1
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Osteraas ND. Sex-based difference in selected stroke etiologies: cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, dissection, migraine, pregnancy/puerperium/OC use. J Stroke Cerebrovasc Dis 2024:107753. [PMID: 38703878 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024] Open
Abstract
Females are at higher risk than males for a multitude of cerebrovascular conditions, both common and rare; partially resulting from a complex interplay between differing process involving genetics, hormonal influences, common cerebrovascular risk factors among others. Specific topics including cervical artery dissection, cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, migraine, along with these disorders in the setting of pregnancy, puerperium and oral contraceptive utilization. Epidemiology, pathophysiology, presentation, basics of management and outcomes are presented, with sex differences throughout.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neuroscience at Saint Lukes Hospital, Advocate Aurora Health. 2900 W Oklahoma Ave, Milwaukee, WI 53215.
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2
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Dobson R, Ovadia C, Mathews J, Brex P. Prescribing in pregnancy: navigating risks and benefits. Pract Neurol 2023; 23:366-367. [PMID: 37487704 DOI: 10.1136/pn-2023-003812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Joela Mathews
- Pharmacy, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Peter Brex
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
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3
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Lackovic M, Nikolic D, Jankovic M, Rovcanin M, Mihajlovic S. Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1707. [PMID: 37893425 PMCID: PMC10608338 DOI: 10.3390/medicina59101707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.
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Affiliation(s)
- Milan Lackovic
- University Hospital “Dragisa Misovic”, Heroja Milana Tepica 1, 11000 Belgrade, Serbia; (M.L.); (S.M.)
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Milena Jankovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Rovcanin
- Clinic for Gynecology and Obstetrics “Narodni Front”, 11000 Belgrade, Serbia;
| | - Sladjana Mihajlovic
- University Hospital “Dragisa Misovic”, Heroja Milana Tepica 1, 11000 Belgrade, Serbia; (M.L.); (S.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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4
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Manikinda J, Kaul S. Stroke Around Pregnancy; Protection and Prevention! Ann Indian Acad Neurol 2023; 26:631-637. [PMID: 38022451 PMCID: PMC10666856 DOI: 10.4103/aian.aian_492_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 12/01/2023] Open
Abstract
As per recent studies, incidence of stroke is increasing in pregnant women. It is essential to be vigilant and well-versed in managing stroke in pregnancy, as both the mother and the baby are prone to stroke-related injury. In this viewpoint article, we have reviewed the current data from research publications on the incidence, prevalence, risk factors, and clinical presentation of stroke in pregnancy. Finally, we have discussed the plan of investigations and the current treatment guidelines for stroke in pregnancy.
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Affiliation(s)
- Jayasree Manikinda
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Subhash Kaul
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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5
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Dawson J, MacDonald A. Sex and hypertensive organ damage: stroke. J Hum Hypertens 2023; 37:644-648. [PMID: 37059829 PMCID: PMC10403348 DOI: 10.1038/s41371-023-00830-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 02/08/2023] [Accepted: 04/05/2023] [Indexed: 04/16/2023]
Abstract
Stroke is a common cause of death and disability in both men and women. Differences in the incidence, presenting features and outcome after stroke have been reported between men and women. The global lifetime risk of stroke of approximately 25% is similar in men and women, although in women, the first cardiovascular event is more likely to be stroke than in men. Concerningly, there are reports of underuse of some treatments in women, although these differences may be diminishing over time. In addition, there are specific clinical challenges that can arise in women with stroke, such as stroke in people taking hormonal therapy, and stroke during pregnancy and stroke in the post-partum period. This review will cover these areas highlighting important differences and areas for future research. We found there are important differences in incidence of stroke, which differ by age. Further, there is concerning evidence that some treatments such as intravenous thrombolysis are underused in women. While there may be some differences in the relative effectiveness of treatments such as antiplatelet therapy and blood pressure reduction between men and women, for most aspects of stroke care, benefit is clear in both men and women and the emphasis must be on more equitable access. There is limited evidence to inform decision making during pregnancy and the post-partum period, but guidelines now exist and further research is needed in these areas.
