Surgical removal of an arteriovenous malformation in the anterior perforated substance in a pregnant woman

Anaesthetic management of cerebral arteriovenous malformation hemorrhage during pregnancy: A case series

RATIONALE

There is no clear consensus guidance for anesthesiologists on how to manage patients with cerebral arteriovenous malformation (cAVM) rupture and hemorrhage during pregnancy who need craniotomy. Our objective was to review the anesthesia management of pregnant women who underwent resection of cAVM at our institution and to provide opinions and suggestions.

PATIENT CONCERNS

Herein, we report of 3 patients with cAVM rupture and hemorrhage during pregnancy who underwent neurosurgery at the 22nd, 28th, and 20th weeks of pregnancy.

DIAGNOSES

All 3 patients were admitted to the emergency department of our hospital due to sudden symptoms. Subsequently, their head imaging results confirmed the rupture and hemorrhage of cAVM. The rupture and hemorrhage of cAVM during pregnancy has a low incidence and high mortality, which seriously endangers the safety of the mother and fetus. For this emergency condition, craniotomy for removing intracranial lesions and clear hematoma can result in a chance of a successful delivery. Especially in the second and third trimesters of pregnancy, the management goal of anesthesia is to ensure the maternofetal safety and to maintain continuous pregnancy.

INTERVENTIONS

This article describes the process of intraoperative anesthesia management and maternal-fetal outcomes and discusses the key issues for the anesthesia management of cAVM rupture during pregnancy, including considerations of physiological changes during pregnancy and anesthesia medication, intraoperative monitoring, the maintenance of hemodynamic stability, and the control of intracranial pressure, among other considerations. Resection of intracranial lesions should be performed whenever possible while maintaining the pregnancy for better maternal and infant outcomes.

OUTCOMES

The operations of the 3 pregnant women were successfully completed under our detailed anesthesia planning and careful anesthesia management. All the patients recovered well after the operation, and underwent cesarean section to give birth smoothly.

LESSONS

The preservation of pregnancy under cAVM resection is a complex challenge for anesthesiologists, and these 3 cases provide an extensive amount of experience for anesthesia management in similar situations. Detailed anesthesia planning and careful anesthesia management by anesthesiologists are important guarantees for good maternal and fetal outcomes.

Role of the anterior choroidal artery in the endovascular treatment of brain arteriovenous malformations

The anterior choroidal artery (AchA) is a very important vessel that supplies certain crucial structures that have poor collateral circulation. When the AchA is recruited to supply brain arteriovenous malformations (BAVMs), can the AchA act as a safe path through which endovascular treatment (EVT) be performed? As few studies or reports have investigated this matter, we performed a review to expound upon the role of the AchA in the EVT of BAVMs. In this review, we discussed the anatomy and variation of the AchA, the angioarchitecture of BAVMs fed by the AchA, the status of EVT for BAVMs and its associated problems and their solutions, the choice of embolic materials, new EVT techniques, the complications and prognoses of EVT through the AchA, etc. The review revealed that although EVT of BAVMs through the AchA is challenging and can result in unpredictable complications, it may be an appropriate option prior to surgery and radiation therapies or serve as a curative procedure. A complete and thorough understanding of the functional anatomy and variant of the AchA and proper EVT techniques are crucial for successful embolization of BAVMs via the AchA.

Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review

During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.