Treatment challenges of ruptured intracranial aneurysms during pregnancy: A case record and review of the literature

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy is a rare but serious complication associated with significant maternal and fetal morbidity and mortality. Due to a limited number of published cases, development of guidelines for the management of aSAH in pregnant women has proven difficult. In the present article, we present a case and review the available literature on patients with aSAH during pregnancy. Research question: What is the optimal management of aSAH during pregnancy? Material and methods: We describe the case of a pregnant woman with aSAH. In addition, a search of the PUBMED database was conducted to collect all pertinent case reports of aSAH in pregnant women published since 1990. Results: A 36 years old Caucasian primigravid woman in the 37th GW presented to our department with aSAH, due to rupture of a saccular basilar tip aneurysm. After multidisciplinary discussion, a Caesarian section (CS) and subsequent aneurysm treatment by endovascular coiling were performed without complications. On day four after ictus endovascular spasmolysis were initiated as the patient developed angiographic cerebral vasospasm and delayed cerebral ischemia (DCI). Two days later, brain tissue hypoperfusion was further aggravated by cardiopulmonary failure under induced hypertension, so that the patient died on day seven from severe cerebral infarction. Discussion and conclusion: While there are still no formal studies that could guide the optimal management of aSAH during pregnancy, primary CS prior to definitive management of ruptured aneurysms during the third trimester seems to be the safest treatment approach for both mother and child.