Stroke Snapshot: Maternal Neurovascular Medicine—A Paradigm for Stroke Prevention Through Multidisciplinary Care

A Paradigm for Stroke Prevention Through Multidisciplinary Care

Stroke is a leading cause of maternal morbidity and mortality worldwide, and its incidence has increased over the past 2 decades. The increasing prevalence of vascular risk factors, including chronic hypertension, obesity, diabetes, and advanced maternal age, as well as congenital or acquired heart disease and autoimmune disorders, has transformed pregnancy into an increasingly complex neurovascular state. Advances in acute stroke therapies have improved outcomes in the general population, but maternal stroke represents a fundamental gap in our health care system: cerebrovascular care remains fragmented across obstetrics, neurology, cardiology, hematology, and primary care, often lacking coordinated longitudinal follow-up. In addition, socioeconomic and racial disparities, as well as gaps in knowledge related to stroke during pregnancy and the postpartum period, continue to complicate risk assessment and treatment.¹ As Comprehensive Stroke Centers continue to expand beyond acute intervention to encompass primary and secondary prevention, recovery, and systems of care, maternal cerebrovascular disease represents the next frontier in stroke care delivery.

Pregnancy as a Neurovascular Stress Test

Pregnancy represents one of the most profound physiologic challenges for the female body and cerebral circulation. Changes in hemodynamics, endothelial function, coagulation, immune regulation, and cardiac output are necessary to support fetal development but may also unmask underlying neurovascular vulnerability. These pregnancy-related changes may manifest as cerebrovascular complications, such as cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, cardioembolic stroke due to cardiomyopathy or arrhythmia, arterial dissections, or ischemic insult in the setting of infection or hemorrhage.^2,3 Rather than viewing these conditions as isolated obstetric complications, neurologists should recognize pregnancy as a neurovascular stress test that identifies women at increased risk for both immediate and future cerebrovascular disease.⁴ This shift in perspective transforms pregnancy from a period of transient risk into an opportunity for early stroke prevention.

Predicting Stroke Before It Happens

Many women who experience pregnancy-associated stroke have identifiable vascular risk factors before pregnancy or develop pregnancy-specific complications that substantially increase stroke risk. Chronic hypertension, obesity, diabetes, structural or functional heart disease, migraine, autoimmune disease, thrombophilia, and adverse pregnancy outcomes, including preeclampsia and severe postpartum hypertension, provide opportunities for early intervention.¹ As risk prediction models evolve through the incorporation of biomarkers, advanced imaging, digital health technologies, and artificial intelligence, vascular neurologists will play an increasingly important role in identifying women most likely to benefit from targeted prevention strategies. Integrating neurovascular risk assessment into routine obstetric care has the potential to prevent rather than rescue maternal stroke.

Pregnancy Factors That Increase Risk of Neurovascular Complications

Any hypertensive disorder of pregnancy can increase neurovascular risk. Controlling underlying hypertensive disorders has been shown to decrease the risk of maternal stroke. There are limited data to guide blood pressure goals in pregnancies with underlying risk factors for cerebrovascular disease. However, research supports the risk of stage 1 hypertension in pregnancy and suggests benefits of certain β-blocker and calcium channel blocker antihypertensive medications in the first part of pregnancy to decrease maternal and neonatal complications.¹

Low-dose aspirin starting at 12 weeks of gestation may decrease the risk of hypertensive disorders of pregnancy in some individuals. Reducing the risk of preeclampsia may decrease the risk of posterior reversible encephalopathy syndrome.⁵

For individuals at risk of thrombosis, the fetal safety of heparin and low-molecular-weight heparin is well established; however, a balanced discussion of bleeding risk, neuraxial anesthesia, and timing of delivery is essential.¹

Individuals with underlying severe dyslipidemias, such as those with known early-onset coronary artery disease or familial hypercholesterolemia, are likely to benefit from statin therapy during pregnancy.⁶

Pregnancy Is Not a Contraindication to Reperfusion

For pregnant and postpartum individuals with acute ischemic stroke, pregnancy or recent pregnancy should not delay evidence-based reperfusion therapy. Preserving maternal perfusion and organ function should be the goal of therapy, given that fetal development and outcomes generally improve when the maternal condition is optimized. Intravenous thrombolysis should be considered when the anticipated maternal benefits outweigh the maternal risks. Neither alteplase nor tenecteplase crosses the placenta.¹

Decisions require careful consideration of recent or anticipated cesarean delivery and neuraxial anesthesia. Gestational age should be considered in discussions with the obstetric specialty team.¹ When possible, individuals or their medical power of attorney should be counseled about available options; however, the emergent nature of these cases may limit opportunities for in-depth discussions.

