Maternal Stroke: an Update

Abstract

Purpose of the review: Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence.

Recent findings: The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.

Keywords: Cerebral venous thrombosis; Intracranial hemorrhage; Preeclampsia; Pregnancy; Reversible cerebral vasoconstriction syndrome; Stroke.

Figure 1.. Mechanisms of maternal ischemic and hemorrhagic stroke.

Maternal strokes may occur through multiple pathophysiological mechanisms. Ischemic stroke mechanisms include cardioembolism (including paradoxical embolism), cervical artery dissection, RCVS, moyamoya stenoocclusive vasculopathy, amniotic fluid embolism, and arterial or venous thrombosis due to prothrombotic states such as APLS or sickle cell disease. Hemorrhagic stroke mechanisms include hypertensive hemorrhages due to preeclampsia, with or without HELLP-related coagulopathy; rupture of vascular lesions such as arteriovenous malformations, cerebral aneurysms, or moyamoya vessels; or hemorrhages related to venous sinus thrombosis. RCVS: reversible cerebral vasoconstriction syndrome. APLS: antiphospholipid syndrome. HELLP: hemolysis, elevated liver enzymes, and low platelets.

Figure 2.. Postpartum stroke.

1. A 23 year old woman presented on postpartum day 5 with recurrent “thunderclap” headaches and focal neurological deficits. CT angiography demonstrated multifocal stenoses in the (A) anterior cerebral artery and (B) middle cerebral artery, consistent with reversible cerebral vasoconstriction syndrome. 2. A 28 year old woman with preeclampsia presented on postpartum day 2 with severe headache and altered mental status. CT head without contrast showed a large right frontal intracerebral hemorrhage with intraventricular extension. CT angiography showed no underlying vascular abnormality.