GENERAL NEUROLOGY

Acute stroke management during pregnancy

David Goldemund M.D.
Updated on 08/10/2024, published on 26/09/2024
  • acute stroke during pregnancy and the postpartum period is relatively rare but poses diagnostic and therapeutic challenges due to potential adverse outcomes for both the mother and the fetus
  • the risk of stroke is increased during the peripartum and postpartum periods, especially in the first 6-12 weeks after delivery  (Kittner, 1996)   [Kamel, 2014]
  • standard acute stroke guidelines should be followed unless modified to address maternal concerns and fetal safety
  • collaboration between the stroke and obstetric teams is necessary, and institutions without obstetric services should consider transferring patients to a center with appropriate obstetric expertise
  • this chapter focuses on acute stroke care; the etiology and prevention of pregnancy-related stroke are discussed here
Acute stroke in pregnancy

Stroke in women of reproductive age

  • urine or serum beta-hCG testing is recommended for women of reproductive age with acute stroke/TIA who may be pregnant
  • rapidly establish the likelihood of pregnancy based on patient history, last menstrual period, and use of contraception
  • in patients with acute stroke, testing should not delay imaging or recanalization

Diagnostic evaluation

Initial assessment, laboratory tests

Blood pressure management

  • use standard protocols to manage severe hypertension acutely
  • in preeclampsia or severe hypertension with neurological symptoms, the goal is to reduce blood pressure to < 160/110 mmHg
  • protocols for magnesium sulfate in severe preeclampsia should be available to reduce the risk of eclampsia
  • a stroke secondary to preeclampsia meets a classification of severe preeclampsia and has implications for the timing of delivery
  • do not induce hypotension or hypoperfusion
  • involve obstetrics/maternal-fetal medicine specialists in assessing the maternal-placental-fetal unit and blood pressure management

Neuroimaging

  • neuroimaging has become an essential part of acute stroke management and is used to:
    • differentiate ischemic stroke from hemorrhage and exclude other nonvascular causes (tumors, etc.)
    • detect vascular lesions amenable to thrombolysis/embolectomy
    • distinguish irreversible infarct from salvageable tissue (assess penumbra and core volumes)
    • identify stroke etiology (with implications for stroke prevention)
    • detect hemorrhagic stroke and rapidly identify vascular malformations and aneurysms
  • MRI and MR angiography/venography are safe during pregnancy and should be preferred; avoid gadolinium unless essential and use the lowest effective dose (potential teratogenic effects)  (ACOG Guidelines 2017)
  • CT is used in emergencies when MRI is not available; radiation dose is generally below the threshold for fetal harm; discuss risks and use appropriate shielding

→ Neuroimaging in pregnancy and lactation

→ Overview of imaging modalities for stroke

Differential diagnosis

  • eclampsia with seizures and hypertensive emergencies
  • migraine with aura
  • conversion disorder
  • seizure disorders
  • neurovascular syndromes that may be associated with severe preeclampsia
    • reversible cerebral vasoconstriction syndrome (RCVS)
    • posterior reversible encephalopathy syndrome (PRES)
  • cerebral venous sinus thrombosis (CVST)

Acute headache in pregnancy and puerperium

  • new-onset severe headaches may represent:
    • preeclampsia
    • a complication of delivery (e.g., post-dural puncture headache)
    • benign primary headache syndrome (e.g., migraine)
    • reversible cerebral vasoconstriction syndrome (RCVS)
    • posterior reversible encephalopathy syndrome (PRES)
    • arterial dissection
    • pituitary apoplexy/Sheehan’s syndrome
    • subarachnoid hemorrhage (SAH)
  • pregnant women with severe headache should be evaluated for intensity (i.e., thunderclap vs. gradual onset) and associated features (e.g., neck stiffness, decreased level of consciousness, nausea/vomiting, vision loss, or focal neurologic deficits); if these are identified, the patient must be evaluated with brain imaging and lumbar puncture if imaging is inconclusive

