Neurocritical Care

, Volume 30, Issue 1, pp 5–15 | Cite as

Spontaneous Intracranial Hemorrhage in Pregnancy: A Systematic Review of the Literature

  • Luis C. Ascanio
  • Georgios A. Maragkos
  • Brett C. Young
  • Myles D. Boone
  • Ekkehard M. KasperEmail author
Review Article


Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6 weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.


Pregnancy Intracranial hemorrhage Intraparenchymal hemorrhage Spontaneous subarachnoid hemorrhage Subdural hemorrhage Systematic review 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

12028_2018_501_MOESM1_ESM.docx (33 kb)
Supplementary material 1 (DOCX 32 kb)


  1. 1.
    Fairhall JM, Stoodley MA. Intracranial haemorrhage in pregnancy. Obstet Med. 2009;2:142–8.CrossRefGoogle Scholar
  2. 2.
    James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol. 2005;106:509–16.CrossRefGoogle Scholar
  3. 3.
    Moatti Z, Gupta M, Yadava R, Thamban S. A review of stroke and pregnancy: incidence, management and prevention. Eur J Obstet Gynecol Reprod Biol. 2014;181:20–7.CrossRefGoogle Scholar
  4. 4.
    Liang CC, Chang SD, Lai SL, Hsieh CC, Chueh HY, Lee TH. Stroke complicating pregnancy and the puerperium. Eur J Neurol. 2006;13:1256–60.CrossRefGoogle Scholar
  5. 5.
    Algra AM, Klijn CJ, Helmerhorst FM, Algra A, Rinkel GJ. Female risk factors for subarachnoid hemorrhage: a systematic review. Neurology. 2012;79:1230–6.CrossRefGoogle Scholar
  6. 6.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.CrossRefGoogle Scholar
  7. 7.
    Institute TJB. Joanna Brigss institute reviewer’s manual. 2016th ed. Australia: The Joanna Brigss Institute; 2016.Google Scholar
  8. 8.
    Pahadiya HR, Lakhotia M, Gandhi R, Choudhary A, Madan S. Multiple intracranial hemorrhages in pregnancy: a common autoimmune etiology. J Neurosci Rural Pract. 2016;7:290–4.CrossRefGoogle Scholar
  9. 9.
    Albano B, Del Sette M, Roccatagliata L, Gandolfo C, Primavera A. Cortical subarachnoid hemorrhage associated with reversible cerebral vasoconstriction syndrome after elective triplet cesarean delivery. Neurol Sci. 2011;32:497–501.CrossRefGoogle Scholar
  10. 10.
    Cano A, Valero MV, Llorens J, Santonja JJ. Fulminant subarachnoidal hemorrhage and coma subsequent to sudden-presenting hypertension. Eur J Obstet Gynecol Reprod Biol. 1992;47:80–2.CrossRefGoogle Scholar
  11. 11.
    Chedraui PA, Hidalgo LA, San Miguel G. Fatal intracranial hemorrhage in a pregnant patient with autoimmune thrombocytopenic purpura. J Perinat Med. 2003;31:526–9.CrossRefGoogle Scholar
  12. 12.
    Djoubairou BO, Onen J, Doleagbenou AK, El Fatemi N, Maaqili MR. Chronic subdural haematoma associated with pre-eclampsia: case report and review of the literature. Neurochirurgie. 2014;60:48–50.CrossRefGoogle Scholar
  13. 13.
    Gasco J, Rangel-Castilla L, Clark S, Franklin B, Satchithanandam L, Salinas P. Hemorrhagic stroke with intraventricular extension in the setting of acute posterior reversible encephalopathy syndrome (PRES): case report. Neurocirugia (Astur). 2009;20:57–61.CrossRefGoogle Scholar
  14. 14.
    Giannina G, Smith D, Belfort MA, Moise KJ Jr. Atraumatic subdural hematoma associated with pre-eclampsia. J Matern Fetal Med. 1997;6:93–5.Google Scholar
  15. 15.
    Hameed AB, Shrivastava VK, Blair L, Wing DA. Intracranial hemorrhage in pregnancy. AJP Rep. 2012;2:47–50.CrossRefGoogle Scholar
  16. 16.
    Hashiguchi K, Inamura T, Irita K, et al. Late occurrence of diffuse cerebral swelling after intracerebral hemorrhage in a patient with the HELLP syndrome—Case report. Neurol Med Chir (Tokyo). 2001;41:144–8.CrossRefGoogle Scholar
  17. 17.
    Hirsch KG, Froehler MT, Huang J, Ziai WC. Occurrence of perimesencephalic subarachnoid hemorrhage during pregnancy. Neurocrit Care. 2009;10:339–43.CrossRefGoogle Scholar
  18. 18.
    Laadioui M, Bouzoubaa W, Jayi S, et al. Spontaneous hemorrhagic strokes during pregnancy: case report and review of the literature. Pan Afr Med J. 2014;19:372.CrossRefGoogle Scholar
  19. 19.
    Levy DM, Jaspan T. Anaesthesia for caesarean section in a patient with recent subarachnoid haemorrhage and severe pre-eclampsia. Anaesthesia. 1999;54:994–8.CrossRefGoogle Scholar
