The risk for intracerebral hemorrhage (ICH) in pregnant women was the highest during the 3rd trimester and early postpartum. Intracerebral hemorrhage (ICH) accounts for a substantial portion of pregnancy-related mortality. The risk of ICH associated with pregnancy is greatest in the postpartum period. Advanced maternal age, African American race, hypertensive diseases, coagulopathy, and tobacco abuse were all independent risk factors for pregnancy-related ICH

1. Intracranial Haemorrhage
In Pregnancy
A Life Threatening Emergency

3. Intracranial Haemorrhage
• Intracranial haemorrhage (ICH) is a rare, yet
potentially devastating event in pregnancy.
• There is a risk of maternal mortality or morbidity and
a significant risk to the unborn child.
• The risk of haemorrhage increases during the third
trimester and is greatest during parturition and the
puerperium.

4. Types
• Extradural,
• Subdural,
• Subarachnoid or (intraparenchymal/ intracerebral)

5. Extradural Haemorrhage
• Traumatic- skull fracture and injury to the middle
meningeal artery.
• Primary brain damage is usually minimal and the
prognosis is good with timely surgical treatment.
• Presentation is usually precipitous with rapidly
deteriorating conscious state and urgent operative
treatment is mandatory.

6. Subdural Haemorrhage
• Result of severe traumatic brain injury, carries poor
prognosis.
• The epidemiology and treatment of this injury in pregnancy
are no different from the non-pregnant population.
• Chronic SDH is extremely uncommon in pregnancy, as it is
a disease usually affecting the elderly.
• Several reports in the literature referring to SDH after
epidural or spinal anaesthesia, presumably due to
intracranial cerebrospinal fluid hypovolaemia & low
intracranial pressure causing stretching tearing of bridging
veins between the cortex and dural venous sinuses.
• Surgery for chronic SDH can be carried out under local
anaesthesia, in a pregnant patient.
• Aneurysm rupture may present as a spontaneous acute

7. Subarachnoid Haemorrhage
• The first reported case of SAH in pregnancy was in 1899.
• Pregnancy-related SAH during pregnancy is 0.01–0.03%.
• (90% -pregnancy, 2% - delivery & 8%- puerperium).
• Higher frequency of SAH with advancing gestation, suggesting
that haemodynamic or other physiological changes in
pregnancy do influence the rate of aneurysmal growth or
rupture.
• One-third of patients present in a poor neurological grade with
coma or depressed consciousness. Those patients who present
with a preserved level of consciousness typically describe
sudden onset of severe headache invariably associated with
vomiting.
• Focal neurological deficits may be present, especially if there is
associated intracerebral haemorrhage. The initial symptoms
may be similar to eclampsia or preeclampsia.

8. PREGNANCY AS A RISK FACTOR
• Severe thrombotic microangiopathy
• Brain ischaemia and hemorrhage
Whether hypercoagulable state and vessel wall changes
associated with pregnancy may play a role in the
occurrence of these otherwise unexplained ischemic
strokes remains unknown.

9. Vascular Physiology In Pregnancy
• Pregnancy and labour are hyperdynamic states
• Blood volume increases in early pregnancy and
plateau at 32 week, increased by 50%
• Plasma volume reduction in haematocrit.
• Cardiac output increases by 30–50% first 24 weeks
of pregnancy, systemic vascular tone falls and blood
pressure decreases.
• During the first stage of labour, cardiac output
increases by 50%, mean arterial pressure up to
20% during uterine contractions.
• By 24 h after delivery, all haemodynamic variables
are returned to the prelabour baseline.

10. Pregnancy
• There is not enough information currently … to say that
healthy pregnancy by itself will increase the risk of
complication
• Pregnancy increases the likelihood of cerebral infarction
to about 13 times the rate expected outside of pregnancy.
• In most, it is uncertain whether pregnancy is coincidental
or plays a role in the occurrence of stroke

11. Postpartum – High Risk
• large decrease in blood volume or
• the rapid changes in hormonal status that follow a
live birth or stillbirth,
Perhaps by means of hemodynamic, coagulative, or
vessel-wall changes.

