Long-Term Risk of Recurrent Cervical Artery Dissection and Stroke After Pregnancy

Importance: Cervical artery dissection (CeAD) is a leading cause of stroke in young people and can occur during pregnancy. In women with prior CeAD, it is unclear whether future pregnancies increase the risk of recurrent CeAD, stroke, or death. Objective: To compare the frequency of recurrent CeAD, stroke, or death as a composite outcome between patients with CeAD who became pregnant vs those who did not. Design, Setting, and Participants: The Long-Term Risk of Recurrent Cervical Artery Dissection and Stroke After Pregnancy (LONG-RECAP) study was an international, multicenter, registry-based, explorative cohort study with data from May 1, 1990, and April 30, 2023, among patients with CeAD at 33 stroke centers across 9 countries who had at least 6 months of follow-up for whom detailed information was available on absence vs presence of subsequent pregnancies and the occurrence of outcome events. Exposure: Pregnancy after CeAD. Main Outcomes and Measures: Composite of recurrent CeAD, stroke (any type), and death (all causes) during follow-up at least 6 months after initial CeAD. Secondary outcomes were the components of the composite outcome. Cox proportional hazards regression analysis with and without adjustment for age was used to examine the association between pregnancy and outcomes. Results: Among 1013 female patients with CeAD (median [IQR] age, 42 [35-48] years), 114 (11.3%) became pregnant during a median (IQR) follow-up of 5.3 (2.0-11.3) years. The composite outcome occurred in 10 of 114 patients (8.8%), including 7 patients with recurrent CeADs, 2 with ischemic strokes, and 1 with intracerebral hemorrhage, in the pregnancy group compared with 65 of 899 patients (7.2%), including 32 with recurrent CeAD, 26 with ischemic strokes, 4 with intracerebral hemorrhages, and 5 deaths (2 patients had 2 outcomes), in the nonpregnancy group (unadjusted hazard ratio, 1.08; 95% CI, 0.56-2.08; age-adjusted hazard ratio, 0.77; 95% CI, 0.38-1.56). Five of 10 events in the pregnancy group occurred post partum (4 CeADs and 1 stroke). Age-adjusted hazard ratios for secondary outcomes were 1.03 (95% CI, 0.43-2.46) for recurrent CeAD, 0.53 (95% CI, 0.13-2.12) for ischemic stroke, 1.01 (95% CI, 0.11-9.32) for intracerebral hemorrhage, and 0.90 (95% CI, 0.03-24.88) for death. Conclusions and Relevance: In this cohort study of women with a history of CeAD, becoming pregnant was not associated with an increased risk of recurrent CeAD, stroke, or death. These findings may be helpful for individual counseling and family planning for women with prior CeAD.