Cerebrovascular Disease in Pregnancy: Epidemiology, Pathophysiology, Risk Factors, Diagnostic and Management...

Cerebrovascular disease in pregnancy is a potentially catastrophic complication, affecting approximately 20-50 per 100,000 pregnancies and accounting for 4-6% of maternal deaths in the United States. Unlike the general population, in whom approximately 85% of strokes are ischemic, roughly half of pregnancy-associated strokes are hemorrhagic. The spectrum of pregnancy-associated cerebrovascular disease includes arterial ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome, and posterior reversible encephalopathy syndrome. Hypertensive disorders of pregnancy are the single most important risk factor, present in nearly half of all pregnancy-associated stroke hospitalizations. The physiological adaptations of pregnancy, including hypercoagulability, hemodynamic changes, and immunological modulation, create a unique combination that predisposes to cerebrovascular events, with the highest risk concentrated in the peripartum and early postpartum periods. Diagnosis is frequently delayed, and management is complicated by the exclusion of pregnant individuals from major stroke trials. Nonetheless, emerging evidence supports the safety of acute reperfusion therapies in pregnancy, and recent consensus statements emphasize that pregnancy should not delay evidence-based stroke treatment. Long-term outcomes data reveal that pregnancy-associated stroke confers elevated risks of recurrent cerebrovascular events, cardiovascular morbidity, and reduced vocational function for years to decades after the index event.