Anesthesia and hemorrhagic stroke in pregnancy: case report and literature review

Introduction

Background

Hemorrhagic stroke during pregnancy is rare but clinically complex. Hemorrhagic strokes occur in approximately 10% to 25% of all parturients presenting with stroke and are often accompanied by a greater maternal morbidity and mortality than ischemic strokes (1,2). According to recent data, hemorrhagic stroke mainly occurs in the third trimester and 12 weeks postpartum (1). It is defined as an acute cerebrovascular event resulting from the rupture of an intracranial blood vessel, leading to extravasation of blood into the brain parenchyma (intracerebral hemorrhage, ICH) or into the subarachnoid space (subarachnoid hemorrhage, SAH). It is commonly attributed to hemodynamic and hormonal changes occurring in late pregnancy or immediately following delivery (3).

The physiological alterations during pregnancy, such as hypercoagulability, increased blood volume and cardiac output, predispose all pregnant women to the risk of vascular rupture, particularly in the presence of hypertension conditions such as preeclampsia or eclampsia (4). Furthermore, during pregnancy, structurally innocent vascular malformations such as arteriovenous malformations (AVMs) or cerebral aneurysms can degenerate or rupture secondary to increased vascular pressures (5). In this setting, neuroimaging for early diagnosis, coupled with an aggressive multidisciplinary approach, is essential (3).

Rationale and knowledge gap

Controlled hemorrhagic stroke in pregnancy is an anesthetic conundrum, in which maternal neurologic status and fetal well-being are inextricably tied (6). Decisions concerning mode of delivery, timing, and anesthetic technique must be made by obstetricians, anesthesiologists and neurosurgeons (3). Primary anesthetic goals are to preserve cerebral perfusion pressure (CPP), avoid rises in intracranial pressure (ICP), maintain uteroplacental blood flow, and improve fetal oxygenation (5). Thus, the choice of an anesthetic agent should also contemplate the effect on cerebral hemodynamics and fetal outcome.

Objective

The present report outlines the anesthetic considerations and management strategies in the case of a pregnant patient with a spontaneous ICH. An analysis of 17 similar cases published over the past 15 years was performed to identify trends in anesthetic strategies and maternal-fetal outcomes, and to propose an evidence-based approach to the management of such complex scenarios. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-221/rc).

Case presentation

A 39-year-old gravida 3, para 1 woman at 35 weeks of gestation was referred/presented to the emergency department with sudden onset of severe pulsatile headache, nausea, photophobia, left ophthalmoplegia, and left-sided body weakness.

On arrival, vital signs included blood pressure 240/130 mmHg, while medical history included poorly controlled pregnancy-acquired hypertension. Neurological examination revealed left hemiparesis, facial asymmetry, and dysarthria. Normal heart rate patterns were seen on fetal monitoring. Intravenous (IV) antihypertensive therapy was promptly initiated. Labetalol was administered as the first-line agent, followed by hydralazine due to persistently elevated blood pressure. Additionally, magnesium sulfate was administered (4 g IV loading dose, followed by 2 g/h infusion) for seizure prophylaxis, in line with current recommendations for preeclampsia with severe features.

Emergency computed tomography (CT) scan revealed an intraparenchymal hematoma in the right side of the pons, exhibiting characteristics of a recent or subacute event, accompanied by perilesional edema and compression of the fourth ventricle and cerebral aqueduct (Figures 1,2). The CT scan was performed without the use of an intravenous iodinated contrast agent due to fetal considerations and urgent MRI was not available. Consequently, the presence of an underlying vascular malformation (e.g., aneurysm, AVM, cavernous malformation) could not be fully excluded at that time and endovascular therapy could not be evaluated as a treatment option. Considering gestational age and maternal status, the obstetrics team proceeded with an emergency cesarean section to minimize fetal risk and improve maternal outcome.

Figure 1 Axial non-contrast CT at the level of brainstem. The image demonstrates the hemorrhagic lesion (arrow). CT, computed tomography.

Figure 2 Coronal non-contrast CT at the level of brainstem. The image demonstrates the hemorrhagic lesion in the right posterior aspect of the pons (arrow). CT, computed tomography.

Rapid sequence induction (RSI) with thiopental (4 mg/kg) and rocuronium (1 mg/kg) followed by endotracheal intubation was performed in the operating room. Sevoflurane (minimum alveolar concentration, MAC 1.5) was used to maintain anesthesia in a 50:50 oxygen/air mixture. Fentanyl (1 µg/kg) was administered after delivery to deepen anesthesia and control the sympathetic response. A radial arterial line was instituted for continuous invasive blood pressure monitoring, and central venous access was secured. Cerebral edema was reduced with mannitol (0.25 g/kg) and furosemide.

