Pregnancy-associated Intracranial Hemorrhage: Results of a Survey of Neurosurgical Institutes across Japan

doi:10.1016/j.jstrokecerebrovasdis.2013.08.017

Journal of Stroke and Cerebrovascular Diseases

Volume 23, Issue 2, February 2014, Pages e65-e71

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.08.017 Get rights and content

Background

Pregnancy-associated hemorrhagic stroke is considered a serious complication. Although coagulopathy, pregnancy-induced hypertension, eclampsia, and other systemic complications have been emphasized, pre-existing cerebrovascular diseases (CVDs) have not been fully analyzed. To clarify the role of these vascular lesions more in detail, the Japan Neurosurgical Society conducted a nationwide survey on all the neurosurgical institutes across Japan.

Methods

This 2-year survey focused on hemorrhagic stroke occurring in pregnancy, delivery, and puerperium. Clinical data based on retrospective chart review were obtained through a questionnaire and analyzed according to the time of onset, underlying CVDs, obstetric systemic complications, therapeutic approaches, and maternal and neonatal prognoses.

Results

The survey identified 97 hemorrhagic strokes that were associated with pregnancy. Baseline CVDs responsible for hemorrhage were detected in 54 cases (55.7%), among which 47 lesions (87.0%) had been undiagnosed before stroke onset. The detection rate of baseline CVDs before the 32nd week of gestation was significantly higher than that after the 32nd week (90.0% versus 53.3%, P = .0017). Arteriovenous malformations (AVMs) were the most frequent CVDs causing intracranial hemorrhage, occurring at 1.8 times the frequency of ruptured aneurysms during pregnancy. Poor outcomes, including 10 deaths, were seen in 36.1% of the cases despite aggressive treatment.

Conclusion

Pregnancy-associated hemorrhagic strokes frequently concealed baseline CVDs, especially when they occurred before the 32nd week of gestation. AVMs were the predominant bleeding source. For appropriate treatment, therefore, close examination for cerebral vascular lesions is essential when a pregnancy-associated hemorrhagic stroke is encountered.

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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Remote critical care has come increasingly into focus owing to the COVID-19 pandemic as well as rapid changes in technology. This method of delivering care is likely to benefit less common and highly specialized branches of medicine disproportionately because they frequently have an even greater shortage of trained experts than do specialties that are more prevalent. Neurocritical care is an emerging field with few global experts. This gap is more glaring in the developing world. Thus, remote care is likely to be acutely useful for delivering this rare expertise to pregnant patients with neurologic complications, surmounting geographic and socioeconomic barriers.
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An aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare congenital anomaly that can present with both ischemic and hemorrhagic stroke. The etiology of this pathology has remained unclear. Here, we report 2 cases of intracerebral hemorrhage (ICH) owing to an Ap/T-MCA in pregnant patients.
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Original ArticlePregnancy-associated Intracranial Hemorrhage: Results of a Survey of Neurosurgical Institutes across Japan

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Patient Demographics

Causes of Hemorrhage in Each Period

Discussion

Conclusions

Acknowledgment

Am J Obstet Gynecol

Am J Obstet Gynecol

Stroke complicating pregnancy and the puerperium

Eur J Neurol

Stroke in pregnancy and the puerperium

Postgrad Med J

Incidence and risk factors for stroke in pregnancy and the puerperium

Obstet Gynecol

Incidence and etiologies of stroke during pregnancy and puerperium as evidenced in Taiwanese Woman

Cerebrovasc Dis

Pregnancy and the risk of stroke

N Engl J Med

Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis

Stroke

Incidence, risk factors, management, and outcomes of stroke in pregnancy

Obstet Gynecol

Stroke and pregnancy

Stroke

Interobserver agreement for the assessment of handicap in stroke patients

Stroke

Increased risks of circulatory diseases in late pregnancy and puerperium

Epidemiology

Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome

Neurology

Incidence and causes of strokes associated with pregnancy and puerperium: a study in public hospitals of Ile de France

Stroke

Cerebrovascular accidents complicating pregnancy and the puerperium

Obstet Gynecol

Original Article
Pregnancy-associated Intracranial Hemorrhage: Results of a Survey of Neurosurgical Institutes across Japan