Anesthetic management for cesarean section in a patient with rupture of a cerebellar arteriovenous malformation

Intracranial hemorrhage in the pregnant patient is a rare cause of peripartum morbidity, and it presents a diagnostic and management dilemma. The case of a term parturient who presented with headache is presented. Clinical suspicion led to the diagnosis of ruptured cerebellar arteriovenous malformation. Optimal timing of interventions, both neurosurgical and obstetric, are discussed. We chose to pursue Cesarean section prior to definitive neurosurgical intervention in this term parturient. Delivery of the fetus before surgery eliminates concern for adverse pregnancy outcome when interventions for cerebral protection are used, such as hyperventilation, administration of mannitol, barbiturate coma, and induced hypertension or hypotension. Subsequent management options, including general, spinal, epidural, and combined-spinal epidural (CSE) anesthesia for Cesarean delivery, are discussed. We selected CSE anesthesia so as to provide a hemodynamically stable delivery followed by planned endovascular embolization.