Transient Neurologic Symptoms During Pregnancy
May 1, 2008 3 minutes read
Transient Neurologic Symptoms During Pregnancy
Abstract & Commentary
By John J. Caronna, MD, Professor of Clinical Neurology, Weill Cornell Medical College, New York, NY Dr. Caronna reports no financial relationships relevant to this field of study
Synopsis: Transient neurological symptoms during pregnancy are usually benign and related to migraine.
Source: Liberman A, et al. Natural course and pathogenesis of transient focal neurologic symptoms during pregnancy. Arch Neurol 2008;65:218-220.
Pregnancy and the puerperium are prothrombotic states. During pregnancy, many pathologic conditions have been linked to stroke: preeclampsia and eclampsia, arterial dissection, cardioembolism, thrombophilia, systemic lupus erythematosus, anticardiolipin antibody syndrome, smoking, recreational drug abuse, migraine, and others. Nevertheless, ischemic strokes and transient ischemic attacks (TIA) are rare with an estimated incidence that varies widely from 8 to 68 events per 100,000 pregnancies.1
Liberman and associates studied the pathogenesis and course of transient neurologic symptoms (TNS) in pregnant women. They evaluated pregnant women presenting to a university hospital in Israel with focal neurologic symptoms lasting between five minutes and 24 hours. Women with a history of migraine, stroke, TIA (transient ischemic attack), deep vein thrombosis, pulmonary embolism, systemic thrombosis, or known coagulopathy were excluded. All subjects underwent magnetic resonance (MR) imaging with a stroke protocol, MR angiography and MR venography, transesophageal echocardiography, and testing for hypercoagulability. Fourteen patients with TNS were enrolled out of almost 24,000 pregnancies registered during the study period (frequency = 58 of 100,000 pregnancies). The mean age of subjects was 31 and the mean gestational age at onset of TNS was 28 weeks.
TNS included aphasia in 6 patients, hemisensory symptoms in 5 patients, and hemimotor symptoms in 7 patients. In 4 patients, TNS were preceded by a migrainous visual aura; in 9 patients, TNS were followed by a first-ever migraine-like headache. Brain MRI showed evidence of acute infarction in only one patient and single, small hyperintense foci in two others. Eleven patients had normal MRI results. All patients had negative results from echocardiography and hypercoagulability tests. None of the patients had recurrent TNS or a clinical stroke. Four patients developed recurrent migraine headaches with aura during the mean follow-up period of 12 months after the primary event.
Commentary
These data suggest that in otherwise healthy patients, TNS during pregnancy frequently are caused by the first attack of migraine with aura and have a benign prognosis. Screening with brain MRI is necessary and sufficient to rule out other causes. Although all women are at increased risk of thromboembolic events during pregnancy and for approximately 6 weeks after delivery, pregnancy-related stroke is rare. The risk of ischemic events in pregnancy is influenced by many factors, including ethnic background and age (see Davie and O'Brien for a review.)2 African-American women have a higher risk than Caucasian. Women older than age 35 are at increased risk of pregnancy-related stroke. Caesarean delivery is associated with a 3-12 times increased risk of stroke, but this may be due to a higher likelihood of caesarean delivery among women who already have had a stroke or who have other pregnancy-related conditions such as preeclampsia. Other factors, in addition to the known medical conditions linked to stroke in pregnancy (hypertension, diabetes, sickle cell disease, smoking, etc.), include multiple gestation and greater parity. Studies have shown a greater association of stroke with migraine headaches but it is difficult to know whether it is an independent risk factor for pregnancy-related stroke. The occurrence of stroke or TNS during pregnancy and the puerperium is a challenging diagnostic and management problem that requires specialized multi-disciplinary acute care by experts in obstetrics, neurology, and neuroradiology, and by rehabilitation specialists afterward.
References
1. James AH, et al. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106:509-516.
2. Davie CA, O'Brien P. Stroke and pregnancy. J Neurol Neurosurg Psychiatry 2008;79:240-245.
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