Background: Cranial arteriovenous malformations (AVM) are vascular anomalies that result in shunting between small arteries and veins in cerebral or cerebellar circulation and can present clinically either as intracranial haemorrhage, focal neurologic deficits or seizures1, 2. The risk of re- rupture throughout pregnancy is estimated at 3,5%1, 3, but it should be emphasized that intrapartum intracranial haemorrhage is responsible for 5-12% of obstetric mortality overall.

Case report: 30-year-old, ASA 3 female patient with an occipital AVM discovered 7 years before during the medical workup of headache. She underwent 3 embolization attempts, the last of which 5 years before (with a consequent decrease in the size of the AVM), maintaining follow-up as an outpatient. She was admitted at 39 weeks+4 days into her pregnancy for an elective caesarean section, with a spinal block being performed at the L3-L4 interspace, allowing for continued neurologic monitoring in the intraoperative period. The patient remained hemodynamically stable, with no neurologic changes, and the postoperative period was uneventful, allowing discharge on the 4th postoperative day.

Discussion: In these patients marked changes in blood pressure and Valsalva maneuvers should be avoided. General anaesthesia is considered especially troublesome in the emergence period1, not only due to blood pressure changes but also for the possibility of nausea, vomiting and reacting to the presence of the endotracheal tube.
Approaches to the neuroaxis may also lead to important haemodynamic changes, but as an added advantage allow for continued neurologic monitoring as the patient remains awake during surgery. Some authors uphold the use of an epidural block to allow for a more progressive block installation. However, the risk of dural puncture with an 18G epidural needle and subsequent loss of CSF with potential change in ICP has been described in the literature, leading us to ellect a spinal block, performed at the L3-L4 interspace with a 27G Sprotte needle. ICU vacancy was secured, but not used.

Learning points: Neurosurgical consult and timely preparation of both obstetricians and anaesthesiologists are of paramount importance in the management of these patients. Although the anaesthesiologist should choose a technique with which he/she is confortable, special attention should be paid to avoiding haemodynamic instability and Valsalva manoeuvres, as well as ensuring adequate neurologic monitoring.

My pregnant patient proposed for a C-section has a history of intracranial arteriovenous malformation... what now?