiotherapy had longer survival than counter groups. Nevertheless, similar clinical studies which should be larger samples, multicenter, and collaborative are needed further.