Long-term neurological consequences of hypertensive disorders of pregnancy: Implications for postpartum monitoring and intervention

Table 3 Structural and neuroimaging findings after hypertensive disorders of pregnancy per PubMed analysis, including white matter hyperintensities, brain atrophy, and vascular changes

Ref.	Country/design	Exposure (HDP subtype)	Sample (exposed/ref)	Time since index pregnancy	Imaging modality/measure	Main finding(s)	Notes/adjustments
Hussainali et al[41], 2025	ORACLE substudy, Netherlands	Gestational HTN or PE	63 GH, 30 PE/445 ref (n = 538 total)	Median 14.6 years	MRI markers of CSVD (WMH volume, lacunes, microbleeds)	WMH volume increase after HDP [β = 0.32 (0.08-0.56)]; driven by GH [β = 0.39 (0.10-0.67)]; no differences in lacunes or microbleeds. Trend increase with later chronic HTN	Adjusted for age, BMI, education, ICV
Alers et al[42], 2023	Netherlands; cohort MRI + cognition	Prior PE	96/96 ref	Approximately 15 years	MRI-gray and white matter volumes, WML load, and cognitive testing	Cortical and subcortical gray and white matter volumes decrease after PE; WML burden increase; slower processing speed and impaired executive function vs controls (all P < 0.05)	Adjusted for age, BMI, and education
Canjels et al[43], 2022	Netherlands; case-control MRI	Prior PE	22/13 ref	6.6 years PE vs 9.0 years ref	Contrast-enhanced MRI: BBB leakage (Ki, vl)	BBB leakage higher in PE across whole cerebrum-global WM Ki increase (P = 0.001) and GM Ki increase (P = 0.02); aOR for high Ki approximately 48 (3.5-651) WM, 3.5 (1.1-30.8) GM	Adjusted for age, HTN at MRI, Fazekas
Akhter et al[34], 2019	Sweden; vascular imaging	Prior PE	23/35 ref	Approximately 7 years	Carotid ultrasound: Intima thickness increase, I/M ratio increase, IMT decrease	At 7 years, intima 012 mm vs 0.09 mm, I/M increase (P < 0.001); IMT paradoxically lower. Correlated with MAP and biomarkers	Adjusted for BMI, BP, MAP
Siepmann et al[44], 2017	Germany; cohort imaging	Prior PE	34/40 ref	5-15 years	3T MRI: WM lesions, microstructure (DTI), cortical volumes	Temporal-lobe WM lesion volume increase after PE (P = 0.04); cortical GM volume decrease and DTI showed lower FA in parietal-occipital regions (P < 0.05)	Associations persisted after adjustment for MAP, HDL, and age
Postma et al[52], 2016	Netherlands; cross-sectional	Prior PE	41 eclampsia, 49 PE/47 ref	Approximately 6 years	MRI: WML presence, infarcts, periventricular/subcortical	WML more frequent in PE (40% vs 21%, P = 0.03). Infarcts only in PE. WML not tied to objective cognition	Adjusted for age and risk factors; subcortical WML P = 0.06; infarcts 4 vs 0
Mielke et al[46], 2016	United States; community cohort	History of HDP	286 HDP/297 ref	Approximately 35 years median follow-up	MRI: Total brain volume, WM lesion volume; cognition	Smaller brain volume in HDP (P = 0.023). WMH volume slightly increase (8.9 mL vs 8.1 mL, NS). Processing speed slower in HDP	Adjusted for demographics and vascular risk
Akhter et al[35], 2014	Sweden; case-control	Prior severe PE	42/44 ref	Approximately 9 years (range 1-13)	Carotid wall imaging (intima, I/M, IMT)	Intima 013 mm vs 0.08 mm (+63%); I/M ratio 0.27 vs 0.15 (+80%); IMT no difference	Structural differences persisted after adjustment for BMI, age, BP
Aukes et al[47], 2012	Netherlands; cross-sectional	Prior PE (early vs late onset)	73/75	Approximately 5 years	MRI: WM lesion volume, periventricular WML, infarcts	WML burden increase after PE (β = 0.77; P = 0.04); early-onset PE highest (P < 0.01); periventricular WML 5 vs 0	Current HTN independently increase WML risk
Aukes et al[48], 2009	Netherlands; case-control	Former eclampsia	39/29	Median 7 years (IQR 3-14)	MRI: WML load (volume and severity)	WML volume greater in eclampsia (0.041 mL vs 0.004 mL, P = 0.016). More WML in women with seizures (P = 0.01)	WML load is correlated with seizure recurrence

HDP: Hypertensive disorder of pregnancy; Ref: Reference/control group; HTN: Hypertension; PE: Preeclampsia; GH: Gestational hypertension; MRI: Magnetic resonance imaging; CSVD: Cerebral small-vessel disease; WMH: White-matter hyperintensity; BMI: Body mass index; ICV: Intracranial volume; WML: White-matter lesion; BBB: Blood-brain barrier; K_i: Leakage rate constant; v_l: Leakage volume fraction; WM: White matter; aOR: Adjusted odds ratio; GM: Gray matter; aOR: Adjusted odds ratio; I/M: Intima/media ratio; IMT: Intima-media thickness; BP: Blood pressure; MAP: Mean arterial pressure; DTI: Diffusion tensor imaging; FA: Fractional anisotropy; HDL: High-density lipoprotein; NS: Not significant; β: Regression coefficient; IQR: Interquartile range.