Pregnancy and stroke

Adrian Marchidann MD (Dr. Marchidann of SUNY Health Science Center has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released June 3, 2003; last updated November 9, 2017; expires November 9, 2020

Overview

Stroke during pregnancy is an uncommon but serious cause of morbidity and mortality. In this review, the author discusses the etiologies of pregnancy-specific ischemic and hemorrhagic strokes, diagnostic approaches, and therapeutic challenges. The updated article includes the revised definition of preeclampsia and the recommendations for its treatment; new data on the risk of hemorrhage of cavernous hemangioma, arteriovenous malformation, and aneurysm; and the recommendations for antiplatelet and anticoagulation management for secondary stroke prevention during pregnancy and puerperium.

Key points

 

• Because of the change of stroke definition and similarity of symptoms of different conditions associated with pregnancy, the true incidence of ischemic stroke during pregnancy and puerperium is still unknown.

 

• There is an incomplete overlap between the mechanism, clinical presentation, and complications of preeclampsia, eclampsia, posterior reversible encephalopathy syndrome (PRES), and reversible cerebral vasoconstriction syndrome (RCVS).

 

• Primary CNS vasculitis is extremely rare during pregnancy and outcome with treatment is better than considered in the past.

 

• Patients with ischemic stroke may benefit from intravenous rt-PA.

 

• Intraarterial therapy of ischemic stroke may be useful if intravenous rt-PA is contraindicated or ineffective in a large vessel occlusion.

 

• Decompressive craniotomy may be lifesaving in patients with venous sinus thrombosis, even in patients with severe edema, herniation, or in coma.

Historical note and terminology

Stroke is 1 of the most feared complications of pregnancy. Although the risk of stroke during pregnancy and the puerperium is low, it accounts for considerable morbidity and mortality. For the purposes of this review, pregnancy-related stroke refers to all ischemic and hemorrhagic events occurring during the 3 trimesters of pregnancy as well as the first 6 weeks of the postpartum period (puerperium). Stroke is an episode of neurologic dysfunction caused by focal cerebral, spinal, or retinal infarction attributable to ischemia or hemorrhage. The key component of the new definition is the presence of infarction of brain, spinal cord, or retinal cell death attributable to ischemia. Therefore, transient neurologic symptoms associated with infarction on MRI, which were attributed to transient ischemic attack (TIA) in the past, are now classified under the category of ischemic stroke (Sacco et al 2013).

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