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Affiliation(s)
- Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Alexander MacDonald
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
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6
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Richardt A, Aarnio K, Korhonen A, Rantanen K, Verho L, Laivuori H, Gissler M, Tikkanen M, Ijäs P. Etiology and risk factors of ischemic stroke during pregnancy and puerperium: A population-based study. Eur Stroke J 2023; 8:475-482. [PMID: 37231685 DOI: 10.1177/23969873231170096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Ischemic stroke (IS) is an uncommon, but potentially life-changing, complication of pregnancy. The aim of this study was to analyze the etiology and risk factors of pregnancy-associated IS. PATIENTS AND METHODS We collected a population-based retrospective cohort of patients diagnosed with IS during pregnancy or puerperium in Finland from 1987 to 2016. These women were identified by linking the Medical Birth Register (MBR) with the Hospital Discharge Register. Three matched controls were selected from MBR for each case. The diagnosis and temporal relationship of IS to pregnancy, and clinical details were verified from patient records. RESULTS A total of 97 women (median age 30.7 years) were identified as having pregnancy-associated IS. The most common etiologies based on TOAST classification were cardioembolism in 13 (13.4%), other determined in 27 (27.8%) and undetermined in 55 (56.7%) patients. Fifteen patients (15.5%) had embolic strokes of undetermined sources. The most important risk factors were pre-eclampsia, eclampsia, gestational hypertension, and migraine. IS patients had more frequently traditional and pregnancy-related stroke risk factors than the controls (OR 2.38, 95% CI 1.48-3.84) and the risk of IS multiplied with the number of risk factors (4-5 risk factors: OR 14.21, 95% CI 1.12-180.48). DISCUSSION AND CONCLUSION Rare causes and cardioembolism were frequent etiologies for pregnancy-associated IS, but in half of the women, the etiology remained undetermined. The risk of IS increased with the number of risk factors. Surveillance and counseling of pregnant women, especially with multiple risk factors, is crucial for the prevention of pregnancy-associated IS.
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Affiliation(s)
- Anna Richardt
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aino Korhonen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Verho
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannele Laivuori
- Department of Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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7
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Elmashala A, Garg A, Ghannam M, Shaban A. Thrombolysis in Extended Time Window for Acute Ischemic Stroke during Pregnancy. Clin Neurol Neurosurg 2023; 228:107713. [PMID: 37043843 DOI: 10.1016/j.clineuro.2023.107713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023]
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8
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Garg A, Roeder H, Leira EC. In-hospital outcomes and recurrence of stroke during pregnancy and puerperium. Int J Stroke 2023; 18:445-452. [PMID: 35838335 DOI: 10.1177/17474930221116209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are limited data regarding the best management and outcomes of acute stroke during pregnancy and the puerperium. METHODS Pregnancy-related hospitalizations with age > 18 years were identified from the Nationwide Readmissions Database 2016-2018. The study cohort consisted of all patients with acute stroke and a 5% random sample of the remaining non-stroke hospitalizations. Logistic regression and survival analyses were used to compare the in-hospital outcomes and readmissions in patients with and without acute stroke. RESULTS There were 11,829,044 pregnancy-related hospitalizations, of which 4057 had acute stroke. The mean ± SD age of the study cohort was 29.0 ± 5.7 years. Among patients with acute ischemic stroke, 60 (3.7%) patients received intravenous thrombolysis and 112 (6.8%) patients underwent endovascular thrombectomy. Among patients with intracranial hemorrhage, 205 (10.5%) patients underwent ventriculostomy and 18 (0.9%) patients underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 10.7 vs 2.7 days), higher in-hospital mortality (4.6% vs 0.0001%) and were less likely to discharge home (73.0% vs 98.6%). Non-elective readmission within 90 days of discharge occurred in 14.8% of patients with stroke versus in 3.9% of patients without stroke. Readmissions due to cerebrovascular events occurred in 2.3% of patients with stroke versus in 0.007% of patients without stroke within 1 year of discharge, with mean ± SD time to readmission 66.2 ± 78.0 days. CONCLUSION Stroke is a serious complication of pregnancy, associated with high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients, and the risk is highest during the initial 3 months.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hannah Roeder
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Enrique C Leira
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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9
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Stroke in Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023. [DOI: 10.1007/s13669-023-00351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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10
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Melliti M, Messelmani M, Zaouali J, Derbali H, Mrissa R. Postpartum ischemic stroke: a successful intravenous thrombolysis. Acta Neurol Belg 2023; 123:271-274. [PMID: 34661877 DOI: 10.1007/s13760-021-01789-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Maroua Melliti
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia.
