Stroke in young adults

Pregnancy
Article section 13 of 16.  Previous  Next

By Bartlomiej Piechowski-Jozwiak MD, Jorge Moncayo-Gaete MD, and Julien Bogousslavsky MD

Pregnancy and the postpartum period have long been recognized as important risk factors for both ischemic and hemorrhagic strokes, which occur with similar frequency during this period. Pregnancy increases the risk of stroke by 3-fold to 13-fold; causes of stroke during pregnancy are listed in Table 8 (Dafer and Biller 2009). An important study by James and colleagues reported the incidence of pregnancy-related stroke to be 34.2 per 100,000 deliveries, and the mortality rate to be 1.4 per 100,000 deliveries (James et al 2005). Factors associated with a higher risk for stroke included older age (older than 35 years), African-American race, history of migraine (O.R. 16.9), thrombophilia (O.R. 16.0), SLE (O.R. 15.2), heart disease (O.R. 13.2), sickle cell disease (O.R. 9.1), hypertension (O.R. 6.1), and thrombocytopenia (O.R. 6.0). A higher risk for stroke was found with pregnancy-related complications such as postpartum hemorrhage, preeclampsia, gestational hypertension, need for blood transfusion, postpartum infection, and placental abruption with disseminated intravascular coagulation.

The risk for pregnancy-related stroke is highest in the postpartum period (up to 6 weeks postpartum). Kittner and colleagues found the relative risk for ischemic stroke to be 0.7 during pregnancy; this increased to 8.7 during the postpartum period. The relative risk was found to be 2.5 for intracerebral hemorrhage (exclusive of subarachnoid hemorrhage) but dramatically increased to 28.3 for the postpartum period (Kittner et al 1996). Most arterial strokes occurred in the third trimester and puerperium, whereas all but one venous infarct occurred in the puerperium (Jaigobin and Silver 2000). In addition to cerebral venous thrombosis, postpartum angiopathy is an important cause for headache in the postpartum period (Singhal 2004b; Gladstone et al 2005; Singhal and Bernstein 2005). Therefore, postpartum patients with headache or focal deficits should be evaluated with CT angiography with venography or MRI with MR angiography and venography.

Stroke occurred during pregnancy or postpartum in 11% of the patients in an ischemic stroke series involving 958 women with a mean age of 34 at 12 tertiary care centers in 8 Asian countries (Wasay et al 2010). In 240 women of Hispanic origin with cerebrovascular complications occurring during pregnancy and in the first 5 weeks after delivery, 56% developed cerebral venous thrombosis (mean age of 23), 27% had cerebral infarction (mean age of 26), and 16% suffered an intracerebral hemorrhage (mean age of 29) (Cantu-Brito et al 2011). Cerebral venous thrombosis and cerebral hemorrhage peaked during the first and third trimester of pregnancy, respectively, and cerebral infarcts also occurred most frequently in the first and third trimester. Preeclampsia and eclampsia were noted in around one half and one third of cerebral hemorrhages and infarcts, respectively, whereas frequencies were lower in cerebral venous thrombosis. Outcome was favorable in over one half of the women with cerebral venous thrombosis and cerebral infarction, but in only one third of the women with intracerebral hemorrhage.

In a retrospective study of 24 women with a previous ischemic stroke (20 of which were of arterial origin), no recurrence of cerebral infarct was found during pregnancy and puerperium, although one woman had a transient ischemic attack at the 35th week of gestation. The main etiologies of previous ischemic stroke were hypercoagulable state (41%) and cardioembolism (17%); etiology remained unknown in approximately 40% of these strokes. All the women received prophylactic treatment (antiplatelet therapy, low molecular weighted heparin, or both) at the time of index pregnancy and puerperium. The mean interval between previous stroke and index pregnancy was 6.2 years (Crovetto et al 2012).

Table 8. Etiologies of Stroke in Pregnancy

 

Ischemic

Hemorrhagic

 

• Thromboembolic occlusive disease

• Cerebral venous sinus thrombosis

 

   - Hypercoagulable state

 

   - Infectious

 

   - Cryptogenic

 

• Cardioembolic

• Intraparenchymal hemorrhage

   - Peripartum cardiomyopathy

   - Eclampsia

   - Mitral valve prolapsed

   - Hypertension (other causes)

   - Prosthetic heart valves

   - Cerebral venous sinus thrombosis

   - Atrial fibrillation

   - Arteriovenous malformation

   - Rheumatic heart disease

   - Vasculitis

   - Bacterial endocarditis

   - Choriocarcinoma

   - Nonbacterial (marantic) endocarditis

 

   - Paradoxical embolism

 

 

• Rare embolic etiologies

• Subarachnoid hemorrhage

   - Amniotic fluid

   - Aneurysm

   - Air

      Saccular

 

      Mycotic

 

   - AVM

 

   - dAVF

 

      Cerebral

 

      Spinal cord

 

   - Vasculitis

 

   - Eclampsia

 

   - Cerebral venous thrombosis

 

   - Placental abruption with

     disseminated intravascular

     coagulation

 

   - Choriocarcinoma

 

• Arterial hypotension

 

   - Border-zone infarction

 

   - Sheehan syndrome

 

 

• Hematologic disorders

 

   - Disseminated intravascular

      coagulation

 

   - Thrombotic thrombocytopenic

      purpura

 

   - Sickle cell disease

 

 

• Arteriopathies and arteritis

 

   - Fibromuscular dysplasia

 

   - Systemic lupus erythematosus

 

   - “Isolated” cerebral angiitis

 

 

• dAVF

Adapted from (Dafer and Biller 2009)

In This Article

Introduction
Historical note and nomenclature
Clinical manifestations
Clinical vignette
Etiology
Pathogenesis and pathophysiology
Epidemiology
Prevention
Differential diagnosis
Diagnostic workup
Prognosis and complications
Management
Pregnancy
Anesthesia
References cited
Contributors