12. Incidence & Risk Factors In Pregnancy
• 6 per 100,000 deliveries (12% of maternal deaths)
• Maximum risk – postpartum period
• Advanced maternal age, obesity
• Pre existing hypertension
• Pre eclampsia, superimposed preeclampsia
• Gestational Hypertension
• Pregnancy – preeclampsia (twice the risk of stroke and
four times the risk of high blood pressure later in life.)

13. Risk For Stroke In Women
• Diabetes
• Migraine with aura
• Heart disease
• Atrial fibrillation
• Depression and emotional stress
• Coagulopathy
• Tobacco abuse

14. Etiology Of ICH
• AVM & aneurysm most common cause 41%
• Preeclampsia 20%
• Moya moya disease
• Cavernous angioma
• Cerebral venous sinus thrombosis
• Tumor
• Unknown / Spontaneous

15. Presentation
• Depends on the cause
• Sudden Collapse
• Unconscious state
• Severe headache, vomiting
• Seizures
• Breathing difficulty
• Restless – altered sensorium

17. Arteriovenous Malformation
• Arteriovenous malformation chief cause of intracerebral
haemorrhage in pregnancy.
• prevalence of AVMs is 15–18 per 100,000
• maternal mortality rate of 28% after AVM haemorrhage,
• The risk of haemorrhage from a previously unruptured
AVM in pregnant women is estimated at 3.5% against
3.1% in non-pregnant women of child-bearing age,
suggesting that pregnancy is not a significant risk factor
for haemorrhage.
• the risk of further haemorrhage is 27%, which is higher
than the rebleeding rate in non-pregnant patients.

18. • Pregnancy-associated Intracranial Haemorrhage: Results of a
Survey of Neurosurgical Institutes across Japan
• Jun C. Takahashi, MD, PhD ,Journal of Stroke & Cerebrovascular Disease, Feb 2014
• This 2-year survey focused on haemorrhagic stroke occurring in pregnancy,
delivery, and puerperium.
• The survey identified 97 haemorrhagic strokes that were associated with
pregnancy. Baseline CVDs responsible for haemorrhage 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 haemorrhage, 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- For appropriate treatment, therefore, close examination for
cerebral vascular lesions is essential when a pregnancy-associated
hemorrhagic stroke is encountered.

19. Preeclampsia-associated CNS Complications
Eclampsia
Intracranial hemorrhage
Cerebral edema
Encephalopathy
Visual disturbances, usually transient
Ischemia including ischemic stroke
Vascular thrombosis

20. CNS Bleeding In Preeclampsia
Variety of types of bleeding reported:
Petechial hemorrhages without clinically notable
bleeding are commonly seen in imaging studies,
especially in areas of edema
Subarachnoid hemorrhage and bleeding related
t
o
vascular anomalies reported
Intracerecral hemorrhage=Intraparenchymal bleeding
responsible for the majority of CNS mortality and
morbidity
Bateman,BT et al Neurology 2006;67:424

21. Mechanisms For Increased Risk Of Intracerebral
Hemorrhage In Pregnancy, Pre-eclampsia And
Eclampsia
Impaired cerebral autoregulation and alteration of t
h
e
blood-brain barrier in pregnancy (animal data):
 Arterial vasoconstriction rather than vasodilatation in response t
o
serotonin in pregnancy and post-partum
 Impaired arterial remodeling: lack of medial hypertrophy i
n
pregnant females with chronic hypertension.
 Enhanced permeability of the blood-brain barrier with acute
hypertension in pregnant females.

22. Copyright ©2007 American Heart Association
CBF Autoregulatory Curves (Hypothetical) Under Various
conditions Solid black line: normal CBF as a function
of CPP. CBF remains relatively constant
between 60 and 150 mm Hg of CPP,
whereas above and below these limits,
autoregulation is lost and CBF changes
linearly with pressure.
Solid red lines: chronic hypertension
(chronic HTN). autoregulatory curve is
shifted to the higher pressures.
Solid blue line: potential shift in the
autoregulatory curve during normal
pregnancy.
Dashed blue line: Loss of autoregulation in
which CBF changes linearly with pressure
and is thought to occur during eclampsia.
The arrows point to pressures at which
cerebral perfusion breakthroughs occur,
demonstrating a large, steep increasedin
CBF.
Modified after Cipolla, M. J. Hypertension 2007;50:14-24

23. Pregnancy & Preeclampsia
• Systemic small artery spasms
• Vascular endothelial cell damage
• Increased brain capillary permeability
• Plasma and red blood cells can leak into the
extravascular space in the brain and cause spotting.

