Stroke and pregnancy: clinical presentation, evaluation, treatment, and epidemiology

Evaluation of stroke in pregnant and non-pregnant women of reproductive years: A multicenter ambispective cohort study in a low- to middle-income country

Objective

Early recognition of stroke symptoms and risk factors is important for timely intervention to improve outcomes. This study aimed to investigate differences in stroke frequency, risk factors, and presentation in pregnant and non-pregnant women of reproductive years.

Methods

This multicenter ambispective cohort study, conducted from 4th August 2021 to 4th March 2023, examined strokes in women of reproductive years at the neurology outpatient/emergency department of five busiest/referred neuro-medical facilities in Karachi, Pakistan, where patients from across the nation are assessed. In all, 1210 patients were enrolled via consecutive or convenient sampling retrospectively from January 2017 to August 2021 and prospectively from August 2021 to March 2023. Pregnancy-related and non-pregnancy-related stroke occurrence and characteristics were compared using the chi-square/Fischer's exact test.

Results

56% were non-pregnancy-related strokes and 44% were pregnancy-related strokes with non-pregnancy-related strokes approximately equal throughout the reproductive years (15-24 years = 34%, 25-34 years = 25%, 35-45 years = 41%) and pregnancy-related stroke between 15 and 35 years (82%). In the non-pregnancy-related stroke, arterial stroke dominated (96.4%); while in pregnancy-related stroke, arterial stroke accounted for 61.4% and venous stroke for 38.6% of cases. Middle cerebral artery was a typical stroke site (66%). Infarction was the most significant CT/MRI finding (PRS = 89%, NPRS = 66%), with pregnancy-related stroke hemorrhagic stroke occurring in only 11% of cases and non-pregnancy-related stroke comprising one-third (34%). The most prevalent etiologies were eclampsia in pregnancy-related stroke (32%), hypertension in non-pregnancy-related stroke (40%), and cardiac problems among both groups (25%:33%). Weakness and headache were the common clinical manifestations among both groups. In the pregnancy-related and non-pregnancy-related stroke groups, the initial presentation of stroke resulted in severe disability for 91% and 75%, respectively. With timely treatment, the outcome improved significantly. The mortality rate was 7% for the pregnancy-related stroke group and 4% for the non-pregnancy-related stroke group.

Conclusions

Our findings show that stroke is prevalent among reproductive-year women, posing a significant mortality risk if not adequately recognized and treated. Awareness, research, and screening of stroke risk factors and their often-overlooked early presentation (i.e., headache and weakness) in reproductive years are essential to reducing stroke occurrence among reproductive-year women.

Hypertensive disorders of pregnancy in moyamoya disease: A single institution experience

OBJECTIVE

The characteristics of pregnancy and delivery in patients with moyamoya disease (MMD) remain unclear. We retrospectively investigated perinatal outcomes in patients with MMD to evaluate the risks associated to this condition.

MATERIALS AND METHODS

Clinical data of women with MMD who delivered at the University of Tokyo Hospital between 2000 and 2021 were collected. Maternal characteristics including genetic data, obstetric complications, method of delivery and anesthesia, neonatal outcomes, neurological events during pregnancy, delivery, and postpartum course, were reviewed.

RESULTS

Thirteen pregnancies with MMD were identified. The median maternal age was 30 years. The initial clinical symptoms were identified as transient ischemic attack, infarction, and headache. Eight patients had a history of bypass surgery. The median gestational age at delivery was 37 weeks. DNA samples were collected from five patients, responsible for six pregnancies. Of these six cases, five had the RNF213 c.14429G > A (p.Arg4810Lys) heterozygous variant. Of the 13 pregnancies, seven had hypertensive disorder of pregnancy (HDP). Additionally, three of five pregnancy cases with RNF213 p.Arg4810Lys heterozygous variant presented with HDP. Nine patients underwent cesarean section, and four delivered vaginally with epidural anesthesia. One case of ischemic stroke was confirmed during the postpartum period. Regarding newborns, neither Apgar scores lower than 7 nor neonatal intensive care unit admissions were reported.

CONCLUSIONS

This study suggests that the frequency of HDP is higher in patients with MMD compared to those with normal pregnancies. Strict blood pressure control should be performed in patients with MMD during pregnancy and postpartum period.

Secondary headaches in pregnancy and the puerperium

Headache during pregnancy can be due to primary causes such as migraine but can also be a presenting symptom of secondary causes including life threatening conditions. This is a minireview of secondary causes of headache during pregnancy and the puerperium. Unique alterations in physiological and vascular functions as well as in the coagulation pathway which occur during pregnancy increase the risk of most of these secondary conditions which include preeclampsia, eclampsia, hemorrhagic stroke, cerebral venous, sinus thrombosis, reversible cerebral vascular syndrome, and posterior reversible encephalopathy. Marked increase in progesterone level in pregnancy is also associated with the growth of tumors such as meningiomas, as 70% of these tumors are positive for progesterone receptors and increase in size can lead to headache along with other neurological symptoms. Hemodynamic changes can lead to the growth of meningiomas as well. Although hormone producing pituitary tumors are usually not conducing to pregnancy, women with known pituitary tumors who do get pregnant may become symptomatic during pregnancy and develop secondary headache. Another rare cause of secondary headache during pregnancy is pituitary apoplexy. Although its occurrence is uncommon, it needs to be properly recognized and treated to avoid endocrine and visual complications. Other rare entities with increased incidence during the puerperium such postdural puncture headache will be also discussed. In summary, new onset headache during pregnancy deserves special attention because in the absence of proper recognition and treatment, secondary headache disorders can endanger the life of the mother and the fetus.

Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy

Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.