  20. 20.
    Pandey M, Saraswat N, Vajifdar H, Chaudhary L. Subdural haematoma in pregnancy-induced idiopathic thrombocytopenia: conservative management. Indian J Anaesth. 2010;54:470–1.CrossRefGoogle Scholar
  21. 21.
    Wayhs SY, Wottrich J, Uggeri DP, Dias FS. Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy. Rev Bras Ter Intensiva. 2013;25:175–80.CrossRefGoogle Scholar
  22. 22.
    Yokota H, Miyamoto K, Yokoyama K, Noguchi H, Uyama K, Oku M. Spontaneous acute subdural haematoma and intracerebral haemorrhage in patient with HELLP syndrome: case report. Acta Neurochir (Wien). 2009;151:1689–92.CrossRefGoogle Scholar
  23. 23.
    Bateman BT, Olbrecht VA, Berman MF, Minehart RD, Schwamm LH, Leffert LR. Peripartum subarachnoid hemorrhage: nationwide data and institutional experience. Anesthesiology. 2012;116:324–33.CrossRefGoogle Scholar
  24. 24.
    Sameshima H, Nagaya K. Intracranial haemorrhage as a cause of maternal mortality during 1991–1992 in Japan: a report of the confidential inquiry into maternal deaths research group in Japan. Br J Obstet Gynaecol. 1999;106:1171–6.CrossRefGoogle Scholar
  25. 25.
    Werner RA, Priebe MM. Stroke during pregnancy. Top Stroke Rehabil. 1994;1:41–7.CrossRefGoogle Scholar
  26. 26.
    Semere LG, McElrath TF, Klein AM. Neuroimaging in pregnancy: a review of clinical indications and obstetric outcomes. J Matern Fetal Neonatal Med. 2013;26:1371–9.CrossRefGoogle Scholar
  27. 27.
    Ohno Y, Kawai M, Morikawa S, et al. Management of eclampsia and stroke during pregnancy. Neurol Med Chir (Tokyo). 2013;53:513–9.CrossRefGoogle Scholar
  28. 28.
    Leffert LR, Clancy CR, Bateman BT, et al. Patient characteristics and outcomes after hemorrhagic stroke in pregnancy. Circ Cardiovasc Qual Outcomes. 2015;8:S170–8.CrossRefGoogle Scholar
  29. 29.
    Ng J, Kitchen N. Neurosurgery and pregnancy. J Neurol Neurosurg Psychiatry. 2008;79:745–52.CrossRefGoogle Scholar
  30. 30.
    Kittner SJ, Stern BJ, Feeser BR, et al. Pregnancy and the risk of stroke. N Engl J Med. 1996;335:768–74.CrossRefGoogle Scholar
  31. 31.
    Sharshar T, Lamy C, Mas JL. Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Ile de France. Stroke in Pregnancy Study Group. Stroke. 1995;26:930–6.CrossRefGoogle Scholar
  32. 32.
    Block HS. Neurological complications of pregnancy. Curr Neurol Neurosci Rep. 2016;16:67.CrossRefGoogle Scholar
  33. 33.
    Miller EC, Yaghi S, Boehme AK, Willey JZ, Elkind MS, Marshall RS. Mechanisms and outcomes of stroke during pregnancy and the postpartum period: a cross-sectional study. Neurol Clin Pract. 2016;6:29–39.CrossRefGoogle Scholar
  34. 34.
    Lin LT, Tsui KH, Cheng JT, et al. Increased risk of intracranial hemorrhage in patients with pregnancy-induced hypertension: a nationwide population-based retrospective cohort study. Medicine (Baltimore). 2016;95:e3732.CrossRefGoogle Scholar
  35. 35.
    Moulin S, Cordonnier C. Prognosis and outcome of intracerebral haemorrhage. Front Neurol Neurosci. 2015;37:182–92.CrossRefGoogle Scholar
  36. 36.
    Samarasekera N, Fonville A, Lerpiniere C, et al. Influence of intracerebral hemorrhage location on incidence, characteristics, and outcome: population-based study. Stroke. 2015;46:361–8.CrossRefGoogle Scholar
  37. 37.
    American College of. O, Gynecologists’ Committee on obstetric P. Committee Opinion No. 656: guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol. 2016;127:e75–80.CrossRefGoogle Scholar
  38. 38.
    Yoshitani K, Inatomi Y, Kuwajima K, Ohnishi Y. Anesthetic management of pregnant women with stroke. Neurol Med Chir (Tokyo). 2013;53:537–40.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Luis C. Ascanio
    • 1
  • Georgios A. Maragkos
    • 1
  • Brett C. Young
    • 2
  • Myles D. Boone
    • 3
  • Ekkehard M. Kasper
    • 1
    Email author
  1. 1.Neurosurgical Service, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Department of Obstetrics/Gynecology, Division of Maternal-Fetal Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  3. 3.Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA

Personalised recommendations