This case is of a 32-year-old woman with an insignificant medical history and family history. In addition, she has no history of hypertension, cerebral arteriovenous malformation, and stroke. She also does not smoke, use drugs, or alcohol. Her obstetric history revealed three spontaneous vaginal deliveries previously and gestational diabetes mellites in her last previous pregnancy.
Moreover, her current pregnancy was uneventful till her presentation. She suddenly developed a severe headache and loss of vision in her left eye at the 31st week and 3rd day of gestation. Hence, she sought medical advice from an ophthalmologist. she described the nature of her headache as throbbing and on the left side. According to the Numerical Rating Pain Scale, it was 10/10. Furthermore, coughing and lying down exacerbated the pain, associated with photophobia. However, prior to the episodes, she experienced the headaches for many years with a frequency of thrice or four times a week.
Doctors described the monocular left visual loss as complete blindness. Physical examination revealed that the visual acuity of the left eye was poor. Her light perception was intact, but she could not identify hand movement and count fingers. Moreover, the right eye visual fields and visual acuity were intact.
Diagnosis
Doctors performed an MRI of the brain that confirmed a right parieto-occipital AVM, causing subarachnoid haemorrhage. Her left monocular visual loss may not be explained completely by her right parieto-occipital arteriovenous malformation. Since the pathology of the right occipital lobe typically causes a left homonymous hemianopia visual defect and not monocular visual loss.
Upon referral to the ophthalmologist, there was no obvious intraocular pathology. Given her stable neurological status and stable fetus status, doctors treated her conservatively and discharged her after three days. Moreover, she was then transferred to an institution for care.
Treatment and Follow Up
At 36 weeks and 5 days of gestation, she complained of worsened headache. CT scan revealed no cute bleeding. However, her headache concerns continued to persist and become worse. Moreover, a repeat of the CT imaging was challenging due to radiation risks to the fetus.
Given the gestational age and steroid treatment completion, doctors decided to deliver LSCS under regional anaesthesia the next morning. The delivery wasn’t complicated, and the fetus was delivered at 34 weeks and 6 days.
Post-operative CT of the brain did not show any intracranial haemorrhage. After returning to the neurosurgical intensive care unit for post-op recovery, she underwent a gamma knife procedure for AVM for six days.