| | - Meriem Messelmani
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
| | - Jamel Zaouali
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
| | - Hajer Derbali
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
| | - Ridha Mrissa
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
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11
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Yu AYX, Nerenberg KA, Diong C, Fang J, Chu A, Kapral MK, Edwards JD, Dancey SR, Austin PC, Auger N. Maternal Health Outcomes After Pregnancy-Associated Stroke: A Population-Based Study With 19 Years of Follow-Up. Stroke 2023; 54:337-344. [PMID: 36689587 DOI: 10.1161/strokeaha.122.041471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/07/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pregnancy-associated stroke carries high short-term morbidity and mortality, but data on subsequent maternal outcomes are limited. We evaluated long-term maternal health outcomes after pregnancy-associated stroke. METHODS In this retrospective cohort study, we used administrative data to identify pregnant adults aged ≤49 years with stroke between 2002-2020 in Ontario, Canada and 2 comparison groups: (1) non-pregnant female patients with stroke and (2) pregnant patients without stroke. Patients who survived the index admission were followed until 2021. After propensity score matching, we used Cox regression with a robust variance estimator to compare pregnant patients with stroke and the 2 comparison groups for the composite outcome of death and all-cause non-pregnancy readmission. Where proportional hazard assumption was not met, we reported time-varying hazard ratios (HR) with 95% CIs by modeling the log-hazard ratio as a function of time using restricted cubic splines. RESULTS We identified 217 pregnant patients with stroke, 7604 non-pregnant patients with stroke, and 1 496 256 pregnant patients without stroke. Of the 202 pregnant patients with stroke who survived the index stroke admission, 41.6% (6.8 per 100 person-years) subsequently died or were readmitted during follow-up. Median follow-up times were 5 years (pregnancy-associated stroke), 3 years (non-pregnant stroke), and 8 years (pregnant without stroke). Pregnant patients with stroke had a lower hazard of death and all-cause readmission compared with non-pregnant patients with stroke at 1-year follow-up (HR, 0.64 [95% CI, 0.44-0.94]), but this association did not persist during longer-term follow-up. Conversely, pregnant patients with stroke had higher hazard of death and readmission compared with pregnant patients without stroke at 1-year follow-up (HR, 5.70 [95% CI, 3.04-10.66]), and this association persisted for a decade. CONCLUSIONS Stroke during pregnancy is associated with long-term health consequences. It is essential to transition care postpartum to primary or specialty care to optimize vascular health.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada (A.Y.X.Y.)
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Kara A Nerenberg
- Departments of Medicine and Obstetrics and Gynecology, University of Calgary, Alberta, Canada (K.A.N.)
| | - Christina Diong
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Jiming Fang
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Anna Chu
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Moira K Kapral
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
- Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, Ontario, Canada (M.K.K.)
| | - Jodi D Edwards
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
- University of Ottawa Heart Institute, Ontario, Canada (J.D.E., S.R.D.)
| | - Sonia R Dancey
- University of Ottawa Heart Institute, Ontario, Canada (J.D.E., S.R.D.)
- School of Epidemiology and Public Heath, University of Ottawa, Ontario, Canada (J.D.E.)
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Nathalie Auger
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Quebec, Canada (N.A.)
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12
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Kirkpatrick L, Waters J, O'Neal MA. Preventive Approaches in Women's Neurology: Prepartum, Pregnancy, and Postpartum. Semin Neurol 2022; 42:665-678. [PMID: 36216357 DOI: 10.1055/a-1958-0633] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Women's neurology is the subspecialty within neurology concerned with the distinct healthcare needs of women. In this article, we review current literature and expert management strategies regarding disease-specific neurologic concerns of women, with an emphasis on issues related to contraception, pregnancy, and lactation. Health conditions that we discuss in this article include epilepsy, headache, stroke, multiple sclerosis, and Chiari I malformation. Current findings on neurologic disease in women suggest that many women with neurologic disease can safely manage their disease during pregnancy and have healthy children, though pregnancy planning is important in many conditions to mitigate risks and effective contraceptive management is important when pregnancy prevention is desired.
