Postpartum stroke: A twenty-year experience

OBJECTIVE: The aim of this study was to characterize the clinical presentat ion, 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 d iagnoses of postpartum stroke. RESULTS: Eight of 20 women (40%) were delivered abdominally. Conduction ane sthesia was induced in 9 of 20 women (45%). Causes of stroke included cereb ral infarction (n = 13, 7 venous, 6 arterial), intracerebral hemorrhage (n = 5; 1 cocaine-induced 1 anatomic malformation), cerebritis (n = 1), and ce rebral atrophy (n = 1). The median time at onset of stroke was 8 days post partum (range, 3-35 days). Headache, seizures, visual change, and hemipares is were the most common presenting findings but were neither specific to th e underlying pathologic condition nor predictive of ultimate maternal outco me. There were 2 maternal deaths, both caused by severe intracerebral hemor rhage. Intracerebral hemorrhage was associated with the poorest outcome (2 deaths and 1 residual neurologic deficit). Eight women had residual neurolo gic deficit. There was no correlation between a trial of labor (P = .4; odd s 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 popul ation (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 disc harge. New-onset hypertension or exacerbation of existing hypertension occu rred after the acute neurologic insult; subsequent mean (+/- SD) arterial b lood pressure was 128.9 +/- 24.0 mm Hg. CONCLUSION: Postpartum stroke is a multifactorial, uncommon, and nonprevent able complication of pregnancy. There was an association between postpartum stroke and hypertensive disorders of pregnancy and cesarean delivery. Howe ver, this study refutes any etiologic association between conduction anesth esia and postpartum stroke.