Maternal Stroke: A Call for Action

Abstract

Maternal mortality rates have been steadily increasing in the United States, and cardiovascular mortality is the leading cause of death among pregnant and postpartum women. Maternal stroke accounts for a significant burden of cardiovascular mortality. Data suggest that rates of maternal stroke have been increasing in recent years. Advancing maternal age at the time of birth and the increasing prevalence of traditional cardiovascular risk factors, and other risk factors, as well, such as hypertensive disorders of pregnancy, migraine, and infections, may contribute to increased rates of maternal stroke. In this article, we provide an overview of the epidemiology of maternal stroke, explore mechanisms that may explain increasing rates of stroke among pregnant women, and identify key knowledge gaps for future investigation in this area.

Keywords: cerebral hemorrhage; hemorrhagic stroke; ischemic stroke; postpartum period; pre-eclampsia; pregnancy; subarachnoid hemorrhage.

Figure 1:

Risk factors and pathophysiology of maternal stroke. Risk factors for maternal stroke are traditional and other risk factors including hypertensive diseases of pregnancy, migraine, infections, and hypercoagulable states. The pathophysiological mechanisms implicated in maternal stroke involve hemodynamic, vascular, immune-modulatory, and hypercoagulable changes.

Figure 2:

Examples for cases of maternal stroke. (A) Right frontal intracerebral hemorrhage with surrounding edema and brain herniation in a post-partum woman with the HELLP syndrome. No underlying vascular lesion was identified, and the stroke was felt like due to hypertension and HELLP-related coagulopathy; (B) Arterial ischemic stroke due to paradoxical embolus related to patent foramen ovale, although no deep venous thrombosis was identified to left posterior cerebral artery in a post-partum woman; (C) Multifocal vasogenic edema due to the posterior reversible encephalopathy syndrome (PRES) in a woman with eclampsia. Note that not all lesions are posterior. A small area of infarction on diffusion-restricted imaging is noted, occasionally seen in association with PRES. (D) Cerebral angiogram demonstrating multifocal vasospasm due to reversible cerebral vasoconstriction syndrome in a postpartum woman with pre-eclampsia. She developed ischemic strokes distal to the areas of vasospasm, as well as intracerebral hemorrhage.

Figure 3:

Potential mechanisms of maternal stroke. Summary of possible mechanisms of maternal stroke. PFO= patent foramen ovale; RCVS= reversible cerebral vasoconstriction syndrome