Cerebral vascular malformations in pregnancy: Considerations for diagnosis and management

Cerebral vascular malformations comprise a diverse set of pathologies ranging from high-flow arteriovenous malformation and fistula to cavernous malformations and capillary telangiectasia. While rare, vascular malformations occurring during pregnancy present a unique challenge for diagnosis and management due to the need to balance both maternal and fetal well-being. Historically, concern regarding increased risk of rupture and hemorrhage of cerebral vascular malformations has led to the counseling of women with such lesions against pregnancy and vaginal delivery. However, this has been refuted by the results of more recent studies. The presence of a cerebral vascular malformation should not be a contraindication to pregnancy; however, preconception treatment should be performed for high-risk lesions. Identification of a lesion during pregnancy should be treated based on neurosurgical indications. Finally, in women with unruptured, lower risk malformations, vaginal delivery with precautions to minimize undue stress appears to be safe. However, in untreated, higher risk lesions and those that have ruptured, we recommend delivery via cesarean section. Decision making in this setting should follow that of all medical decisions: minimizing risks of harm while maximizing the benefit for the patient.