A healthy 2.5 kg male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, was delivered via cesarean section. Magnesium therapy continued during the cesarean section and for 24 hours postpartum with close monitoring for toxicity signs. After surgery, the patient was transferred to the Intensive Care Unit (ICU) for further monitoring. Upon admission, she required mechanical ventilation and antihypertensive therapy with labetalol, olmesartan/hydrochlorothiazide, and furosemide, with a satisfactory antihypertensive response. Echocardiography revealed concentric hypertrophy of the left ventricle with an ejection fraction >55%, and a tricuspid aortic valve without signs of valvular disease. The right heart chambers had normal dimensions; mild pulmonary hypertension and minimal pericardial effusion were noted. On the second day of hospitalization, a follow-up brain CT scan demonstrated no significant changes compared to the initial imaging, and the patient met clinical criteria for weaning from mechanical ventilation (Figure 3). On the fifth day, she was transferred to a neurological center due to persistent hypertension and suspected cerebrovascular pathology. Routine labs on the same day showed decreased hemoglobin levels without overt bleeding, and she received one unit of packed red blood cells. Gradual clinical improvement was observed, with stabilization of her hemodynamic status and neurological function. After 22 days of hospitalization, the patient was discharged in stable condition. The patient demonstrated partial motor function recovery during hospitalization and regained some voluntary movement in the affected limbs. Further physiotherapy was recommended to support functional improvement. The patient expressed her satisfaction with the outcome of the treatment and recovery. The follow-up recommendations were repeat neuroimaging and close neurologic and obstetric surveillance. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was obtained from the patient. A copy of the written consent is available for review by the editorial office of this journal.

Figure 3 Axial non-contract CT performed after 3 weeks. The image shows a hypodense area in the location of the prior pontine hemorrhage (arrow). CT, computed tomography.

Discussion

Key findings

This case provides important insight into the management of hemorrhagic stroke in late pregnancy. Rapid diagnosis and coordinated multidisciplinary decision-making enabled timely emergency cesarean delivery, resulting in maternal stabilization and the birth of a healthy neonate. From an anesthetic standpoint, general anesthesia allowed rapid airway control, tight hemodynamic control, and cerebral protection in the setting of severe hypertension and brainstem hemorrhage. This staged approach contributed to a favorable maternal and neonatal outcome in a rare but high-risk clinical scenario.

Strengths and limitations

A key strength of this report lies in the detailed documentation of perioperative management and the multidisciplinary approach adopted to optimize both maternal and fetal outcomes. The combination of case presentation and literature review enhances the clinical relevance of the report, providing practical guidance for anesthetic decision-making in hemorrhagic stroke during pregnancy. In addition, the favorable maternal and neonatal course illustrates that timely multidisciplinary intervention and staged management can be effective in selected high-risk presentations.

However, this report is limited by its single-case nature, which restricts the generalizability of the observations. Future multicenter case series and systematic reviews are warranted to better define evidence-based protocols for anesthetic and obstetric management in such complex situations.

Comparison with similar research

The anesthetic strategy used in this case aligns closely with current evidence and previously reported experiences. In accordance with recent literature, RSI preferably relies on rocuronium as the neuromuscular blocker of choice for rapid intubation while minimizing the risk of aspiration, a danger for pregnant women in whom gastric emptying is delayed (7). Although RSI and intubation with cricoid pressure using thiopental-succinylcholine have been the standard for cesarean section under general anesthesia for a long time, it seems that rocuronium gradually replaces succinylcholine (7). Succinylcholine-induced hyperkalemia questioned its use in acute stroke care, despite its excellent muscle relaxation capacity; therefore, rocuronium was preferred in our case (8). Volatile agents such as sevoflurane are often maintained throughout anesthesia and may assist with cerebral vasodilation and metabolic suppression (9). Ventilation strategies used to maintain normocapnia or mild hypocapnia to prevent further ICP elevation (10).

Review of the literature over the past 15 years, as summarized in Table 1, indicates that most cases occurred in the third trimester (6,11-13). Similar to previous reports, chronic hypertension remains one of the most important predisposing factors for hemorrhagic stroke during pregnancy. A recent case from Shah et al. also described a hypertensive pregnant woman at 37 weeks who presented with ICH, emphasizing that early recognition and prompt multidisciplinary management are crucial for maternal and fetal survival (14).

