The cardinal symptom of a subarachnoid hemorrhage from an aneurysm rupture is sudden severe headache that is accompanied by visual changes, cranial nerve abnormalities, focal neurological deicits, and altered consciousness. Patients typically have signs of meningeal irritation, nausea and vomiting, tachycardia, transient hypertension, low-grade fever, leukocytosis, and proteinuria. Prompt diagnosis and treatment may prevent potentially lethal complications. The American Heart Association recommends noncontrast cranial CT imaging as the irst diagnostic test, although MR imaging may be superior (Connolly, 2012; Smith, 2015).
Treatment of subarachnoid hemorrhage includes bed rest, analgesia, and sedation, with neurological monitoring and strict blood pressure control. Repair of a potentially accessible aneurysm during pregnancy depends in part on the risk of recurrent hem orrhage versus the surgical risks. At least in nonpregnant patients, the risk of subsequent bleeding with conservative treatment is 20 to 30 percent for the irst month and then 3 percent per year.
The risk of rebleeding is highest within the irst 24 hours, and recurrent hemorrhage leads to death in 70 percent.
Early repair after the sentinel hemorrhage is done by surgi cal clipping of the aneurysm. Also, an endovascular coil can be placed using luoroscopic angiography, while attempting to limit fetal radiation exposure. Barbarite and colleagues (2016) report lower complication rates with coil embolization than clipping. For unruptured aneurysms, surgical management resulted in a third fewer complications than no treatment. For gravidas remote from term, repair without hypotensive anes thesia seems optimal. For women near term, cesarean delivery followed by aneurysm repair is a consideration, and we have successfully done this in several cases.
For aneurysms repaired either before or during pregnancy, mal repair. Problems arise in defining "remote," and although some recommend 2 months, the time for complete healing is unknown. For women who survive subarachnoid hemor rhage, but in whom surgical repair is not done, we agree with another way, we favor cesarean delivery.
Arteriovenous Malformations. hese are congenital focal abnormal conglomerations of dilated arteries and veins with sub arteriolar disorganization (see Fig. 60-2). hey lack capillaries and have resultant arteriovenous shunting. Although unclear, the risk of bleeding may rise with gestational age. When arteriovenous malformations (A VMs) bleed, half do so into the subarachnoid space, whereas half are intraparenchymal with subarachnoid extension (Smith, 2015). hey are uncommon and are estimated to occur in 0.01 percent of the general population. Of 65 identiied cases of A VM in pregnancy, 83 percent ruptured during pregnancy or postpartum, and more than 80 percent of these ruptured in the second or third trimester. Hemorrhage upon presentation is associated with poor maternal outcome (Lu, 2016).
Bleeding does not appear to be more likely during pregnancy. lthough these malformations are correspondingly rare during pregnancy, A VM bleeding accounted for 17 percent of hemorrhagic strokes in one study (Yoshida, 2017). At Parkland Hospital in a 33-year period during which there were about 466,000 births, 57 women had a CVA, and five of these strokes were due to a bleeding A M (Simolkie, 1991; Zokie, 2018).