Pregnancy-related stroke through a neuropsychology lens

Objective: Stroke represents a primary cause of morbidity and mortality in pregnant and postpartum people. While pregnancy-related stroke has drawn increased attention in certain domains of health research (e.g. obstetrics, neurology), neuropsychology has yet to contribute to this literature. Given neuropsychologists' crucial role in stroke evaluation and rehabilitation efforts, our field is poised to offer insights into this important topic. Method: This review presents facts about pregnancy-related stroke most relevant for neuropsychologists, including epidemiology, risk factors, and mechanisms, alongside clinical considerations and open areas of inquiry. Structured in the format of a traditional neuropsychological evaluation, we walk readers through factors to consider in record review, the clinical interview, and providing feedback and recommendations. Conclusions: Pregnancy-related stroke can be associated with marked functional disability and decreased quality of life, and it is notable that prevalence rates are increasing. Presenting at a time when people are experiencing adjustment to a new phase of life, and most commonly affecting women of color and other vulnerable populations, pregnancy-related stroke is a unique condition warranting special attention within the broader stroke discourse. This review aims to serve as a starting point for neuropsychologists to better understand the unique attributes of pregnancy-related stroke through a neuropsychology lens. Beyond that, it aims to promote broader meaningful discussion of neuropsychology's role in women's health.

Transient ischemic attack after mRNA-based COVID-19 vaccination during pregnancy: A case report

BACKGROUND

Thrombocytopenia with thrombosis syndrome has been reported after vaccination against severe acute respiratory syndrome coronavirus 2 with two mRNA vaccines. The syndrome is characterized by thrombosis, especially cerebral venous sinus thrombosis, and may lead to stroke. Pregnant women with stroke show higher rates of pregnancy loss and experience serious pregnancy complications. We present the case of a 24-year-old pregnant woman with a transient ischemic attack (TIA) that developed after vaccination with the Moderna mRNA-1273 vaccine (at 37 2/7 wk).

CASE SUMMARY

TIA occurred 13 d following the coronavirus disease vaccination. At 39 1/7 wk of pregnancy, the patient presented with sudden onset of right eye blurred vision with headache, dizziness with nausea, right-hand weakness, anomia, and alexia. The symptoms lasted 3 h; TIA was diagnosed. Blood test results revealed elevated D-dimer, cholesterol, and triglyceride levels. Brain magnetic resonance imaging showed no acute hemorrhagic or ischemic stroke. At pregnancy 37 6/7 wk, she was admitted for cesarean delivery to reduce subsequent risk of stroke during labor. Body mass index on admission was 19.8 kg/m². Magnetic resonance angiography and transesophageal echocardiography showed no abnormalities. The next day, a mature female baby weighing 2895 g and measuring 50 cm was delivered. Apgar scores were 8 and 9 in the first and fifth minutes. D-dimer levels decreased on postoperative day 4. After discharge, the autoimmune panel was within normal limits, including antinuclear and antiphospholipid antibodies.

CONCLUSION

TIA might be developed after the mRNA vaccines in pregnant women.

Pregnancy-Related Stroke: A Review

Importance

The maternal risk of strokes in the United States is approximately 30/100,000 pregnancies, and strokes are the eighth leading cause of maternal death. Because of the relationship between stroke and significant neurological disability/maternal death, obstetrical health care providers must be able to identify, evaluate, diagnosis, and treat these women.

Evidence Acquisition

PubMed was searched using the search terms "stroke" OR "cerebrovascular accident" OR "intracranial hemorrhage" AND "pregnancy complications" OR "risk factors" OR "management" OR "outcome." The search was limited to the English language and was restricted to articles from 2000 to 2020.

Results

There were 319 abstracts identified, and 90 of the articles were ultimately used as the basis of this review. Presenting stroke signs and symptoms include headache, composite neurologic defects, seizures, and/or visual changes. Diagnosis is typically made with computed tomography scan using abdominal shielding or magnetic resonance imaging without contrast. Management options for an ischemic stroke include reperfusion therapy with intravenous recombinant tissue plasminogen activator catheter-based thrombolysis and/or mechanical thrombectomy. Hemorrhagic strokes are treated similarly to strokes outside of pregnancy, and that treatment is based on the severity and location of the hemorrhage.

Conclusions and Relevance

Early recognition and management are integral in decreasing the morbidity and mortality associated with a stroke in pregnancy.

Relevance Statement

This study was an evidence-based review of stroke in pregnancy and how to diagnose and mange a pregnancy complicated by a stroke.

Early Pregnancy Blood Pressure Patterns Identify Risk of Hypertensive Disorders of Pregnancy Among Racial and Ethnic Groups

BACKGROUND

Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality and confer 4-fold higher perinatal mortality in Black women. Early pregnancy blood pressure patterns may differentiate risk of hypertensive disorders of pregnancy.

METHODS

This study identified distinct blood pressure trajectories from 0 to 20 weeks' gestation to evaluate subsequent pregnancy-related hypertension in a retrospective cohort of 174 925 women with no prior hypertension or history of preeclampsia, prenatal care entry ≤14 weeks, and a stillborn or live singleton birth delivered at Kaiser Permanente Northern California hospitals in 2009 to 2019. We used electronic health records to obtain clinical outcomes, covariables, and longitudinal outpatient blood pressure measurements ≤20 weeks' gestation (mean 4.1 measurements). Latent class trajectory modeling identified 6 blood pressure groups: ultra-low-declining(referent), low-declining, moderate-fast-decline, low-increasing, moderate-stable, and elevated-stable. Multivariable logistic regression evaluated trajectory group-associations with the odds of preeclampsia/eclampsia and gestational hypertension' and effect modification by race-ethnicity and prepregnancy body size.