Management

  • management of acute stroke in pregnancy follows general acute stroke management protocols but requires additional considerations to ensure fetal safety
  • multidisciplinary collaboration involving neurologists, obstetricians, neonatologists, and anesthesiologists is essential

Supportive care

  • Intensive care unit (ICU) monitoring is recommended.
    • neurocritical care controls intracranial pressure, maintains cerebral perfusion, and prevents secondary complications
  • continuous fetal monitoring is recommended whenever possible, especially during thrombolysis
  • delivery decisions are based on gestational age, fetal viability, and maternal stability; severe hemorrhage or eclampsia require urgent delivery

Anesthetic management

  • both general and regional anesthesia can be safely administered but require careful planning to avoid hypotension and ensure fetal safety
    • in the acute stroke setting, alternatives to general anesthesia should be considered
  • interdisciplinary team goals for maternal blood pressure and intracranial pressure can be incorporated into the overall anesthetic plans
  • concurrent cesarean delivery and resection of a vascular lesion should be discussed in advance

Pharmacological considerations

  • preferred antihypertensive agents: labetalol, hydralazine, and nifedipine due to their safety profile in pregnancy
  • avoid ACE inhibitors and angiotensin II receptor blockers (ARBs) because of teratogenic risks
  • non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in severe preeclampsia and HELLP syndrome

Recanalization therapy

Intravenous thrombolysis (IVT)

  • due to its large molecule size, tPA does not cross the placental barrier; there is no evidence of teratogenicity
  • there are concerns about placental abruption, intrauterine hemorrhage, preterm delivery, or fetal death
  • there are no data from RCTs (pregnancy was an exclusion criterion)
  • most case reports and small series are from patients who received thrombolysis for non-stroke diagnoses rather than stroke (PE, valvular thrombosis, DVT, stroke, myocardial infarction)
    • in 8 published cases of IVT, only 1 case of uterine bleeding occurred
    • according to a published cohort of 28 patients, the risk of TL-related abortion was 8%, and the maternal risk of IVT did not differ from that of non-pregnant patients  [Leonhardt, 2006]
    • case reports of successful IVT for stroke in late pregnancy have also been published [Wiese, 2006]  [Daprich, 2006]
  • all recommendations are based on expert consensus (ESO guidelines 2022)
  • IVT may be considered on an individual basis for moderate and especially severe stroke when the expected benefit of IVT outweighs the risk of uterine bleeding (ESO guidelines 2022 – expert consensus)  (AHA/ASA 2019 IIb/C-LD)
  • factors favoring IVT:
    • severe, debilitating deficit
    • likely benefit of IVT
      • MR DWI/PWI mismatch and small lesion on DWI
      • likely peripheral occlusion – from M2 distally
    • if MT is available and LVO is involved, direct MT is preferable to bridging therapy
  • stroke occurring shortly after delivery
    • the safety and efficacy of IVT shortly after delivery (<10 days) are not established, and no recommendation exists (AHA/ASA 2019 IIb/C-LD)
    • if the stroke occurs > 10 days after delivery, IVT may be given after individual consideration  (ESO guidelines 2022 – expert consensus)
    • if MT is available and there is a presumption of increased bleeding risk, dMT is preferred   (ESO guidelines 2022 – expert consensus)

Mechanical recanalization

  • there is relatively limited experience with MT in pregnant women; no RCTs are available
  • direct MT may be preferable to bridging therapy for LVO during pregnancy and shortly after delivery
  • fetal shielding with lead vests is required  (Michel, 2021)
The stroke occurred 6 weeks after delivery with M1 occlusion on the right side. IV thrombolysis was without adverse events but ineffective. Mechanical recanalization was performed and TICI 2c was achieved. Follow-up MRI showed a putaminal infarct.

