Ruptured Brain Arteriovenous Malformation (AVM) Diagnosed During Pregnancy

It may feel like the “worst headache of your life,” say Baptist Health neurologists about what happens when someone suffers a ruptured brain arteriovenous malformation, or AVM. For Jessica Velandia, 33 and pregnant at the time, that headache hit last June while she was driving to the hair salon on an otherwise normal day for an otherwise healthy expectant mom.

“I was in my car and I experienced a strong headache, and I’m usually not one to experience headaches, let alone migraines,” recalls Mrs. Velandia, who was born in Fort Lauderdale and who lived in Boca Raton at the time with her husband and two young boys. “I really felt like it was a migraine because it was like a headache that I had never experienced before. It was so strong that it started to affect my right eye.”

Mrs. Velandia called her obstetrician (OB) for advice and was instructed to immediately go to the nearest emergency room. “I was terrified. I didn’t know if I would come home that night. I didn’t know how long they were going to keep me,” says Mrs. Velandia. “It was emergency mode all around me. I was worried and I felt alone too.” She called her husband who was in Europe on business and he immediately got on the next plane and was by her side the next day.

(Watch now: Jessica Velandia recalls what it was like suffering a hemorrhage, or brain bleed, when she was just weeks away from delivering her baby. Video by Michael Justiz.)

It’s always the right move to seek urgent medical attention with the unexpected and sudden onset of severe headache because it may represent a serious medical condition, such as a brain bleed, or hemorrhage, says Guilherme Dabus, M.D., co-director of interventional neuroradiology and vice-chief of the department of neuroscience at Baptist Health Miami Neuroscience Institute.

Guilherme Dabus, M.D., co-director of interventional neuroradiology and vice-chief of the department of neuroscience at Baptist Health Miami Neuroscience Institute

A CAT scan revealed that Mrs. Velandia did indeed have a hemorrhage on the left occipital region, at the very back of her brain. “Because of our specialties within neurosurgery and neuroradiology, we were able to identify that the actual cause of her bleed was an AVM,” Dr. Dabus says.

A tangle of veins and arteries

“Mrs. Velandia was 33 weeks pregnant when she had the hemorrhage, which was caused by a rare condition known as a brain arteriovenous malformation,” says Robert Wicks, M.D., co-director of cerebrovascular surgery and director of the Neurosurgical Anatomy Laboratory at Miami Neuroscience Institute. “AVMs are actually quite rare. They’re basically a tangle of arteries and veins within the brain that are very fragile and therefore are prone to causing a hemorrhage.”

Robert Wicks, M.D., co-director of cerebrovascular surgery and director of the Neurosurgical Anatomy Laboratory at Miami Neuroscience Institute

Treating two patients, not one

Being pregnant further complicated matters for Mrs. Velandia’s treatment. “One of the challenges of treating a brain hemorrhage in a pregnant patient is you have to remember that you’re actually treating two patients,” says Dr. Wicks. “You want to fully evaluate the cause of the hemorrhage, but you also want to limit any potential injury to the baby from different tests or imaging studies, some of which have require very low doses of radiation.”

Mrs. Velandia says she and her OB both were worried about her baby and were all for delaying her treatment a month or so. “My OB was really fighting for them to wait until my baby was 37 weeks so she could be delivered safely at full term,” she says, adding that her pregnancy precluded her from having an angiogram, a crucial first step in her treatment.

An angiogram is considered the gold standard for evaluating the possible causes of brain hemorrhage by using X-rays, computed tomography angiography (CTA), or magnetic resonance angiography (MRA), Dr. Wicks explains.

“We don’t want to put undue stress on the mother or the baby, so if we’re able to fully evaluate the cause of the hemorrhage but delay treatment until after the pregnancy, then that’s the path we usually choose,” says Dr. Wicks. Mrs. Velandia gladly accepted her care team’s recommendations that treatment for her AVM take place after delivery.

