J Neurocrit Care.  2019 Jun;12(1):20-29. 10.18700/jnc.190087.

Cerebrovascular complications during pregnancy and postpartum

• Hong JH

• KMID: 2452823
• DOI: http://doi.org/10.18700/jnc.190087

Abstract

Cerebrovascular complications that more likely to occur during pregnancy or postpartum include cerebral venous thrombosis, ischemic and hemorrhagic stroke, posterior reversible encephalopathy syndrome, and postpartum angiopathy, which although rare, can lead to serious outcomes for both mother and fetus. Pregnancy is a very unique condition, especially, in terms of treatment and, as such, neurointensivists must always consider its potential effects on the fetus. The purpose of this review is to help understand the physiological changes during pregnancy and postpartum, and to inform treatment decisions regarding pregnancy-related cerebrovascular complications.

Keyword

Critical care; Pregnancy complications; Venous thromboembolism; Hypertension, pregnancy-induced; Stroke

MeSH Terms

Critical Care
Female
Fetus
Humans
Hypertension, Pregnancy-Induced
Mothers
Posterior Leukoencephalopathy Syndrome
Postpartum Period*
Pregnancy Complications
Pregnancy*
Stroke
Venous Thromboembolism
Venous Thrombosis

Figure

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  Fig. 1. Changes in the coagulation system during the third trimester of pregnancy and early puerperium. vWF, von Willebrand factor; d/t, due to.

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  Fig. 2. Cerebral venous thrombosis. (A) Diffusion-weighted magnetic resonance (MR) imaging (MRI) revealing acute cerebral infarctions (arrows) at both frontal lobes. (B, C) T1-weighted MRI revealing hyperintense signal of the thrombus at the superior sagittal sinus and right transverse sinus (filled arrows). (D) Gradient echo sequences demonstrating hypointense thrombus (filled arrow) in the superior sagittal sinus. (E) There is no superior sagittal sinus (arrowheads) detectable on coronal MR venography. (F) Sagittal MR venography demonstrates absent flow due to occlusion of the superior sagittal sinus and right transverse sinus (arrowheads). Filled arrowheads indicate straight sinus in (E) and left transverse sinus in (F).

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  Fig. 3. Posterior reversible encephalopathy syndrome. (A) Axial fluid-attenuated inversion recovery magnetic resonance image revealing abnormal signal intensity in both parieto-occipital lobes. (B) Apparent diffusion coefficient map reveals increased values in the areas of fluid-attenuated inversion recovery abnormality, indicative of cortical vasogenic edema.

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  Fig. 4. The overlapping mechanism of postpartum angiopathy (PPA) and posterior reversible encephalopathy syndrome (PRES) during pregnancy and postpartum. BBB, blood-brain barrier.

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  Fig. 5. Postpartum angiopathy. (A) Multiple acute cerebral infarctions in both cerebral hemispheres and right cerebellum. (B) Multifocal mild to moderate stenosis at both middle cerebral artery M2 segments, right anterior cerebral artery proximal A2 segment, right posterior cerebral artery (PCA) P1 segment, and left PCA P2 segment.

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