Hemorrhagic stroke

  • after a hemorrhagic stroke is confirmed, vascular imaging (MRA/CTA) is performed to identify the source of bleeding and guide further management decisions
  • pregnancy is not a contraindication to angiography and treatment of a vascular cause of hemorrhage; delaying necessary maternal care is not reasonable
  • recognize and reduce potential fetal risks (radiation and contrast exposure, infection, and arterial puncture complications); use abdominal shielding and judicious exposures

Intracerebral hemorrhage

  • therapy focuses on blood pressure control and the identification and correction of coagulopathies
  • first-line medications include labetalol, methyldopa, and long-acting nifedipine
  • angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should be avoided

Unruptured cerebral aneurysm

  • time-of-flight (TOF) MRA is appropriate to visualize the lesion
  • if the patient’s neurological and overall clinical status is stable, deferral of treatment until the postpartum period should be considered

Ruptured cerebral aneurysm

  • ruptured aneurysms require urgent treatment
  • the decision to coil or clip the ruptured aneurysm should be based on the best available option for the patient, regardless of pregnancy status
  • reduce BP to < 140/90 mmHg
  • an interdisciplinary approach involving neurosurgeon/endovascular interventionalist, neurologist, and physicians with expertise in maternal-fetal medicine should be used
  • maternal safety and outcomes are paramount, and treatment decisions can potentially compromise the fetus
  • concurrent cesarean delivery should be considered when possible

Unruptured AV malformation

  • individualized approach is required

Ruptured AV malformation

  • low-grade symptomatic AVMs amenable to surgical resection should be resected (with or without preoperative embolization) in the same timeframe as it would be for non-pregnant women, with every possible effort to reduce the risk of fetal injury
  • the timing of treatment of high-grade AVMs that require a multimodality approach (endovascular/surgery or endovascular/radiosurgery) should be made with an interdisciplinary team, including neurosurgery, neurology, and expertise in maternal-fetal medicine
  • maternal safety and outcomes may require treatment decisions that potentially compromise the pregnancy or the fetus
    • viable gestational age – consider concurrent cesarean delivery
    • pre-viable gestational age – treat as outside of pregnancy to maximize maternal safety

Post-stroke rehabilitation

  • rehabilitation should start early in acute care and include early mobilization, physical, occupational, and speech therapy tailored to the patient’s needs
  • psychosocial support should address the emotional and psychological impact on the patient and family

Early post-stroke management

  • determine the cause of stroke as early as possible to guide proper stroke prevention
  • rehabilitation should start early during acute care and include early mobilization, physical, occupational, and speech therapy
  • psychosocial support should address the emotional and psychological impact on the patient and family
  • the risk of stroke recurrence is highest in the peripartum period (the first 12 weeks after delivery); women should be warned about the signs of stroke occurrence/recurrence and the need to  contact emergency health services immediately

Intra-partum considerations after stroke

  • a history of stroke does not necessarily rule out vaginal delivery
  • the decision on the preferred mode of delivery depends on the cause of the previous stroke and the risk of the Valsalva maneuver
    • if the patient can tolerate some increased intracranial pressure (i.e., low risk of Valsalva maneuver), unassisted vaginal delivery may be considered
    • women in whom increased intracranial pressure should be avoided may be candidates for assisted vaginal delivery (using forceps or vacuum) during the second stage of labor
      • neuraxial anesthesia can facilitate a forceps or vacuum-assisted second stage of vaginal delivery
    • for women at high risk of intracranial bleeding (due to an unsecured aneurysm, AVM, or a CVST with elevated intracranial pressure), cesarean delivery may be considered, acknowledging its risks
  • decisions regarding the mode of delivery should also consider patient preferences and be made on an individual basis
  • a history of stroke places the woman in a risk category that would require continuous fetal monitoring
  • if delivery is anticipated in preterm or extremely preterm gestation, maternal-fetal medicine and neonatal counseling should be provided

Prognosis

  • maternal outcomes
    • mortality and morbidity are higher for hemorrhagic stroke than for ischemic stroke; early and successful intervention improves outcomes
    • long-term disability is similar to that of the nonpregnant population
  • fetal outcomes
    • increased risk of preterm birth due to maternal instability or the need for urgent delivery
    • fetal hypoxia
  • all women should get counseling before future pregnancy
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