Background: Stroke in pregnancy is a rare but serious complication associated with significant maternal and fetal morbidity. Brainstem infarction is uncommon and may present with non-specific neurological symptoms, making diagnosis challenging. Early recognition and multidisciplinary management are essential to optimise outcomes.
Aim: To describe a rare case of recurrent bilateral pontine ischaemic stroke during pregnancy and highlight the importance of investigating persistent neurological symptoms in pregnancy.
Case: A G2P2 woman presented at 29+5 weeks’ gestation with persistent headache, visual disturbance and clonus despite being normotensive. Her history included early-onset pre-eclampsia in a prior pregnancy and idiopathic thrombocytopenia. MRI brain demonstrated a subacute right pontine lacunar infarct, managed conservatively. Stroke work-up, including cardiac imaging and evaluation for alternative aetiologies, was unremarkable except for a bicuspid aortic valve. Despite multidisciplinary care, she re-presented at 35+2 weeks with persistent headache, new gestational hypertension and MRI evidence of an acute left pontine infarct. Following exclusion of other causes, the mechanism was felt most consistent with hypertensive small vessel disease related to gestational vascular pathology. Escalating hypertension and recurrent neurological symptoms prompted elective caesarean delivery at 36+2 weeks. Postpartum care included thromboprophylaxis, secondary stroke prevention and strict blood pressure management.
Discussion: This case highlights that persistent neurological symptoms may precede overt hypertensive disease in pregnancy and should prompt early neuroimaging, particularly in women with prior pre-eclampsia. Recurrent pontine stroke in pregnancy is exceptionally rare and emphasises the need for early multidisciplinary involvement to guide timely diagnosis, delivery planning and secondary prevention.