Stroke in Pregnancy

Abstract

Although pregnancy-associated stroke is uncommon, the risk of stroke is greatly increased above the low baseline rate in young patients during late pregnancy and, even more so, during the puerperium. Stroke is a major contributor to the serious morbidity and mortality of pregnancy. The physiological hormonally mediated changes in circulation, vascular tissue structure, and coagulability, and the pathological state of pre-eclampsia-eclampsia contribute to this increased risk of stroke. Pregnancy-associated strokes are roughly evenly divided among hemorrhagic strokes, mainly from rupture of aneurysms and arteriovenous malformations (AVMs); ischemic strokes, mainly from late pregnancy and postpartum cerebral venous thrombosis; and strokes associated with pre-eclampsia-eclampsia, with a contribution from cardioembolism, especially in populations at risk from a high rate of underlying rheumatic valvular heart disease. Awareness of the types of stroke to expect during pregnancy will facilitate early diagnosis. This article discusses the pathogenesis of pregnancy-associated stroke, its epidemiology, and some diagnostic and therapeutic issues unique to pregnancy.

Occurrence of Perimesencephalic Subarachnoid Hemorrhage During Pregnancy

“…Although studies of cerebral hemodynamics during pregnancy do suggest increased vascular pressure and higher cerebral blood flow [7,[11][12][13] which may increase risk of SAH in patients with vascular anomalies, we did not find any evidence of vascular lesions to explain the condition.…”

“…Hemorrhagic stroke is rare during pregnancy with an occurrence rate of approximately 5-31 per 100,000 [7]. Relative risk is increased during late pregnancy and in the puerperal period.…”

“…The recommended diagnostic and therapeutic approach to SAH during pregnancy is based on neurosurgical principles and includes four-vessel digital subtraction angiography (DSA) in most cases with shielding of the fetus and adequate hydration when iodinated contrast agents are given [7]. While conventional angiography remains the diagnostic standard of care in the evaluation of P-SAH, several studies have confirmed the high negative predictive value of computed tomographic angiography for aneurysm in patients with this condition and promote CTA alone as a conclusive diagnostic test to rule out aneurysms in patients with the classic perimesencephalic SAH pattern and clinical history [3,17].…”

Migraine Headache and Ischemic Stroke Risk: An Updated Meta-analysis

“…This finding could represent a true increased risk, or it could be the consequence of residual or unmeasured confounding. Important potential confounders include those that reflect hormone status in women, including pregnancy52 and oral contraceptive53 and post-menopausal hormone use,54 and factors such as smoking that may interact with these risk factors to further increase the risk of ischemic stroke 53. Increased estrogen levels may increase the risk of ischemic stroke via their affect on endothelial function, coagulation factors, and inflammation 55…”

Thromboembolic Diseases in Families of Women With Placental Abruption

“…Pregnant women are at increased risk for stroke (although uncommon), possibly due to hormone-induced vascular changes that accompany pregnancy, such as hypervolemia, increased cardiac output, and hypercoagulapathies. 29 Acquired thrombophillias are more frequent in women with abruption and could potentially also increase their risk for thromboembolic diseases.…”