Mechanical thrombectomy is recommended for otherwise eligible individuals with large-vessel occlusion. When feasible, a radial approach could be considered to decrease the risk of infection and theoretically decrease fetal radiation exposure, although this recommendation is based on limited data. A transfemoral approach should be considered if a radial approach is not feasible^.1

Special attention should be given to anesthesia, as pregnancy-related airway edema and hyperemia may complicate airway management and increase the risk of aspiration.¹

Fetal monitoring may be considered when there is concern for maternal decompensation during the procedure, which could result in fetal hypoxemia or fetal loss. Fetal monitoring should be interpreted cautiously, as findings may lead to unnecessary cesarean delivery. Cesarean delivery can increase maternal risk, particularly in an emergency or during thrombolytic therapy.¹

Management should involve multidisciplinary coordination among vascular neurology, maternal-fetal medicine or obstetrics, anesthesiology, and other relevant specialists. In remote areas with limited access to these subspecialty teams, telehealth support with backup from a referral center can be beneficial.¹

Beyond Acute Stroke: A Continuum of Maternal Neurovascular Care

Timely diagnosis and evidence-based reperfusion therapies are essential, but comprehensive maternal neurovascular care extends beyond hospitalization. Women require coordinated postpartum care including blood pressure surveillance, optimization of vascular risk factors, individualized antithrombotic management, counseling regarding future pregnancies, and long-term cerebrovascular follow-up. Pregnancy complications frequently represent the earliest clinical manifestation of lifelong vascular disease, making the postpartum period a critical window for secondary prevention.¹ A continuum of care that extends across the reproductive lifespan offers an opportunity not only to reduce recurrent maternal stroke but also to improve long-term cardiovascular and brain health.

Maternal Neurovascular Medicine: A Co-Led Model of Care

The traditional consultation model is no longer sufficient for women with complex pregnancy-associated cerebrovascular disease. Obstetric specialists and maternal-fetal medicine subspecialists possess expertise in pregnancy physiology, placental disease, fetal well-being, obstetric risk stratification, and delivery planning that is indispensable to clinical decision-making. Vascular neurologists contribute expertise in stroke diagnosis, acute treatment, secondary prevention, neuroimaging, and long-term cerebrovascular management. No specialty alone can provide comprehensive maternal stroke care.

Maternal neurovascular medicine should therefore be envisioned as a co-led clinical program, jointly directed by vascular neurology and maternal-fetal medicine within Comprehensive Stroke Centers. This core partnership should lead a larger medical team tailored to each individual’s needs and might also include specialists in cardiology, hematology, anesthesiology, neuroradiology, genetics, rehabilitation, pharmacy, and primary care. Ideally, subspecialty team members can see the individual during the same visit. Rather than coordinating care only after stroke occurs, this integrated model spans preconception counseling, antenatal risk assessment, delivery planning, postpartum surveillance, secondary stroke prevention, and counseling for future pregnancies. Such programs not only improve communication and standardize evidence-based care but also establish infrastructure for clinical research, education, quality improvement, and implementation of best practices across institutions.

Looking Ahead: Defining the Future of Maternal Neurovascular Medicine

Maternal neurovascular medicine represents more than the intersection of obstetrics and vascular neurology; it reflects a fundamental reorganization of maternal stroke care. Future priorities include validating prediction models, incorporating digital monitoring into postpartum surveillance, defining longitudinal care pathways, and addressing persistent racial, geographic, and socioeconomic disparities in maternal outcomes. Just as Comprehensive Stroke Centers have evolved to incorporate neurocritical care, endovascular therapy, cerebrovascular surgery, and neurorehabilitation as core components of stroke systems of care, the next evolution should be the establishment of maternal neurovascular medicine programs co-led by vascular neurology and maternal-fetal medicine. The ultimate success of this paradigm will not be measured solely by improved treatment of maternal stroke but by preventing these events through coordinated, multidisciplinary care that protects the neurologic health of women across their reproductive lifespan and beyond.