Stroke in pregnancy

Maternal stroke, while rare, leads to significant maternal morbidity and mortality. Physiologic changes in pregnancy and the postpartum period disrupt cerebrovascular homeostasis, predisposing to pregnancy-specific syndromes and tripling stroke risk. Mechanisms of pregnancy-related stroke are diverse and include cardioembolism, vasculopathies (cervical artery dissections, reversible cerebral vasoconstriction syndrome), intracranial hemorrhage related to vascular lesions or preeclampsia, and cerebral venous thrombosis. Heterogeneity of presentation and limited experience treating pregnant women can contribute to challenges in diagnosis and management. This article reviews physiologic changes of pregnancy, as well as pregnancy-associated syndromes that predispose to stroke, including preeclampsia and other hypertensive disorders of pregnancy, peripartum cardiomyopathy, and amniotic fluid embolism. We propose that hypertensive disorders of pregnancy and certain types of pregnancy-related stroke may share underlying mechanisms and represent a continuum of pregnancy-associated vasculopathy characterized by endothelial dysfunction and sympathetic hyperactivity. We also offer practical considerations for stroke clinicians, including safety of imaging modalities, therapeutic options both for prevention and treatment of pregnancy-related stroke, and prognosis after pregnancy-associated stroke.