24. • BP - damaging to vessel walls, & it increases
sharply when the pressure in the brain's blood
vessels increases, which can easily lead to rupture
& bleeding
• Multiple organ failure
• Concurrent cerebral haemorrhage might be the
end-stage manifestation of pre- eclampsia, and
the presence of clotting during late pregnancy
can lead to ICH
Pregnancy & Preeclampsia

25. Cerebral Edema: Background
Proposed etiologies include
 Vasogenic
 Hyperperfusion from failure of autoregulation
 Ischemia related to vasospasm
 Endothelial damage
Varying degrees of severity with predilection for occipital
and posterior parietal lobes
 Explains prominence of visual symptoms
 Wide variety described : blurriness, scotomata, cortical blindness,
more rarely distortions of size or color etc.
 Monocular deficits should prompt examination for ocular, retinal
or CN II pathology

26. Cerebral Edema: Management
Typically diagnosed based on imaging
study obtained
PRES
Diagnose on CT or MRI
Secondary to anoxia post eclamptic seizure
Secondary to loss of cerebral autoregulation
Treatment:
 Aggressive blood pressure control
 Preeclampsia management

27. Temporary Blindness
Occurs in 1-3 % of
preeclampsia/eclampsia
Majority follow eclampsia
Tends to resolve within 8days
Differential diagnosis:
 retinal vasculature damage
 retinal detachment
 occipital lobe ischemia
 occipital lobe edema
Management:
 Neurology consult
 Ophthalmology consult
 Image with CT or MRI

28. ICH In The Preeclampsia Patient
Principles:
Recognition of the signs and symptoms by the
obstetric team is crucial
Prompt evaluation and consultation required
Interdisciplinary management including: obstetrics, critical
care, neurology, neurosurgery
Guidelines exist for treating elevated blood
pressure i
n
spontaneous ICH
Monitoring of intracranial pressure may be indicated
Safe medication options exist for the antepartum patient
Maintain cerebral perfusion while prevention extension.

29. Cerebral Venous Thrombosis
• Pregnancy and particularly the puerperium are
significant risk factors for cerebral venous
thrombosis.
• Pregnant patients with prothrombotic disorders such
as protein C or S deficiency are at particular risk.
• Caesarean section, hypertension, dehydration, and
infections also predispose to thrombosis.

30. Cerebral Venous Thrombosis
Treatment
• Anti-coagulation is the main treatment of cerebral
venous thrombosis whether or not there is co-
existent intracerebral haemorrhage.
• Full anti-coagulation is generally safe from 24 h
postpartum.
• Both low molecular weight heparin and warfarin are
safe during breast-feeding.
• Surgical evacuation of large haemorrhages will
occasionally be required.
• An important preventive measure is to ensure
adequate hydration in the puerperium.

31. MRI BRAIN

32. Moya Moya Disease
• Moyamoya is a rare condition characterized by spontaneous gradual
occlusion of the arteries in the circle of Willis. Perforating arteries
dilate in response to the chronic ischaemia and rupture of these
enlarged fragile vessels is a cause of intracerebral haemorrhage in
young adults.
• There are several case studies of ICH during pregnancy in patients
with moyamoya disease.
• Haematomas with significant mass effect should be removed,
although the fragile vessels pose a risk of recurrent haemorrhage.
• Management of the chronic ischaemia is a complex problem, often
requiring revascularization surgery with bypass grafts. Unless there
are transient ischaemic attacks indicating a high-risk of imminent
ischaemic stroke, revascularization surgery may best be delayed
until after delivery.

