Cerebrovascular disorders complicating pregnancy

Abstract

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.

Figure 4-1.

Timing of events during pregnancy and the puerperium. Each dot represents the time during pregnancy (in weeks) or the puerperium (in days) of a single event as color-coded. Reprinted with permission from Feske SK, et al, International Stroke Conference.¹⁷

Figure 4-2.

Brain imaging of a 20-year-old primigravida with right hemichorea. Note the subcortical infarctions predominantly in the left hemisphere (A, fluid-attenuated inversion recovery [FLAIR] MRI) and severe stenosis of the right and left middle cerebral arteries (B, head magnetic resonance [MR] angiogram, three-dimensional time-of-flight image).

Figure 4-3.

Brain imaging of a 36-year-old woman with severe headaches associated with postpartum hypertension. A, fluid-attenuated inversion recovery (FLAIR) image shows hyperintense regions in both parietal and occipital lobes (arrows) with elevated diffusion (not shown), findings that are consistent with vasogenic edema. B, Magnetic resonance (MR) angiography of the circle of Willis shows multifocal stenoses in the proximal anterior, middle, and posterior cerebral arteries. This finding is consistent with postpartum angiopathy. C and D show hyperintense lesions (arrows) on FLAIR and diffusion-weighted images, respectively, from MRI performed 1 day later, a finding consistent with ischemic stroke. E, a follow-up MR angiogram shows worsening of the multifocal cerebral arterial stenosis. F, FLAIR shows bilateral cerebral infarction with edema and hemorrhage. Reprinted with permission from Singhal AB et al, N Engl J Med.³⁷ Copyright © 2009, Massachusetts Medical Society. www.nejm.org/doi/full/10.1056/NEJMcpc0809063.

Figure 4-4.

Brain imaging of a 40-year-old pregnant woman with progressively worsening headaches and nausea. MRI revealed hyperintense signal in the region of the right transverse sinus (A, fluid-attenuated inversion recovery [FLAIR] image), and magnetic resonance (MR) venogram (B) showed absence of flow-related signal within the right transverse sinus and decreased flow-related signal within the right sigmoid sinus and internal jugular vein. These imaging results are consistent with cerebral venous sinus thrombosis. A follow-up MR venogram performed after 2 weeks of treatment with low-molecular-weight heparin showed complete recanalization of the venous sinuses (C).