Most precipitating factors were hypertensive disorders, cerebral aneurysms, and AVMs. Recent evidence confirms that AVM rupture during pregnancy carries a high risk of rebleeding and significant maternal and fetal mortality. Early multidisciplinary management and prevention of rebleeding are considered essential to improve outcomes (15). In most reported cases, general anesthesia was the preferred method, with propofol and isoflurane being the most commonly used agents. Early neurosurgical decompression and meticulous anesthetic control resulted in favorable maternal outcomes, while neonatal outcomes were favorable if delivery preceded surgical intervention, and gestational age was greater than 32 weeks (5).

Explanations of findings

Pregnancy is associated with marked cardiovascular and hemostatic changes such as rapid shear stress, increased cardiac output, plasma volume, and hypercoagulability, which can further increase the risk for hemorrhagic events (13,16). Further complicating matters, hypertensive disorders like preeclampsia and eclampsia both increase susceptibility to cerebral bleeding because of increased vascular permeability and fragility (Guida). Rapid multidisciplinary planning is essential to confirm hemorrhagic stroke on neuroimaging [typically CT or magnetic resonance imaging (MRI)] (1,3). In the present case, severe hypertension and brainstem hemorrhage necessitated immediate confirmation of intracranial pathology with non-contrast CT, as iodinated contrast was avoided due to fetal considerations and urgent MRI was not available. This was followed by coordinated planning between obstetrics, anesthesiology, and neurology.

Anesthetic management is focused on optimizing maternal cerebral perfusion with preservation of uteroplacental blood flow and adequate fetal oxygenation (3). In this context, general anesthesia is preferred in the presence of elevated ICP or the need for neurosurgical intervention, whereas regional anesthesia is contraindicated because of the risk of brain herniation (5). Agents such as thiopental are used for induction due to their rapid onset, neuroprotective properties, and ability to reduce cerebral metabolic rate of oxygen (CMRO₂), leading to the management of raised ICP (17). In the present case, the anesthetic strategy prioritized rapid airway control, tight blood pressure management, and cerebral protection under general anesthesia, while avoiding neuraxial techniques given the risk of elevated ICP and potential herniation.

Maternal hypotension or hypoxia during anesthetic induction or surgery is a serious threat to fetal outcome (18). Therefore, hemodynamic stability requires invasive arterial pressure monitoring (19). In this case, invasive arterial monitoring was instituted to allow continuous blood pressure management. Fetal monitoring is also advised to continue throughout the duration of pregnancy (especially beyond 24 weeks) (18). However, for gestational age that is sufficient (typically >32–34 weeks), case reports often recommend cesarean section before neurosurgical intervention to minimize fetal exposure to intraoperative stress and enable demanding maternal therapy (5,20,21). For younger gestations, it must be a careful balance between neonatal viability and maternal stabilization (5,21). In the present case, gestational age (35 weeks) was considered compatible with neonatal survival and favorable outcome; therefore, emergency cesarean delivery was undertaken prior to definitive maternal neurocritical management to minimize fetal risk and allow aggressive maternal stabilization.

Implications and actions needed

The present case highlights several important implications for clinical practice. Hemorrhagic stroke during pregnancy represents an obstetric and neurosurgical emergency in which timely recognition and rapid coordination among obstetric, anesthetic, and neurocritical care teams are essential to optimize maternal and fetal outcomes. Postoperative and intensive care management play a pivotal role in recovery and in preventing secondary brain injury.

Recent literature also strongly emphasizes the importance of postoperative care. After surgical intervention, standard care included admission to the intensive care unit for continuous neurocritical monitoring, hemodynamic (blood pressure) management, and implementation of measures to prevent secondary brain injury (22). The cornerstone of ICU management includes measures such as head elevation, sedation, osmotic therapy with mannitol or hypertonic saline, and control of seizures with magnesium sulfate or antiepileptics (22). Variable long-term neurological outcome is largely dependent upon the initial severity of the hemorrhage and the promptness of medical and surgical intervention (22). Therefore, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine suggest managing emergency cases during pregnancy, such as hemorrhagic stroke, in a Level III or IV center with immediate access to neurosurgery, interventional radiology, and obstetric anesthesia (23,24).

Conclusions

This case illustrates the complexity of anesthetic planning in hemorrhagic stroke during late pregnancy, in which prompt imaging, effective interdisciplinary communication, and staged intervention—emergency cesarean delivery followed by decompressive craniotomy—were crucial. Key priorities in such cases include strict blood pressure control, prevention of intracranial hypertension, and timely delivery when appropriate. Early recognition of neurologic symptoms and rapid coordinated intervention are essential to optimize both maternal and neonatal outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-221/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-221/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-221/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was obtained from the patient. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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