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Affiliation(s)
- Laura Kirkpatrick
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Janet Waters
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Angela O'Neal
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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13
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Katsafanas C, Bushnell C. Pregnancy and stroke risk in women. Neurobiol Dis 2022; 169:105735. [PMID: 35477033 DOI: 10.1016/j.nbd.2022.105735] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022] Open
Abstract
Stroke associated with pregnancy and post-partum occurs in about 30 per 100,000 deliveries, and includes subtypes of ischemic and hemorrhagic stroke as well as cerebral venous sinus thrombosis (CVST). There are a wide variety of underlying causes and risk factors, some that are common to both pregnant and non-pregnant women, and others that are unique to pregnancy. Although some of the strokes that occur may be a direct result of the pregnancy itself, such as hypertensive disorders of pregnancy, others could be anticipated or prevented by understanding the risk factors. These may include the presence of pre-pregnancy clotting disorders, aneurysms or arteriovenous malformations, hypertension, diabetes, or advanced maternal age. Treatment of stroke during pregnancy is based on the current recommendations for non-pregnant stroke patients, assuming the benefit of these treatments is likely higher than the risks. These decisions must be made with the appropriate specialists in stroke and endovascular treatment, as well as high-risk obstetrician/gynecologists, and most importantly, patient and family preferences.
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Affiliation(s)
- Constance Katsafanas
- University of Florida at Jacksonville, Department of Neurology, United States of America
| | - Cheryl Bushnell
- Wake Forest School of Medicine, Department of Neurology, United States of America.
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14
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Kremer C, Gdovinova Z, Bejot Y, Heldner MR, Zuurbier S, Walter S, Lal A, Epple C, Lorenzano S, Mono ML, Karapanayiotides T, Krishnan K, Jovanovic D, Dawson J, Caso V. European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum. Eur Stroke J 2022; 7:I-XIX. [PMID: 35647308 PMCID: PMC9134774 DOI: 10.1177/23969873221078696] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/19/2022] [Indexed: 01/01/2023] Open
Abstract
Pregnancy, postpartum and menopause are regarded as periods women are more
vulnerable to ischaemic events. There are conflicting results regarding stroke
risk and hormone replacement therapy (HRT) during menopause. Stroke in pregnancy
is generally increasing with serious consequences for mother and child;
therefore, recommendations for acute treatment with intravenous thrombolysis
(IVT) and/or mechanical thrombectomy (MT) are needed. The aim of this guideline
is to support and guide clinicians in treatment decisions in stroke in women.
Following the “Grading of Recommendations and Assessment, Development and
Evaluation (GRADE)” approach, the guidelines were developed according to the
European Stroke Organisation (ESO) Standard Operating Procedure. Systematic
reviews and metanalyses were performed. Based on available evidence,
recommendations were provided. Where there was a lack of evidence, an expert
consensus statement was given. Low quality of evidence was found to suggest
against the use of HRT to reduce the risk of stroke (ischaemic and haemorrhagic)
in postmenopausal women. No data was available on the outcome of women with
stroke when treated with HRT. No sufficient evidence was found to provide
recommendations for treatment with IVT or MT during pregnancy, postpartum and
menstruation. The majority of members suggested that pregnant women can be
treated with IVT after assessing the benefit/risk profile on an individual
basis, all members suggested treatment with IVT during postpartum and
menstruation. All members suggested treatment with MT during pregnancy. The
guidelines highlight the need to identify evidence for stroke prevention and
acute treatment in women in more vulnerable periods of their lifetime to
generate reliable data for future guidelines.
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Affiliation(s)
- Christine Kremer
- Neurology Department, Clinical Sciences Lund University, Skåne University Hospital, Malmö, Sweden
| | - Zuzana Gdovinova
- Neurology Department, Faculty of Medicine, Pavol Jozef Safarik University Košice, Košice, Slovakia
| | - Yannick Bejot
- Dijon Stroke Registry, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University of Burgundy, University Hospital of Dijon, Dijon, France
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Susanna Zuurbier
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Silke Walter
- Department of Neurology, Saarland University, Homburg, Germany
| | - Avtar Lal
- European Stroke Organisation (ESO), Basel, Switzerland
| | - Corina Epple
- Department of Neurology, Klinikum Hanau, Hanau, Germany
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marie-Luise Mono
- Department of Neurology, Municipal Hospital Waid und Triemli, Zürich, University Hospital and University of Bern, Bern Switzerland
| | - Theodore Karapanayiotides
- 2nd Department of Neurology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dejana Jovanovic
- Department of Emergency Neurology, Neurology Clinic, Medical Faculty, University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia Perugia, Italy
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15
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Abstract
Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.
