Presentation, etiology, and outcome of stroke in pregnancy and puerperium.

OBJECTIVE

The purpose of this study was to evaluate the presentation, timing, etiology, and outcome of ischemic stroke (IS), hemorrhagic stroke (HS), and cerebral venous thrombosis (CVT) occurring during pregnancy and puerperium at 3 Indianapolis hospitals.

METHODS

Medical records of patients with a stroke during pregnancy and the puerperium were identified by using International Classification of Diseases (ICD 9) codes and a computerized records database. The records were available from 1992 to 1999 at 2 of the hospitals and from 1994 to 1999 at the third hospital. The records were retrospectively reviewed for presentation, treatment, etiology, and outcome. The sample included all cases of IS, HS, and CVT occurring in our pregnant population and included events up to 12 weeks postpartum.

RESULTS

Thirty-six patients were identified, including 21 with IS, 11 with HS, and 4 patients with CVT. The majority of events (89%) occurred in the third trimester and postpartum period, and 16 of 36 (44%) events occurred in postpartum week 1. Of the 8 African American patients in our study, 5 had HS (63%), whereas 18 of the 25 white patients (72%) had IS. A definable cause was identified in 72% of IS and 82% of HS. Some causes of IS include pre-eclampsia or eclampsia (13%), cardioembolism (23%), and a diverse array of other causes, include hypercoagulable states, thrombotic thrombocytopenic purpura (TTP), cerebral vasculitis, cerebrovascular mucormycosis, and migrainous infarction. Pre-eclampsia/eclampsia (37%) and ruptured atriovenous malformation (AVM) (36%) were the primary causes of HS. None of the cases of CVT had a clear etiology other than the pregnant or puerperal state, although risk factors included systemic lupus erythematosus (negative antiphospholipid antibodies and lupus anticoagulant) in 1 patient and dehydration in a second. Hypertensive disorders of pregnancy were the most common comorbid conditions in both IS and HS, affecting 45% of those with IS and 64% of patients with HS. IS presented with focal deficits (76%), whereas HS tended to present with an altered level of consciousness (73%) and headache (64%). All patients with CVT (4/4) presented with a headache, and 2 of 4 patients presented with an altered level of consciousness. The majority of patients with HS were discharged to nursing homes or rehabilitation centers (63%), whereas 73% of patients with IS and 3 of 4 patients with CVT were discharged home. Only 1 death occurred in our study, because of a brain herniation after a massive hemispheric IS.

CONCLUSIONS

The etiology of stroke in pregnancy and the puerperium is diverse. Strokes are most likely to occur in the third trimester and postpartum period and cluster in the first postpartum week.