///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Not all Sub Arachnoid Hemorrhages in Pregnancy are Intra cranial in origin

Abstract Number: RF5BH-44
Abstract Type: Case Report Case Series

Amar Bhavsar MD1 ; Allison Shannon MD2; David Schreibman MD3; Francois Aldrich MD4; Bhavani Shankar Kodali MD5

A 41 year old, G3P2, at 38.5 weeks, while undergoing induction of labor for severe pre-eclampsia developed significant posterior head, neck and shoulder pain with no neurological deficit. A head CT showed subarachnoid (SAH) and intraventricular hemorrhage in the posterior fossa suspicious for ruptured aneurysm, and transferred to this facility. A repeat contrast CT confirmed blood in the craniocervical region with extension into the supravermian, prepontine and intrapeduncular cisterns and into the fourth ventricle. SAH was also seen in the posterior, temporal and occipital lobes with sulcal effacement. No intracranial aneurysm or AV malformation was noted (figure A) The obstetric team recommended primary cesarean delivery for severe preeclampsia. She was alert, no obvious neurological deficit was observed except head and neck pain. A pre-induction arterial line was placed before rapid sequence induction with propofol, 100 mg succinylcholine and 40 mcg nitroglycerin to keep blood pressures below 140 mm Hg. Her procedure was uncomplicated, and she was brought back to the Neuro ICU intubated and sedated. Hemodynamically, her blood pressures were in the range of 120 to 140 mm systolic during the entire procedure. Upon recovery in the Neuro ICU, she was unable to move lower extremities with intact sensory function, and MRI showed a 5 mm thick intradural extramedullary collection posteriorly at C7-T2 causing moderate to marked spinal stenosis (figure B). She underwent C7-T4 laminectomy. At surgery, hematoma was subdural in origin secondary to vascular malformation in the subdural space. Her lower extremity weakness showed modest improvement.

The findings in this case suggests two possibilities. First, SAH and subdural AV malformation, two independent entities occurring coincidently. But, isolated spontaneous SAH unrelated to intracranial aneurysm, or AV malformation is rare. Second, the epicenter of the bleeding was primarily AV malformation in the cervico thoracic subdual space. The blood initially migrated via foramen magnum and via breaches in subarachnoid membrane into the cranium presenting as cervico cranial subarachnoid hemorrhage. Subsequently continued bleeding from AV malformation resulted in the accumulation of blood in the cervico thoracic region contributing to lower extremity motor deficit. This case demonstrates that cervico thoracic region should be included in the evaluation of SAH if no obvious intracranial lesion is demonstrated

SOAP 2019