33. Management- Principles
• Principles for ICH are similar in pregnant and non-pregnant
patients.
• After resuscitation, the first priority is the evacuation of any
haemorrhage causing critical mass effect
• the next priority is to investigate and address the underlying
source of the haemorrhage such as aneurysm or AVM.
• Attention then turns to preventing further haemorrhage.
• It is important that management of these patients takes place
in facilities where there is appropriate neurosurgical, obstetric,
neurological and neuroradiological expertise.
• Emergency Delivery (POG) – Vaginal or Caesarean

34. Management Of Acute Hemorrhagic Stroke During Pregnancy
(Subarachnoid Hemorrhage, Intracerebral Hemorrhage)
June - 2018 UPDATE
The overall goal is to minimize the risk of rebleeding.
Diagnosis- vessel imaging (time-of-flight MR Angiography, CT
Angiography, catheter angiography) is preferred to guide further
management decisions
Pregnancy should not be regarded as a contraindication for angiography
and endovascular treatment of a vascular cause for hemorrhage.
For unruptured cerebral aneurysm, an MRI without contrast (with time-
of-flight MR angiography) is reasonable to define the lesion.
The acknowledgement of possible fetal risks is appropriate: risks include
radiation and contrast exposure, as well as blood loss that could result in
both maternal and fetal compromise.

35. • Ruptured aneurysm should be treated urgently based on the best
available option for the patient regardless of her pregnancy status.-
choice of coils or clip depending on condition
• Efforts to reduce hypertension to a target of less than 140/90 mmHg, if
clinically indicated, are reasonable.
• The treatment of ruptured aneurysms requires an urgent
interdisciplinary approach including neurosurgeon and/or
endovascular interventionalist, neurologist and physicians with
expertise in maternal-fetal medicine whenever possible.
• Maternal safety and outcomes should be considered throughout all
discussions of management and may require treatment decisions that
potentially compromise the pregnancy or the fetus.

36. • If the timing corresponds with a viable gestational age,
wherwhere neonatal outcomes are considered favourable, an
interdisciplinary team including, for example, neurosurgery
and/or neurointerventionalists, maternal-fetal medicine,
obstetrics, neonatology, neurology, anaesthesia, and obstetrical
medicine where available may consider the benefits of a
concurrent Cesarean delivery.
• If the timing corresponds to a pre-viable gestational age,
treatment should proceed as it would outside of the context of
pregnancy in order to maximize maternal safety and outcomes.

37. Intracerebral Haemorrhage
• expedite delivery by caesarean section in order to avoid
Valsalva manoeuvres and transient blood pressure surges that
may lead to further haemorrhage
• where AVM rupture occurs at an advanced gestational stage –
prompt delivery – the AVM can then be treated along
conventional lines
• Vaginal delivery is not precluded after an AVM resection,
although fragile vessels in the brain at the resection margin
may remain at higher risk of haemorrhage in the first few weeks
after an AVM has been removed.

38. Drugs To Be Utilized With Caution In
Pregnant Women
• Mannitol may result in fetal hypoxia & acid-base shifts
• Antiepileptic drugs - teratogenic risk
• Nimodipine - teratogenicity in some animal experiments
• However, ultimately, the use of these agents in critically ill
pregnant patients may outweigh the potential risks

39. Summary: ICH In The OB Patient
Prevention
Recognize and optimally treat HTN
Diagnose preeclampsia and institute seizure
prophylaxis
Recognize and optimally treat HTN
Recognize and appropriately treat coagulopathy
Recognition
Patients and providers must appreciate the
seriousness o
f
neurologic warning signs
Management
Immediate evaluation of neurologic warning signs
Immediate consultation with neurology
Imaging

40. Prevention
• Whether pregnant or planning to become pregnant
— to take measures to prevent the health problems
commonly associated with stroke.
• Eat a low-fat, low-sodium, high-fiber diet
• Maintain a healthy weight

41. Prevention
• Stay physically active
• Don’t smoke
• Women suffering from heart disease or diabetes should
also begin treatment far in advance of pregnancy,
• Even those carrying a little extra weight can be
proactive by “dropping a few pounds before
pregnancy”

42. Evidence
• There are no follow-up studies that consider the risk of
recurrent stroke in future pregnancies.
• No data are available on the risk associated with use of
OCPs in a woman who had ischemic stroke during
pregnancy.
• The frequency of cerebral venous thrombosis
associated with pregnancy and the puerperium is not
precisely known.

43. Evidence
• Indeed, epidemiologic studies have been difficult to
perform because cerebral venous thrombosis may
have a misleading presentation and a definite
diagnosis requires angiography, MRI or autopsy.
• Whether pregnancy increases the risk of rupture of
an arteriovenous malformation is controversial.