RESULTS

Compared with ultra-low-declining, adjusted odds ratios (95% confidence intervals [CIs]) for low-increasing, moderate-stable, and elevated-stable groups were 3.25 (2.7-3.9), 5.3 (4.5-6.3), and 9.2 (7.7-11.1) for preeclampsia/eclampsia' and 6.4 (4.9-8.3), 13.6 (10.5-17.7), and 30.2 (23.2-39.4) for gestational hypertension. Race/ethnicity, and prepregnancy obesity modified the trajectory-group associations with preeclampsia/eclampsia (interaction P<0.01), with highest risks for Black, then Hispanic and Asian women for all blood pressure trajectories, and with increasing obesity class.

CONCLUSIONS

Early pregnancy blood pressure patterns revealed racial and ethnic differences in associations with preeclampsia/eclampsia risk within equivalent levels and patterns. These blood pressure patterns may improve individual risk stratification permitting targeted surveillance and early mitigation strategies.

Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Neurocritical care of the pregnant patient

INTRODUCTION

An estimated 0.1%-0.8% of obstetric patients require admission to an intensive care unit (ICU) during pregnancy or the puerperium. When neurologic emergencies occur in pregnancy, collaboration between the neurointensivist, obstetric anesthesiologist, and obstetrician is key in minimizing morbidity and mortality.

PRINCIPLES

Care of the critically ill pregnant patient mirrors that of the critically ill nonpregnant patient with some minor exceptions. Special care must be taken to consider the normal physiologic changes of pregnancy as well as possible fetal exposure to medical interventions. Timing and method of delivery must be carefully considered when caring for patients with neurologic emergencies. Common neurologic emergencies in pregnancy include hypertensive disorders of pregnancy, intracranial neoplasms, noneclamptic seizures, cerebrovascular disorders, and ventriculoperitoneal shunt malfunctions.

CONCLUSION

While neurologic emergencies in pregnancy are overall rare, when they do occur, they can be devastating. As in the nonpregnant population, prompt recognition and rapid intervention are crucial in optimizing patient outcomes. When neurologic emergencies occur in pregnancy, maternal and fetal care is optimized through a multidisciplinary care team.

A first trimester pregnancy with cerebrovascular accident treated with thrombolytic therapy: A case report

Pregnant patients are at increased risk of cerebrovascular accident due to the prothrombotic state of pregnancy. This risk is highest in those with pre-eclampsia and eclampsia as well as those of Asian descent. Despite this increased risk, pregnancy was an exclusion criterion for major stroke intervention trials. As a result, there are significant challenges concerning the management of this unique patient population. We describe a case of an early first trimester cerebrovascular accident treated with systemic thrombolysis.

Cerebrovascular disease in pregnancy and puerperium: perspectives from neuroradiologists

Pregnancy-related cerebrovascular disease is a serious complication of pregnancy and puerperium. The etiology and pathological mechanisms of cerebrovascular disease are complex, involving changes in the cardiovascular, endocrine, and immune systems. Vascular risk factors during pregnancy and puerperium may cause vasospasm and endothelial cell damage leading to cerebral ischemia, hemorrhage, posterior reversible encephalopathy syndrome (PRES), and reversible cerebral vasoconstriction syndrome. Arterial or venous obstruction may damage the blood-brain barrier (BBB) and impede venous return, resulting in cerebral edema, hemorrhage, and intracranial hypertension. Pregnancy with hypercoagulability may threaten the lives of both the mother and the developing fetus. With improvements in stroke treatment during pregnancy and puerperium, neuroradiologists have gained new insights into this problem. This article reviews the pathogenesis, imaging findings, and risk factors of stroke during pregnancy and puerperium, focusing on imaging diagnosis and prognostic assessment.

Stroke in pregnancy

Stroke in pregnancy is rare and has a wide range of etiologies and implications on stroke management that differ from nonpregnant individuals. The highest risk of stroke is during the third trimester and puerperium period, where hypertensive disorders of pregnancy occur; however, stroke can occur at any point during pregnancy. In this chapter, we will provide an overview of the epidemiology of stroke in pregnancy and then review the specific etiologies of ischemic and hemorrhagic stroke as they relate to pregnant women. Finally, we discuss the process of acute stroke evaluation in pregnancy and the management of women after stroke with regard to long-term risk factors, medications, and implications in future pregnancies. Throughout the chapter, we highlight relevant guidelines from the American Heart Association and American Stroke Association and key literature on stroke in pregnancy.

Acute Stroke During Pregnancy and Puerperium

BACKGROUND

Acute stroke during pregnancy or within 6 weeks of childbirth is devastating for the mother and her family, yet data regarding incidence and contemporary trends are very limited.

OBJECTIVES

This study sought to investigate the incidence and outcomes of acute stroke and transient ischemic attack during pregnancy or within 6 weeks of childbirth in a large database.

METHODS

The National Inpatient Sample was queried to identify women age ≥18 years in the United States with pregnancy-related hospitalizations from January 1, 2007, to September 30, 2015. Temporal trends in acute stroke (ischemic and hemorrhagic)/transient ischemic attack incidence and in-hospital mortality were extracted.

RESULTS

Among 37,360,772 pregnancy-related hospitalizations, 16,694 (0.045%) women had an acute stroke. The rates of acute stroke did not change (42.8 per 100,000 hospitalizations in 2007 vs. 42.2 per 100,000 hospitalizations in 2015; p_trends = 0.10). Among those with acute stroke, there were increases in prevalence of obesity, smoking, hyperlipidemia, migraine, and gestational hypertension. Importantly, in-hospital mortality rates were almost 385-fold higher among those who had a stroke (42.1 per 1,000 pregnancy-related hospitalizations vs. 0.11 per 1,000 pregnancy-related hospitalizations; p < 0.0001). The rates of in-hospital mortality among pregnant women with acute stroke decreased (5.5% in 2007 vs. 2.7% in 2015; p_trends < 0.001).

