A Systematic Review of Intracranial Aneurysms in the Pregnant Patient ― A Clinical Conundrum

•Coil embolization is safe to treat intracranial aneurysms in pregnant patients.•Pregnant patients with >10 mm unruptured intracranial aneurysm should be treated.•Ruptured intracranial aneurysm treatment takes priority over obstetrical concerns.•C-section is suggested for all patients with intracranial aneurysms.•Aneurysms during pregnancy require a multidisciplinary treatment approach. Hemodynamic and hormonal changes during pregnancy can increase rates of formation, growth, and rupture of intracranial aneurysms (IA), and the increased incidence of subarachnoid hemorrhage (SA) in pregnant patients represents a risk to both mother and fetus. Despite this, management and treatment guidelines have not been defined for this patient population. In most instances, treatment decisions are made on a case-by-case basis with varying degrees of input from subspecialists. Important considerations, such as aneurysm location, morphology, size, growth pattern, and patient characteristics have not been presented in a management algorithm in the context of the pregnant patient. Given limited and controversial literature describing management of IAs in pregnant patients, we performed a systematic literature review. We then describe our multidisciplinary team approach and provide analysis of existing literature to provide guidelines for the management of the pregnant patient with an IA. A systematic review was undertaken to identify studies describing the management of IAs in the pregnant patient using the PubMed database. Overall maternal and fetal morbidity and mortality rates were determined. Data was analyzed for 1537 patients, including 1115 (73%) pregnant with ruptured intracranial aneurysms. In most cases, these aneurysms were managed conservatively (77%; 781/1013); however, when treatment was provided, surgical clipping was the most common modality (15%; 149/1013). Overall maternal outcomes were reported for 934 cases with morbidity and mortality rates of 5% (42/934) and 21% (194/934), respectively. Overall fetal outcomes were reported for 114 cases with morbidity and mortality rates of 10% (12/119) and 8% (9/119), respectively. Pregnancy-associated physiological changes likely elevate the risk of intracranial aneurysm formation, growth, and rupture. Treatment for aneurysms and SAs is safe and effective during pregnancy when risks are properly mitigated. Due to the complexity of care, such patients should be treated using a collaborative, interdisciplinary approach