Stroke in Pregnancy

Christina Mijalski Sells, MD, MPH; Steven K. Feske, MD


Semin Neurol. 2017;37(6):669-678. 

In This Article

Recognition and Diagnosis of Pregnancy-associated Stroke

Awareness of the increased risk of stroke and related cerebrovascular disorders during pregnancy and the puerperium is important for timely recognition, diagnosis, and treatment. Both ischemic and hemorrhagic strokes present with recognizable clinical features, localizable based on the affected brain territory. It is also important to consider cerebrovascular causes when women present with nonfocal signs and symptoms, such as headache, seizures, or an altered level of consciousness. PRES has a predilection for the posterior circulation and may be associated with visual changes and altered levels of consciousness; it may also involve the anterior circulation and present with lateralized sensorimotor deficits. RCVS and postpartum angiopathy usually present with a headache and may present with generalized seizures.

Regardless of the specific mechanism, any new neurological change that appears to be more than simple migraine demands urgent brain imaging. A non-contrast head CT scan is sufficient to evaluate for hemorrhage and contraindications to thrombolytic therapy. However, with the recent trials showing benefits of endovascular therapy in patients with large vessel occlusions, the American Heart Association (AHA) and American Stroke Association (ASA) have updated their recommendations to include a noninvasive intracranial vascular study with acute imaging.[39] Pregnant women with symptoms suggesting possible stroke should get urgent imaging of adequate quality to allow physicians to make rapid therapeutic decisions. Exposure to contrast may be avoided by performing brain MRI with magnetic resonance angiography (MRA) using the time-of-flight technique. This flow-dependent method may overestimate areas of stenosis and is especially susceptible to motion artifact, but it is adequate in most cases to guide the critical decision to pursue or not to pursue endovascular therapy. (A detailed discussion of the risks of neuroimaging during pregnancy can be found in Drs. Chansakul and Young's paper Neuroimaging in Pregnant Women in this issue.) Ultimately, it is recommended that physicians proceed with the diagnostic imaging evaluation needed to provide the best medical management during pregnancy and that concerns regarding contrast exposure should not delay or discourage full and appropriate care.