CONCLUSIONS

In this contemporary analysis of pregnancy-related hospitalizations, acute stroke occurred in 1 of every 2,222 hospitalizations, and these rates did not decrease over approximately 9 years. The prevalence of most stroke risk factors has increased. Acute stroke during pregnancy and puerperium was associated with high maternal mortality, although it appears to be trending downward. Future studies to better identify mechanisms and approaches to prevention and management of acute stroke during pregnancy and puerperium are warranted.

Temporal Trends in Pregnancy-Associated Stroke and Its Outcomes Among Women With Hypertensive Disorders of Pregnancy

Background

Stroke is a serious complication of hypertensive disorders of pregnancy (HDP), with potentially severe and long‐term sequelae. However, the temporal trends, predictors, and outcomes of stroke in women with HDP at delivery remain unknown.

Methods and Results

All HDP delivery hospitalizations with or without stroke event (ischemic, hemorrhagic, or unspecified) between 2004 and 2014 in the United States National Inpatient Sample were analyzed to examine incidence, predictors, and prognostic impact of stroke. Of 4 240 284 HDP delivery hospitalizations, 3391 (0.08%) women had stroke. While the prevalence of HDP increased over time, incident stroke rates decreased from 10 to 6 per 10 000 HDP delivery hospitalizations between 2004 and 2014. Women with stroke were increasingly multimorbid, with some risk factors being more strongly associated with ischemic strokes, including congenital heart disease, peripheral vascular disease, dyslipidemia, and sickle cell disease. Delivery complications were also associated with stroke, including cesarean section (odds ratio [OR], 1.58; 95% CI, 1.33–1.86), postpartum hemorrhage (OR, 1.91; 95% CI, 1.33–1.86), and maternal mortality (OR, 99.78; 95% CI, 59.15–168.31), independently of potential confounders. Women with stroke had longer hospital stays (median, 6 versus 3 days), higher hospital charges (median, $14 655 versus $4762), and a higher proportion of nonroutine discharge locations (38% versus 4%).

Conclusions

The incidence of stroke in women with HDP has declined over time. While a relatively rare event, identification of women at highest risk of ischemic or hemorrhagic stroke on admission for delivery is important to reduce long‐term sequelae.

Temporal Changes in Hypertensive Disorders of Pregnancy and Impact on Cardiovascular and Obstetric Outcomes

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity. However, short-term outcomes of HDP subgroups remain unknown. Using National Inpatient Sample database, all delivery hospitalizations between 2004 and 2014 with or without HDP (preeclampsia/eclampsia, chronic hypertension, superimposed preeclampsia on chronic hypertension, and gestational hypertension) were analyzed to examine the association between HDP and adverse in-hospital outcomes. We identified >44 million delivery hospitalizations, within which the prevalence of HDP increased from 8% to 11% over a decade with increasing comorbidity burden. Women with chronic hypertension have higher risks of myocardial infarction, peripartum cardiomyopathy, arrhythmia, and stillbirth compared to women with preeclampsia. Out of all HDP subgroups, the superimposed preeclampsia population had the highest risk of stroke (odds ratio [OR] 7.83, 95% confidence interval [CI] 6.25 to 9.80), myocardial infarction (OR 5.20, 95% CI 3.11 to 8.69), peripartum cardiomyopathy (OR 4.37, 95% CI 3.64 to 5.26), preterm birth (OR 4.65, 95% CI 4.48 to 4.83), placental abruption (OR 2.22, 95% CI 2.09 to 2.36), and stillbirth (OR 1.78, 95% CI 1.66 to 1.92) compared to women without HDP. In conclusion, we are the first to evaluate chronic systemic hypertension without superimposed preeclampsia as a distinct subgroup in HDP and show that women with chronic systemic hypertension are at even higher risk of some adverse outcomes compared to women with preeclampsia. In conclusion, the chronic hypertension population, with and without superimposed preeclampsia, is a particularly high-risk group and may benefit from increased antenatal surveillance and the use of a prognostic risk assessment model incorporating HDP to stratify intrapartum care.

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

IMPORTANCE

Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancy-related ICH risk, including risk during the extended postpartum period.

OBJECTIVE

To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum.

DESIGN, SETTING, AND PARTICIPANTS

This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7- to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020.

EXPOSURES

Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed.

MAIN OUTCOMES AND MEASURES

Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes.

RESULTS

A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23). Advanced maternal age (adjusted odds ratio [OR], 1.08; 95% CI, 1.05-1.10), nonwhite race (adjusted ORs, 2.44 [95% CI, 1.73-3.44] for black patients, 2.12 [95% CI, 1.34-3.35] for Asian patients, and 1.59 [95% CI, 1.12-2.26] for Hispanic patients), hypertension (adjusted OR, 2.02; 95% CI, 1.19-3.42), coagulopathy (adjusted OR, 14.17; 95% CI, 9.17-21.89), preeclampsia or eclampsia (adjusted OR, 9.23; 95% CI, 6.99-12.19), and tobacco use (adjusted OR, 2.83; 95% CI, 1.53-5.23) were independently associated with ICH during pregnancy and the postpartum period. Pregnancy-related ICH was associated with a higher risk of maternal (relative risk difference, 792.6; absolute risk difference, 0.18) and fetal (relative risk difference, 5.3; absolute risk difference, 0.03) death, compared with pregnancies without ICH.

CONCLUSIONS AND RELEVANCE

These findings suggest that the risk of ICH is significantly higher during the third trimester of pregnancy and the first 12 weeks post partum. There are age and race disparities in ICH risk that are associated with devastating maternal and fetal outcomes. These data illustrate the critical need for continuous monitoring and aggressive management of ICH-associated risk factors. These findings suggest that extended postpartum monitoring of high-risk women may be warranted.

