Original ArticlePregnancy-associated Intracranial Hemorrhage: Results of a Survey of Neurosurgical Institutes across Japan
Introduction
Pregnancy-associated hemorrhagic stroke is well recognized as a serious complication.1, 2 In previous studies conducted mainly by neurologists and obstetricians, systemic obstetric complications including coagulopathies, pregnancy-induced hypertension, and eclampsia were identified as the causes of hemorrhage.2, 3, 4, 5, 6, 7 Pre-existing cerebrovascular diseases (CVDs) such as cerebral aneurysms and arteriovenous malformations (AVMs) were also reported,4, 8 but their incidence and treatments were not fully analyzed. The Japan Neurosurgical Society, therefore, set out to conduct a survey of neurosurgical institutes across Japan regarding pregnancy-associated hemorrhagic stroke with a special focus on identifying underlying CVDs.
Section snippets
Methods
This study is a retrospective analysis based on the clinical chart review in each neurosurgical institute and was conducted in 2 phases (primary and secondary surveys) in 2012 as an official project of the Japan Neurosurgical Society. The society has 109 main training institutes across Japan under which 755 affiliated local training institutes participate in providing neurosurgical services. The target of the primary survey was all strokes occurring during pregnancy, delivery, and puerperium
Patient Demographics
Table 1 summarizes the patient demographics. Among the all 97 hemorrhagic strokes, 60 (61.9%) occurred during pregnancy, 13 (13.4%) at delivery, and 24 (24.7%) during puerperium. Mean gestational age at the onset of hemorrhage during pregnancy was 27.7 ± 10.1 weeks.
Causes of Hemorrhage in Each Period
Figure 1, A shows the causes of hemorrhagic stroke throughout all periods (pregnancy, delivery, and puerperium). Baseline CVDs responsible for hemorrhage were detected in 54 cases (55.7%). Among all vascular lesions, AVMs are the
Discussion
Pregnancy-associated intracranial hemorrhage is a rare but potentially devastating event. A large population-based epidemiologic study in Sweden conducted by retrospective International Classification of Diseases, Ninth Revision, code analysis revealed its incidence to be 6.2 (2.4 for subarachnoid hemorrhage and 3.8 for intracerebral hemorrhage) per 100,000 deliveries.10 A more recent survey in the United States also based on the International Classification of Diseases, Ninth Revision, codes
Conclusions
A nationwide survey revealed that underlying CVDs play an important role in hemorrhagic stroke associated with pregnancy, among which AVM is the predominant bleeding source. Careful examination for vascular lesions is, therefore, essential when dealing with intracranial hemorrhage, especially before the 32nd week of gestation. As maternal prognosis after hemorrhagic stroke has been proved to be poor, a greater effort should be made to prevent tragic pregnancy-associated stroke.
Acknowledgment
The authors express their appreciation to Ms Kayoko Morii (secretary of the Department of Neurosurgery, Graduate School of Medicine, Kyoto University) for her great assistance in conducting the survey.
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Grant support: None.