"One-shot" endovascular management of cerebral aneurysm and fourth ventricle hemangioblastoma in a pregnant woman

Abstract

Aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy is a serious condition [1]. The bestmanagement of aSAHduring pregnancy is not yet established, although endovascular coiling has gained favor over the last few years [2]. The incidence of hemangioblastoma of the posterior fossa in pregnancy is extremely low [3]. Apregnantwomanpresented to the “Maggiore della Carita”Hospital in December 2009 having experienced sudden onset seizures and deterioration of consciousness at 27 weeks of pregnancy. The patient’s systemic blood pressurewas 100/50mmHg and eclampsiawas therefore excluded. CT and MRI scans showed subarachnoid hemorrhage, blood in the lateral ventricles, and ventricular dilation (Fig. 1). The fourth ventricle was occupied by a small mass—with hyperintense nodule enhancement on T2weighted imaging after gadolinium injection—rounded by a small cyst with ring enhancement. MR angiography revealed a subarachnoid aneurysm arising from the right internal carotid artery. The patient underwent digital subtraction angiography that confirmed the presence of a subarachnoid aneurysm of the right internal carotid artery and a hypervascularized nodule with arteriovenous shunt in the posterior fossa, fed by the posterior and anterior inferior cerebellar artery—consistent with hemangioblastoma. Following consultation with neurosurgeons, anesthesiologists, obstetricians, and neuroradiologists, the decision to immediately treat both lesions by an endovascular approachwas taken. Before themedical procedure, the patient was advised about the potential risks and benefits of the intervention and she provided informed consent. To begin, the posterior inferior cerebellar artery to the hemangioblastoma was navigatted with a flow-directed microcatheter to reach the hypervascularized nodule. Then, 0.7 mL of a mixture of glue diluted to 20% in Lipiodol (Guerbet, Bloomington, IN, USA) was injected into the nidus, followed by complete angiographic devascularization of the lesion (Figs. 2, 3). Immediately after, the aneurysm was coiled with three platinum bare coils. The procedure was uneventful. CT scan performed 24 hours after the procedure showed ventricular shrinking to a normal size (Fig. 4). The patient had good clinical status, with a Glasgow Coma Scale score of 14. At 38 weeks of pregnancy the patient was admitted for a scheduled cesarean delivery, resulting in the successful birth of a healthy neonate weighing 3220 g and with an International Journal of Gynecology and Obstetrics 129 (2015) 79–88