Ischemic stroke and cerebral venous sinus thrombosis in pregnancy

Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.

Neurovascular disorders in pregnancy: A review

While rare, neurovascular disorders that occur in pregnant or postpartum women are associated with high morbidity and mortality, thus necessitating prompt identification and treatment. The most common symptoms include headache, focal neurological features, and seizures. Factors such as pregnancy-related hypercoagulability and hemodynamic changes put women at risk for neurovascular disorders in the third trimester and early postpartum period. The biggest risk factors for stroke in pregnancy are hypertension and the preeclampsia/eclampsia spectrum. This review outlines the diagnosis and treatment of pregnant and postpartum women with ischemic and hemorrhagic stroke, cerebral venous sinus thrombosis, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Trial registration: Not applicable.

Preeclampsia and future stroke risk in women: What NPs need to know

Preeclampsia is a complication of pregnancy that affects approximately 4% of pregnancies. Preeclampsia is defined as new-onset hypertension after 20 weeks gestation often accompanied by new-onset proteinuria. Women who experience preeclampsia during pregnancy are at an increased risk for hypertension and stroke later in life. Healthcare providers should screen women appropriately to minimize risk.

Foetal radiation exposure caused by mechanical thrombectomy in large-vessel ischaemic stroke in pregnancy

PURPOSE

There is overwhelming evidence for the clinical benefits that are derived following mechanical thrombectomy in large-vessel acute ischaemic stroke. The risk of stroke is elevated in pregnancy due to many factors. To date, there have been two reports, totalling five patients, who have undergone mechanical thrombectomy in pregnancy, thus demonstrating the feasibility of the procedure; however, there is no data on the radiation exposure to the mother or foetus related to this therapy.

METHODS

We highlight the important technical considerations to minimise the risk of the procedure and report the estimated dose received by mother and foetus. We also compare these doses with those received during whole-body CT in trauma and CT pulmonary angiogram (CTPA) examinations.

RESULTS

Three cases of mechanical thrombectomy were performed at separate tertiary referral neuroscience centres in the UK. Following diagnostic CT and mechanical thrombectomy, the total whole-body effective dose to the pregnant patient was significantly higher than in patients undergoing CTPA (p < 0.05), but not significant different compared to whole-body CT imaging in trauma patients. The estimated dose received by the foetus following diagnostic CT and mechanical thrombectomy was significantly lower than in whole-body imaging in trauma patients at p < 0.05, with no difference in estimated foetal dose compared to CTPA imaging.

CONCLUSION

The estimated doses received by the foetus during diagnostic stroke imaging and mechanical thrombectomy are equivalent to, or less than, purely diagnostic imaging in emergency situations.

Cerebral pontine infarctions during pregnancy - A case report and review of the literature

Cerebrovascular disease is not uncommon during pregnancy as a result of either venous or arterial occlusion, or a hemorrhagic event, resulting in ischemia. Pregnancy may alter the prognosis of these neurologic disorders, with increased risks of morbidity and mortality for the mother and the developing fetus. Etiologies of stroke during pregnancy and the postpartum period include preeclampsia, eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), amniotic fluid embolism, postpartum angiopathy, postpartum cardiomyopathy, thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), cerebral venous thrombosis, CNS infections, and maternal thrombophilia.

Essentially any of the vessels in the brain can be involved in cerebral infarction; however, pontine infarctions are rare and are generally secondary to occlusive insults or after dissection of an aneurysm. Though not common, these conditions can result in devastating sequelae and significant disability. Scant literature is available regarding pontine infarctions during pregnancy. Here we present a rare case of a pregnant patient who presented with new-onset seizures and was found to have a cerebral pontine infarction on imaging. The purpose of this article is to summarize existing data regarding the incidence, risk factors, and potential etiologies, as well as treatment strategies for pontine infarctions during pregnancy.

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Pontine infarctions are rare during pregnancy and do not differ compared to non-pregnant women.

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A CT scan, MRI and lumbar puncture can safely be performed during pregnancy for diagnosis purposes.

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Treatment options available during pregnancy is similar to those used in non-pregnant women.

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Immediate delivery of a pregnant woman with a vascular cerebral injury is not always indicated.

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The risk of recurrence is likely to be low, and thus should not impact on mode of delivery.

Spontaneous haemorrhagic stroke complicating severe pre-eclampsia in pregnancy: a case report in a resource-limited setting in Cameroon

BACKGROUND

Spontaneous intracerebral haemorrhage is a rare complication of preeclampsia during pregnancy associated with a high morbidity and mortality. Compared with the non-pregnant women stroke rates are relatively rare during pregnancy.

CASE PRESENTATION

We report the case of a 32-year-old female Cameroonian gravida 4 para 3 who presented at 34 weeks of gestation with sudden onset of right sided hemiplegia associated with headache, blurred vision and a blood pressure of 182/126. Cerebral CT scan confirmed a left parietal spontaneous haemorrhage. Emergency caesarean delivery was done and the recovery uneventful.

CONCLUSION

This case highlights the importance of good neurological examination in pregnant women presenting with neurological symptoms as well as the place of multidisciplinary management in severe life threatening conditions.

A headache-free reversible cerebral vasoconstriction syndrome (RCVS) with symptomatic brain stem ischemia at late pregnancy as a rare manifestation of RCVS resolved with termination of pregnancy by semi-urgent cesarean section

A 32-year-old pregnant woman in her 39th week of pregnancy presented at the emergency room complaining of sudden-onset dizziness with gaze disturbance and was admitted to our hospital. Her past medical history included hypertension, diabetes mellitus and infarction in the right medulla oblongata 18 months prior to this event. Magnetic resonance (MR) angiography showed multiple irregular stenosis of the intracranial arterial system. Although MR images revealed no fresh ischemic or hemorrhagic lesions, she was diagnosed with reversible cerebral vasoconstriction syndrome (RVCS) associated with pregnancy. Cesarean section immediately resolved the headache-free ischemic RCVS. The postpartum course of the patient was uneventful as well as that of her baby. Follow-up MR angiography showed improvement of intracranial vasoconstriction and follow-up MR imaging showed improvement of a left medial pontine ischemic lesion on diffusion-weighted image. This report describes a rare manifestation of pregnancy-related RCVS.

