Postpartum stroke: A twenty-year experience

OBJECTIVE: The aim of this study was to characterize the clinical presentation, etiology, and acute and subsequent outcomes of postpartum stroke. STUDY DESIGN: This 20-year, single-center, retrospective review included 20 women without previous neurologic deficit with clinical and neuroimaging diagnoses of postpartum stroke. RESULTS: Eight of 20 women (40%) were delivered abdominally. Conduction anesthesia was induced in 9 of 20 women (45%). Causes of stroke included cerebral infarction (n = 13, 7 venous, 6 arterial), intracerebral hemorrhage (n = 5; 1 cocaine-induced 1 anatomic malformation), cerebritis (n = 1), and cerebral atrophy (n = 1). The median time at onset of stroke was 8 days post partum (range, 3-35 days). Headache, seizures, visual change, and hemiparesis were the most common presenting findings but were neither specific to the underlying pathologic condition nor predictive of ultimate maternal outcome. There were 2 maternal deaths, both caused by severe intracerebral hemorrhage. Intracerebral hemorrhage was associated with the poorest outcome (2 deaths and 1 residual neurologic deficit). Eight women had residual neurologic deficit. There was no correlation between a trial of labor (P = .4; odds ratio, 0.4; 95% confidence interval, 0.01-6.5) or vaginal versus cesarean mode of delivery (P = .6; odds ratio, 1.3, 95% confidence interval 0.1-16.8) and ultimate neurologic diagnosis (cerebral infarction or intracerebral hemorrhage). However, the incidence of cesarean delivery was greater in the cohort of women with postpartum stroke than in the overall obstetric population (P = .015; odds ratio, 3.2; 95% confidence interval, 1.2-8.5). One of the 20 women received methergine; 1 received bromocriptine. All women were either normotensive or had well-controlled hypertension at postpartum discharge. New-onset hypertension or exacerbation of existing hypertension occurred after the acute neurologic insult; subsequent mean (+/- SD) arterial blood pressure was 128.9 +/- 24.0 mm Hg. CONCLUSION: Postpartum stroke is a multifactorial, uncommon, and nonpreventable complication of pregnancy. There was an association between postpartum stroke and hypertensive disorders of pregnancy and cesarean delivery. However, this study refutes any etiologic association between conduction anesthesia and postpartum stroke.