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

Emergent decompressive craniotomy in a 27-week parturient with intracranial AVM rupture and refractory elevated intracranial pressure

Abstract Number: RF5BH-90
Abstract Type: Case Report Case Series

Leslie J Matthews MD, PharmD1 ; Christopher A. Huber MD2; Samuel N. Blacker MD3

A 35-year-old G2P1 female at 26 weeks and 3 days’ gestation, with no past medical history, presented to an outside hospital emergency department with headache, expressive aphasia and left hemiparesis. Initial CT imaging revealed a large left parietal hemorrhage with intraventricular extension, so the patient was transferred to a tertiary care center for further management given significant pathology with concomitant pregnancy. Further workup revealed the large hemorrhage was likely related to a previously undiagnosed bleeding arteriovenous malformation (AVM). Due to malignant cerebral edema and refractory intracranial pressures, which peaked at 68 mmHg despite maximum medical management, patient was taken to the operating room for emergent decompressive hemicraniectomy with AVM resection. Obstetric teams were immediately available for resuscitative cesarean section in case of maternal hemodynamic compromise. The decision was made not to deliver emergently for fetal distress, thus fetal heart tones were obtained pre- and post-operatively. Intraoperatively, the patient was resuscitated using the massive transfusion protocol as it was a brisk and uncontrolled bleed. Total blood loss was 2.5 liters. After surgical hemostasis was achieved, the patient was maintained in a pentobarbital coma for five days, and after neurological improvement, was eventually extubated on hospital day #13. She continued to improve and was discharged to acute inpatient rehab on hospital day #30, then home on hospital day #58 at 34 weeks and 4 days gestation. Remarkably, she recovered nearly completely neurologically, with her only residual deficits being impaired short term memory, occasional mild expressive aphasia, and a right sided visual field deficit. She re-presented at 39 weeks and 0 days’ gestation, and underwent scheduled repeat cesarean section under spinal anesthesia without complications. She was discharged home on post-partum day 3 with a healthy baby girl.

SOAP 2019