Imaging neurological emergencies in pregnancy and puerperium

The altered physiologic state of female patients during and just after pregnancy places them at an increased risk for several potentially life-threatening neurologic disorders. Swift diagnosis of such pathology and related complications is critical in order to reduce risk of morbidity and mortality to both the mother and the fetus. Neuroimaging plays an important role in the emergent diagnosis of pathology associated with pregnancy and puerperium, and it is critical for the radiologist to be cognizant of correlative imaging findings. Furthermore, given concerns regarding risks of neuroimaging to the fetus, it is important for the radiologist to act as an informed consultant regarding balancing fetal risks and the mother's health. The purpose of this review is to elucidate the underlying pathophysiology and neuroimaging findings associated with diagnoses that are unique to or highly associated with pregnancy and puerperium, as well as to understand the role that CT and MR play in diagnosis during and just after pregnancy, and their respective risks to the fetus.

Pancreatic Cancer in Pregnancy Presenting with Thromboembolic Events: Case Report and Review of the Literature

Stroke and hepatic vein thrombosis are highly associated with neoplasia but are extremely rare events in young, pregnant women. Rare and recurrent thrombotic events in pregnancy increase the suspicion for occult malignancy. We describe the case of a healthy 31-year-old G2P1 who presented with visual changes and dysarthria during pregnancy. Imaging showed cerebral infarcts. Her thrombophilia evaluation was negative. During delivery, she was diagnosed with fulminant Budd-Chiari Syndrome. Hepatic ultrasound suggested malignancy or metastasis, and postpartum CT scan and biopsy confirmed the diagnosis of Stage IV pancreatic cancer. Although rare in pregnancy, a new diagnosis of malignancy should be considered in patients with recurrent unexplained hypercoagulable complications. We propose an evidence-based algorithm for evaluation of occult malignancy in pregnancy based upon this case and review of the literature.

Pregnancy-Associated Stroke

Cerebrovascular accident, or stroke, is the fourth leading cause of death for all women and the eighth leading cause of pregnancy-associated death. The physiologic changes of pregnancy increase the risk of cerebrovascular accident for women. With current incidence rates, a facility with 3300 births per year can anticipate caring for one woman with a pregnancy-related stroke at least every 2 years. All maternity care providers must be able to assess women experiencing stroke-like symptoms and initiate timely care to mitigate brain tissue damage, decrease long-term morbidity, and prevent mortality. The 2 main types of stroke, ischemic and hemorrhagic, have similar presenting symptoms but very different pathophysiology and treatment. This article reviews assessment and initial treatment of pregnant and postpartum women experiencing stroke and provides guidance for subsequent maternity and primary care to assist front-line perinatal care providers who may be the first to treat affected women or may resume primary care after diagnosis.

Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department

OBJECTIVE

Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting.

METHODS

A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors.

RESULTS

Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals.

CONCLUSION

Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.

Neurologic Deterioration in Patients with Moyamoya Disease during Pregnancy, Delivery, and Puerperium

BACKGROUND

We reviewed our clinical experience of patients with moyamoya disease (MMD) who gave birth and assessed characteristics of those experiencing neurologic deterioration.

METHODS

The patients were classified into patients diagnosed with MMD during pregnancy and puerperium (group 1) and those diagnosed before pregnancy (group 2). We retrospectively reviewed patient characteristics, MMD treatment, neurologic symptoms before and during pregnancy and/after puerperium, obstetrical history, and delivery type in groups 1 and 2.

RESULTS

Group 1 included 2 patients with deterioration of pre-existing transient ischemic attacks (TIAs) and acute cerebral infarction and 1 patient with seizures and newly developed TIAs during pregnancy and/or puerperium. Group 2 included 20 patients with 23 pregnancies. In group 2, 4 patients had deterioration of TIAs during pregnancy and puerperium. There were significant differences between the cases without neurologic deterioration and with deterioration in group 2 (TIAs ≥10 before pregnancy, 0% vs. 75%, P = 0.002; severely reduced regional cerebrovascular reserve on single-photon emission computed tomography, 10.5% vs. 100%, P = 0.002; and surgical revascularization before pregnancy, 75% vs. 15.8%, P = 0.04). In groups 1 and 2, 6 of the 7 cases in which TIAs occurred or worsened during pregnancy or puerperium recovered to prepregnancy TIA levels after puerperium.

CONCLUSIONS

Patients with severely reduced regional cerebrovascular reserve on single-photon emission computed tomography and frequent TIAs before pregnancy may experience neurologic deterioration during pregnancy, delivery, and puerperium. Surgical revascularization before pregnancy may decrease neurologic deterioration during these periods.

Stroke in women - from evidence to inequalities

Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke - including diabetes mellitus and atrial fibrillation - are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials - despite governmental actions highlighting the need to include both men and women in clinical trials - resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women.

The incidence of first stroke in and around pregnancy: A population-based cohort study from Sweden

Introduction

Research has suggested that delivery is associated with an increased risk of stroke in women; however, there is a lack of contemporary estimates on the incidence of stroke in and after pregnancy compared with the baseline risk in women of childbearing age in Sweden.

