Graded Epidural Anaesthesia for Caesarean Section in the Presence of an Untreated Spetzler-Martin Grade V Cerebral Arteriovenous Malformation With Radiological Progression Over Six Years: A Case Report.
A 33-year-old woman with an untreated cerebral AVM successfully underwent a Caesarean section using a graded epidural technique, with no reported complications.
Where it sits
this study against the rest of the carbetocin corpusSummary and findings
This case report discusses a 33-year-old woman with an untreated cerebral arteriovenous malformation (AVM) who underwent an elective lower-segment Caesarean section using a graded epidural technique. Carbetocin was administered as the uterotonic agent. The mother and infant were reported to be healthy post-procedure.
Abstract
Cerebral arteriovenous malformations (AVMs) are rare during pregnancy, when the haemodynamic and hormonal changes of gestation may increase the risk of rupture. Lesions that are large, located in eloquent regions, and drained by deep venous channels represent a surgically high-risk subtype, carry substantial surgical morbidity, and are frequently managed conservatively when unruptured. We describe a 33-year-old G3P1L1A1 parturient at 36 weeks and six days of gestation with an untreated right parieto-temporo-occipital AVM, who declined intervention across three encounters and underwent an elective lower-segment Caesarean section (LSCS) with bilateral tubal ligation. The anaesthetic approach chosen was a graded epidural technique: fractionated bupivacaine boluses with real-time haemodynamic monitoring between increments. This allowed the rate of sympathectomy to be controlled, avoiding the abrupt sympathectomy associated with a subarachnoid block. Carbetocin was used as the uterotonic agent. Levetiracetam was continued perioperatively. A healthy male infant was delivered, and the mother was discharged neurologically intact on day seven, with no AVM rupture, seizure, or new deficit.
Background
Cerebral arteriovenous malformations (AVMs) during pregnancy are rare and can pose significant risks due to hormonal and hemodynamic changes. Previous literature indicates that large AVMs in eloquent regions are often managed conservatively to avoid surgical morbidity. This case report is significant as it explores the management of a high-risk patient during a Caesarean section, contributing to the understanding of anaesthetic approaches in similar cases.
Methods
This is a case report detailing the management of a single patient. The patient was a 33-year-old woman at 36 weeks and six days of gestation with an untreated right parieto-temporo-occipital AVM. The anaesthetic approach involved graded epidural anaesthesia with fractionated bupivacaine boluses, and the patient underwent an elective lower-segment Caesarean section.
Results
A healthy male infant was delivered, and the mother was discharged neurologically intact on day seven. There were no reported incidents of AVM rupture, seizure, or new neurological deficits.
Interpretation
The findings suggest that graded epidural anaesthesia can be a viable option for patients with untreated AVMs undergoing Caesarean sections. However, the lack of quantitative data and the single-case nature of this report limit the ability to draw broader conclusions. Further studies are needed to evaluate the safety and efficacy of this approach in larger populations.
Key findings
- 33-year-old G3P1L1A1 parturient at 36 weeks and six days of gestation.
- Healthy male infant delivered.
- Mother discharged neurologically intact on day seven.
- No AVM rupture, seizure, or new deficit reported.
Limitations
- Single-case report limits generalizability.
- No quantitative data on outcomes or complications provided.
- Lack of control group for comparison.