Association between preeclampsia and reversible cerebral vasoconstriction syndrome: A case-control study

Pregnancy-related reversible cerebral vasoconstriction syndrome (RCVS) has higher rates of intracerebral complications and mortality compared to non-pregnant RCVS. Case reports suggest preeclampsia-eclampsia as an important risk factor; however, data are limited regarding this association. We hypothesized that pregnancy-related RCVS is strongly associated with preeclampsia-eclampsia.

We performed a single-center, retrospective, case-control study to estimate the association between preeclampsia-eclampsia and RCVS. Cases between January 1, 2010, and June 30, 2024, were identified from hospital billing data and defined as RCVS in pregnancy or postpartum (<12 weeks) based on the combination of (1) typical clinical presentation, (2) ≥1 imaging modality consistent with vasoconstriction, and (3) the absence of an alternative diagnosis. Controls were pregnant or postpartum patients selected randomly from our hospital quality database and matched with cases (3:1 ratio) for delivery month and year. The primary exposure was preeclampsia-eclampsia diagnosed preceding or concurrent with the RCVS diagnosis. We created logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) for the association of preeclampsia-eclampsia with RCVS, adjusting for confounders. We calculated the fraction of RCVS attributable to preeclampsia-eclampsia using the unadjusted OR.

We identified 40 RCVS cases and 120 controls. Age, delivery mode, gestational and chronic hypertension, and peripartum complications did not differ between groups. Preterm birth (20.6% vs. 8.3%, p < 0.001) and preeclampsia-eclampsia (73% vs. 10%, p < 0.001) were more prevalent in cases compared to controls. Most RCVS (80%) and preeclampsia-eclampsia (62%) occurred postpartum. Antepartum RCVS occurred at a median of 30 weeks (interquartile range [IQR] 20-33). Fifty-five percent of RCVS cases had associated intracranial complications such as hemorrhage, infarction, or posterior reversible encephalopathy syndrome, 45% required intensive care, and 15% were discharged to rehabilitation. Adjusting for gravidity, pregnancy length, and timing of preeclampsia-eclampsia diagnosis (antepartum, intrapartum, or postpartum), preeclampsia-eclampsia was associated with increased odds of RCVS (adjusted OR [aOR], 37.1; 95% CI, 10.6-129.9; p < 0.001). The fraction of RCVS attributable to preeclampsia-eclampsia was 95%.

Preeclampsia-eclampsia is associated with increased odds of pregnancy-related RCVS, suggesting possible shared mechanisms. Prospective studies of preeclampsia-eclampsia patients, including neurovascular imaging, are needed to confirm these findings and explore the underlying pathophysiology.