Patients and methods

All women aged 15-49 years with live births/stillbirths in 1992-2011 were identified from the Swedish Medical Birth Registry linked with the National Patient Registry. First stroke during the study period was identified. Incidence rates per 100,000 person-years and adjusted incidence rate ratios (IRRs) were calculated for antepartum, peripartum and early and late postpartum periods, compared with all other available follow-up time (time before pregnancy and after postpartum) using Poisson regression adjusted for maternal age, education attainment and calendar time.

Results

Of 1,124,541 women, 3094 had a first incident stroke (331 occurred during pregnancy or first 12 weeks postpartum), about half having ischaemic stroke. The incidence was 15.0 per 100,000 person-years (95% confidence interval 14.5-15.6) in non-pregnant time. The incidence was lower antepartum (7.3/100,000 person-years, 6.0-8.9; adjusted IRR = 0.7, 0.5-0.8) but higher peripartum (314.4/100,000 person-years, 247.5-399.5; adjusted IRR = 27.3, 21.4-34.9) and early postpartum (64.0/100,000 person-years, 54.1-75.7; adjusted IRR = 5.5, 4.6-6.6). The increased risk in peripartum was more evident for intracerebral haemorrhage than other types of stroke.

Conclusion

Overall risk of stroke was low in women of childbearing age, but stroke risk peaks in the peripartum and early postpartum periods. Future work should address factors that contribute to this increased risk in order to develop approaches to attenuate risk.

Patient Characteristics and Outcomes After Hemorrhagic Stroke in Pregnancy

BACKGROUND

Hospitalizations for pregnancy-related stroke are rare but increasing. Hemorrhagic stroke (HS), ie, subarachnoid hemorrhage and intracerebral hemorrhage, is more common than ischemic stroke in pregnant versus nonpregnant women, reflecting different phenotypes or risk factors. We compared stroke risk factors and outcomes in pregnant versus nonpregnant HS in the Get With The Guidelines-Stroke Registry.

METHODS AND RESULTS

Using medical history or International Classification of Diseases-Ninth Revision codes, we identified 330 pregnant and 10 562 nonpregnant female patients aged 18 to 44 years with HS in Get With The Guidelines-Stroke (2008-2014). Differences in patient and care characteristics were compared by χ(2) or Fisher exact test (categorical variables) or Wilcoxon rank-sum (continuous variables) tests. Conditional logistic regression assessed the association of pregnancy with outcomes conditional on categorical age and further adjusted for patient and hospital characteristics. Pregnant versus nonpregnant HS patients were younger with fewer pre-existing stroke risk factors and medications. Pregnant versus nonpregnant subarachnoid hemorrhage patients were less impaired at arrival, and less than half met blood pressure criteria for severe preeclampsia. In-hospital mortality was lower in pregnant versus nonpregnant HS patients: adjusted odds ratios (95% CI) for subarachnoid hemorrhage 0.17 (0.06-0.45) and intracerebral hemorrhage 0.57 (0.34-0.94). Pregnant subarachnoid hemorrhage patients also had a higher likelihood of home discharge (2.60 [1.67-4.06]) and independent ambulation at discharge (2.40 [1.56-3.70]).

CONCLUSIONS

Pregnant HS patients are younger and have fewer risk factors than their nonpregnant counterparts, and risk-adjusted in-hospital mortality is lower. Our findings suggest possible differences in underlying disease pathophysiology and challenges to identifying at-risk patients.

Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium

The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly affect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specificity in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confined to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specific adjustments in the management of these disorders.

Mechanisms and outcomes of stroke during pregnancy and the postpartum period: A cross-sectional study

BACKGROUND

Pregnancy-associated stroke remains incompletely characterized because of the rarity of these potentially devastating events. We investigated whether mechanism and outcome of ischemic pathophysiology stroke differ between young pregnant and nonpregnant women.

METHODS

We identified 135 consecutive women ages 18-40 years admitted to our center from January 2008 through June 2014 with ischemic stroke, TIA, cerebral venous thrombosis, or nonaneurysmal subarachnoid hemorrhage due to reversible cerebral vasoconstriction syndrome (RCVS). We reviewed charts for pregnancy status, demographics, medical comorbidities, stroke severity, etiology, and discharge outcomes.

RESULTS

There were 33 women with pregnancy-associated stroke (PAS) and 102 with non-pregnancy-associated stroke (NPAS). Among women with PAS, 73% of strokes occurred postpartum. In the PAS group, the most common cause of cerebrovascular events was RCVS (n = 12), 11 postpartum and 4 in women with preeclampsia. There were no significant differences between the groups in demographics. Women with PAS were less likely to have vascular risk factors such as hyperlipidemia and history of thromboembolism but more likely to have cerebral venous thromboses (21% vs 7%, p = 0.02). Women with PAS were more likely to have RCVS as stroke mechanism (36% vs 1%, odds ratio 57.7, 95% confidence interval 7-468, p = 0.0001).

CONCLUSION

Compared with nonpregnant women of the same age group, women with PAS had fewer vascular risk factors. Cerebral venous thrombosis and RCVS were more common in PAS, most of which occurred postpartum. These results provide further evidence for the unique pathophysiology of pregnancy-related stroke, raising important questions for future investigation.

Wallenberg Syndrome with Associated Motor Weakness in a Two-Week-Postpartum Female

A 30-year-old, right-handed female presented 2 weeks postpartum with acute-onset severe headache, vertigo, and vomiting. Initial neurologic examination illustrated lingual dysarthria, horizontal nystagmus, right dysmetria on finger-to-nose testing, and weakness of the extremities. Magnetic resonance imaging showed a large, left lateral medullary infarction (Wallenberg syndrome) with cephalad extension into the ipsilateral pons as well as involvement of the left middle cerebellar peduncle. The patient was discharged 3 weeks later to an inpatient rehabilitation facility with gradual improvement of her symptoms.

Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery

Stroke during pregnancy is fortunately a rare event, however, it can have severe consequences, with 9.5% of all maternal deaths being related to stroke. The most common presentation is an ischaemic stroke. There has been much debate as to the correct treatment for such cases' and whether thrombolysis can be used safely in pregnancy. Our case describes a 28-year-old woman with a previous normal vaginal delivery presenting in her third trimester with a sudden onset of dense left hemiparesis. She was successfully treated with alteplase, an intravenous recombinant tissue-type plasminogen activator, and made a full recovery after normal delivery of a healthy infant. This case report highlights one of the first documented successful outcomes from thrombolysis for this condition in the UK and may help inform future management of these women.

Cerebrovascular complications of pregnancy and the postpartum period

Cerebrovascular complications of pregnancy, though uncommon, threaten women with severe morbidity or death, and they are the main causes of major long-term disability associated with pregnancy. In this review, we discuss the epidemiology, pathophysiology, presentation and diagnosis, and management and outcomes of ischemic and hemorrhagic stroke and cerebral venous thrombosis. We also discuss the posterior reversible encephalopathy syndrome, the reversible cerebral vasoconstriction syndrome including postpartum cerebral angiopathy, and their relationship as overlapping manifestations of pre-eclampsia-eclampsia.

Hypertensive disorders and pregnancy-related stroke: frequency, trends, risk factors, and outcomes

OBJECTIVE

To evaluate trends and associations of hypertensive disorders of pregnancy with stroke risk and test the hypothesis that hypertensive disorders of pregnancy-associated stroke results in higher rates of stroke-related complications than pregnancy-associated stroke without hypertensive disorders.

METHODS

A cross-sectional study was performed using 81,983,216 pregnancy hospitalizations from the 1994-2011 Nationwide Inpatient Sample. Rates of stroke hospitalizations with and without these hypertensive disorders were reported per 10,000 pregnancy hospitalizations. Using logistic regression, adjusted odds ratios (OR) with 95% confidence intervals were obtained.

RESULTS

Between 1994-1995 and 2010-2011, the nationwide rate of stroke with hypertensive disorders of pregnancy increased from 0.8 to 1.6 per 10,000 pregnancy hospitalizations (103%), whereas the rate without these disorders increased from 2.2 to 3.2 per 10,000 pregnancy hospitalizations (47%). Women with hypertensive disorders of pregnancy were 5.2 times more likely to have a stroke than those without. Having traditional stroke risk factors (eg, congenital heart disease, atrial fibrillation, sickle cell anemia, congenital coagulation defects) substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations: from adjusted OR 2.68 for congenital coagulation defects to adjusted OR 13.1 for congenital heart disease. Stroke-related complications were increased in stroke with hypertensive disorders of pregnancy compared with without (from adjusted OR 1.23 for nonroutine discharge to adjusted OR 1.93 for mechanical ventilation).

CONCLUSION

Having traditional stroke risk factors substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations. Stroke with hypertensive disorders in pregnancy had two distinctive characteristics: a greater increase in frequency since the mid-1990s and significantly higher stroke-related complication rates.

LEVEL OF EVIDENCE

III.

Acute cerebrovascular disease occurring after hospital discharge for labor and delivery

BACKGROUND AND PURPOSE

The risk of stroke and other postpartum cerebrovascular disease (CVD) occurring after hospital discharge for labor and delivery is uncertain.

METHODS

We performed a retrospective cohort study using administrative databases to identify all pregnant women who were hospitalized for labor and delivery at nonfederal, acute care hospitals in California from 2005 to 2011 and who were discharged without an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of CVD. The primary outcome was an acute CVD composite defined as any ischemic stroke, intracranial hemorrhage, cerebral venous sinus thrombosis, pituitary apoplexy, carotid/vertebral artery dissection, hypertensive encephalopathy, or other acute CVD occurring after hospital discharge and before 6 weeks after labor and delivery. Descriptive statistics were used to estimate the incidence of postdischarge CVD. Multivariate logistic regression was used to evaluate the association between selected baseline factors and postdischarge CVD.

RESULTS

The rate of any postdischarge acute CVD was 14.8 per 100 000 patients (95% confidence interval [CI], 13.2-16.5). Risk factors for any acute CVD were eclampsia (odds ratio [OR], 10.1; 95% CI, 3.09-32.8), chronic kidney disease (OR, 5.4; 95% CI, 2.5-11.8), black race (OR, 2.5; 95% CI, 1.9-3.3), preeclampsia (OR, 2.1; 95% CI, 1.6-2.8), pregnancy-related hematologic disorders (OR, 1.8; 95% CI, 1.3-2.5), and age (OR, 1.5 per decade; 95% CI, 1.3-1.8).

CONCLUSIONS

The incidence of postpartum acute CVD after hospital discharge for labor and delivery is similar to rates reported for all postpartum events in previous publications, suggesting that a substantial proportion of postpartum CVD occurs after discharge.

Cerebrovascular disorders complicating pregnancy

PURPOSE OF REVIEW

This article discusses the physiologic changes of pregnancy and how they affect risk of ischemic and hemorrhagic stroke and then reviews epidemiology, diagnosis, and treatment of ischemic and hemorrhagic stroke in pregnancy and the puerperium.

RECENT FINDINGS

This article updates our understanding of the relationship of preeclampsia/eclampsia to the posterior reversible encephalopathy syndrome and the reversible cerebral vasoconstriction syndrome, emphasizing their shared pathogenesis. It reviews the most recent data and offers recommendations concerning the use of thrombolytic and other revascularization therapies for pregnancy-related strokes.

SUMMARY

Although cerebrovascular complications are uncommon occurrences during pregnancy and the puerperium, stroke is still the most common seriously disabling complication of pregnancy. Therefore, stroke and other vascular issues raise questions about the best evaluation and management that is safe for mother and child.