Mrs. Velandia delivered a healthy baby girl on July 13 and once she was cleared for the procedure, Dr. Dabus performed the angiogram – a diagnostic cerebral angiography, as it is called in this case – to get a clear picture of what was going on in his patient’s brain.

“This is a catheter-based procedure which allowed us to map out the vessels in her brain and determine what her AVM really looks like,” Dr. Dabus explains. “We needed to know what was feeding it, how it was draining and where exactly it was located. Only then could we come up with the best plan for treatment.”

Treating AVMs takes a team

Once the AVM in Mrs. Velandia’s brain was identified, Dr. Wicks and Dr. Dabus discussed treatment options with their patient. According to Dr. Wicks, treating an AVM requires a multidisciplinary team of neurologists, neurosurgeons and neuroradiologists. Working together, they can determine which approach is safest for the patient and offers the best possible outcome.

“Treatment of AVMs is quite complex, so we take a multi-step approach,” notes Dr. Wicks. “One potential risk of operating on AVMs is that, because they’re so fragile, they can easily rupture and cause massive bleeding.”

Considering Mrs. Velandia’s young age, how her AVM looked and where it was located, it was agreed that a two-step procedure would provide the best outcome. The first procedure, performed by Dr. Dabus on September 22, was an embolization to decrease the risk of bleeding during the surgery that followed.

“An embolization is a catheter-based surgery performed under general anesthesia where we go in very close to where the AVM is located, using tiny plastic tubes called microcatheters, and then we inject a type of medical glue to block off some of those vessels,” Dr. Dabus says. “It’s not always possible to completely close off these vessels but in this case, we were able to decrease blood flow to the AVM by about 50 percent.”

The procedure is not without risks, Dr. Dabus adds, and requires great expertise. “When you insert the microcatheter you can easily perforate a vessel and rupture it, so you need to be very careful.”

Surgically removing the AVM

Mrs. Velandia’s embolization was followed the next day by a craniotomy, performed by Dr. Wicks, to surgically remove her AVM. Using microscopic and imaging guidance, he took a step-by-step approach in order to limit any blood loss or injury to her brain and was able to resect the AVM. A follow-up angiogram confirmed that the surgery was successful and that Mrs. Velandia’s AVM was gone.

“We were able to address her AVM, both from an endovascular and a neurosurgical standpoint, and safely treat the AVM and allow her to have a full recovery without any significant long-term deficits,” Dr. Wicks says. “Today, she’s back to normal activities and taking care of her baby and her family. For us, that’s a great outcome.”

Enjoying family life to the fullest now

“My recovery was rough,” admits Mrs. Velandia, who experienced headaches, dizziness and other side effects for a while following her surgery. “Physically, it was really hard. The headaches were very strong and would come and go. I would feel dizzy, too. But at the same time, I was feeling so much relief and gratitude that everything turned out great and that I was perfectly fine, miraculously.”

Now, Mrs. Velandia says, her life is back to normal. “I feel great, completely normal. Sometimes I even forget that all of this is going on, and then randomly I’ll see the scar. I’ll feel the scar, and then I remember that, oh, I’m still recovering from a major surgery.”

In addition to the multidisciplinary teamwork at Miami Neuroscience Institute, Dr. Wicks credits Mrs. Velandia’s strength and courage for playing a role in her successful outcome.

“What’s really impressed me about Mrs. Velandia is how strong she is. She was able to go through pregnancy, make it through the hemorrhage with a full recovery, have a healthy baby, and then she was able to go through a very complex treatment and make a full recovery,” Dr. Wicks says. “She’s had great courage throughout this entire treatment and I think that’s really been key to her success.”

As for Mrs. Velandia, the grateful patient says she can now focus on her growing family, which recently relocated to Venezuela for her husband’s work. “I’m looking forward to just kind of leaving this in the past and enjoying my life to the fullest, enjoying my family,” she says. “Thankfully I’m okay and my baby’s okay. I see myself with my kids for the long future.”