Intracranial haemorrhage in pregnancy

Abstract

Intracranial haemorrhage (ICH) is a rare, yet potentially devastating event in pregnancy. There is a risk of maternal mortality or morbidity and a significant risk to the unborn child. The risk of haemorrhage increases during the third trimester and is greatest during parturition and the puerperium. ICH can be extradural, subdural, subarachnoid or intraparenchymal. Causes of bleeding include trauma, arteriovenous malformations, aneurysms, preeclampsia/eclampsia and venous thrombosis. Urgent neurosurgical conditions generally outweigh obstetric considerations in management decisions, although anaesthetic and surgical modifications can be made to minimize adverse effects to the fetus.

Keywords: arteriovenous malformations; cerebral aneurysms; intracerebral haemorrhage; pregnancy; stroke; subarachnoid haemorrhage.

Figure 1

Non-contrast computed tomography demonstrating left putaminal haemorrhage (arrow). This 35-year-old patient was being treated for depression with a monoamine oxidase inhibitor (MAOI) during pregnancy. After delivery, she ate a large amount of cheese and had an MAOI hypertensive crisis. She had a depressed conscious state on admission and was treated with craniotomy and evacuation of the haematoma. She made a full neurological recovery

Figure 2

Dural venous sinus thrombosis resulting in intracranial haemorrhage. (a) T1-weighted non-contrast sagittal magnetic resonance imaging (MRI) demonstrating thrombosis of the vein of Galen (white arrow) and straight sinus (arrow). (b) MR venogram showing patent left transverse (arrow) and sigmoid (black arrow) sinuses and absent signal on the left, indicating occlusion. (c) Non-contrast computed tomography showing intra-parenchymal haemorrhage in the right cerebellar hemisphere (arrow)

Figure 3

Brainstem cavernous malformation with oedema and small intra-axial haemorrhage. This woman of 21 weeks' gestation presented with headache and hemianaesthesia. (a) T2-weighted axial magnetic resonance imaging (MRI) demonstrating cavernoma in the right middle cerebellar peduncle with prominent perilesional oedema (arrow). (b) Gradient echo sequence axial MRI showing a cavernous malformation with haemorrhage and haemosiderin deposits (arrow). (c) T1-weighted coronal MRI with acute haemorrhage in the left middle cerebellar peduncle, surrounding a cavernous malformation (arrow)