Ruptured Cerebral Arteriovenous Malformation Initially Managed As Presumed Eclampsia: A Diagnostic Challenge Following Initial Management in a Resource-Limited Setting

Seizures occurring during late pregnancy frequently raise immediate concern for eclampsia. However, persistent neurological deterioration despite definitive obstetric management should prompt consideration of alternative intracranial pathology. Cerebral arteriovenous malformations (AVMs) are uncommon vascular lesions that may rarely present during pregnancy with intracerebral hemorrhage and seizures. We report the case of a 31-year-old gravida 3 para 2 woman at 36 weeks of gestation with a history of two previous uncomplicated lower-segment cesarean sections who presented with generalized tonic-clonic convulsions followed by depressed consciousness (Glasgow Coma Scale score E2V1M2) and a blood pressure of 160/90 mmHg. Presumed eclampsia was diagnosed, and emergency lower-segment cesarean section was performed. Despite delivery, seizures persisted with poor neurological recovery. Computed tomography of the brain demonstrated a large left intracerebral hemorrhage with significant mass effect and midline shift, necessitating emergency decompressive craniectomy and hematoma evacuation. As neurological improvement remained unsatisfactory, further vascular evaluation was undertaken. Computed tomography angiography identified a cerebral AVM supplied predominantly by branches of the left middle cerebral artery, with venous drainage through the superior anastomotic vein (vein of Trolard) into the superior sagittal sinus. Digital subtraction angiography confirmed the diagnosis, and endovascular embolization achieved approximately 85% reduction of the AVM nidus. The patient remained seizure-free, demonstrated progressive neurological recovery, and was discharged with a Glasgow Coma Scale score of 15. Follow-up showed independent ambulation, improvement in motor function, and no recurrent neurological events. This case highlights the diagnostic challenges encountered in resource-limited settings, where eclampsia is frequently the initial working diagnosis for seizures during late pregnancy. Failure of neurological recovery in a young adult after appropriate obstetric management should prompt urgent neuroimaging and consideration of alternative intracranial pathology. Definitive diagnosis followed by multidisciplinary management resulted in progressive neurological improvement.