Intracerebral hemorrhage (ICH) is a subtype of stroke that is rare in pregnancy, but when it occurs, can result in disability or even death. One of the key risk factors for ICH in pregnancy and the postpartum period is hypertension, specifically hypertensive disorders of pregnancy that are not well controlled. The more severe forms of these include preeclampsia and HELLP syndrome, which is characterized by hemolysis, elevated liver enzymes, and low platelets. People are also at risk if they have had chronic hypertension and then develop preeclampsia during pregnancy.
Preeclampsia puts pregnant patients at higher risk for pregnancy-associated ICH.
However, little is known about how pregnancy-associated ICH differs from ICH that occurs in males and non-pregnant females. New research led by a multidisciplinary team at NewYork-Presbyterian and Columbia provides insight into whether ICH in pregnant people has a unique pathogenesis. NewYork-Presbyterian and Columbia physicians Eliza C. Miller, MD, MS, a neurologist, and Whitney A. Booker, MD, a maternal-fetal medicine specialist, discuss the genesis of this research and the importance of recognizing signs of hemorrhagic stroke during pregnancy and the postpartum period.
Research Methods
We performed a retrospective analysis of 134 young adult patients, aged 18 to 44 years, who were treated for nontraumatic ICH at Columbia University Irving Medical Center over a 10-year period. Some patients were part of the Intracerebral Hemorrhage Outcomes Project (ICHOP), a long-term study on ICH outcomes, and the others came from a separate registry of patients with pregnancy-related stroke. Since the patients were all treated at our center, we had extremely granular data, including complete imaging and specifics on the location of the stroke.
Research Goals
In general, hemorrhagic stroke is extremely rare in adults under 45 years old. There has been a general sense that most intracerebral hemorrhages in young adults are caused by the rupture of a lesion in the brain. However, our clinical experience at NewYork-Presbyterian and Columbia has been different. We have seen ICH associated with preeclampsia and HELLP syndrome or other hypertensive disorders where there was no underlying vascular malformation. Part of what motivated us to conduct this study was the need to better understand these spontaneous hemorrhages and to find out if there were differences in the cause of ICH in young adults who were pregnant, compared with young adult males and non-pregnant females.
Key Findings
This was a descriptive study but one conclusion that we can draw is that these three patient groups are quite different from each other when it comes to ICH. Among the 134 young adults in our study with ICH, one in five cases was pregnancy-related. Patients with pregnancy-related ICH had more lobar hemorrhages, as well as more hemorrhages associated with posterior reversible cerebral vasoconstriction syndrome or reversible cerebral vasoconstriction syndrome. The findings clearly indicate that pregnancy deserves its own study to better understand the neurological changes happening during this period. But a clinical lesson to take from this study is to recognize that there is a risk for ICH in pregnancy. When a pregnant woman presents with signs and symptoms of ICH, including an intense headache or altered mental status, she could be having a neurological complication of pregnancy.
Next Steps
One of the projects we’re working on now is a pilot study using advanced neuromonitoring techniques to observe the brain activity of patients with preeclampsia. The project is a partnership between the vascular neurology and maternal-fetal medicine teams, and it is just the latest example of how the multidisciplinary approach at NewYork-Presbyterian and Columbia is helping to answer important research questions.