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Affiliation(s)
- Kathryn M. Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence RI
| | - Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cheryl Carcel
- Neurology Program, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Eliza C. Miller
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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16
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Miller EC. Maternal Stroke Associated With Pregnancy. Continuum (Minneap Minn) 2022; 28:93-121. [PMID: 35133313 PMCID: PMC10101187 DOI: 10.1212/con.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women. RECENT FINDINGS Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life. SUMMARY Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.
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Abstract
PURPOSE OF REVIEW Cerebrovascular disorders during pregnancy and puerperium are uncommon but potentially serious entities. This review aims to provide guidance on the diagnosis and management of these diseases, according to the most recent findings. RECENT FINDINGS Proteinuria is no longer a mandatory criterion for the diagnosis of preeclampsia. Favourable long-term foetal and maternal outcomes are achieved in most patients with ruptured cerebral arterial malformations during pregnancy receiving interventional treatment prior to delivery. Despite the recent recommendations, physicians still hesitate to administer thrombolysis in pregnant women. In women with a history of cerebral venous thrombosis, prophylaxis with low molecular weight heparin during pregnancy and puerperium is associated with lower rates of recurrent thrombotic events and miscarriage. SUMMARY Hypertensive disorders of pregnancy are a continuum of failure of autoregulation mechanisms that may lead to eclampsia, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome and stroke. MRI is the preferred imaging modality of choice. In the absence of specific contraindications, treatment of cerebrovascular complications should not be withheld from pregnant women, including reperfusion therapies in acute ischemic stroke and treatment of ruptured cerebral aneurysms. Previous history of stroke alone does not contraindicate future pregnancy, but counselling and implementation of prevention strategies are needed.
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Affiliation(s)
- Mónica Santos
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria - CHULN
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria - CHULN
- Faculdade de Medicina, Universidade de Lisboa
- Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
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18
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Dicpinigaitis AJ, Sursal T, Morse CA, Briskin C, Dakay K, Kurian C, Kaur G, Sahni R, Bowers C, Gandhi CD, Mayer SA, Al-Mufti F. Endovascular Thrombectomy for Treatment of Acute Ischemic Stroke During Pregnancy and the Early Postpartum Period. Stroke 2021; 52:3796-3804. [PMID: 34538088 DOI: 10.1161/strokeaha.121.034303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke (AIS) is a rare occurrence during pregnancy and the postpartum period. Existing literature evaluating endovascular mechanical thrombectomy (MT) for this patient population is limited. METHODS The National Inpatient Sample was queried from 2012 to 2018 to identify and characterize pregnant and postpartum patients (up to 6 weeks following childbirth) with AIS treated with MT. Complications and outcomes were compared with nonpregnant female patients treated with MT and to other pregnant and postpartum patients managed medically. Complex samples regression models and propensity score matching were implemented to assess adjusted associations and to address confounding by indication, respectively. RESULTS Among 4590 pregnant and postpartum patients with AIS, 180 (3.9%) were treated with MT, and rates of utilization increased following the MT clinical trial era (2015-2018; 1.9% versus 5.3%, P=0.011). Compared with nonpregnant patients with AIS treated with MT, they experienced lower rates of intracranial hemorrhage (11% versus 24%, P=0.069) and poor functional outcome (50% versus 72%, P=0.003) at discharge. Pregnant/postpartum status was independently associated with a lower likelihood of development of intracranial hemorrhage (adjusted odds ratio, 0.26 [95% CI, 0.09-0.70]; P=0.008) following multivariable analysis adjusting for age, illness severity, and stroke severity. Following propensity score matching, pregnant and postpartum patients treated with MT and those medically managed differed in frequency of venous thromboembolism (17% versus 0%, P=0.001) and complications related to pregnancy (44% versus 64%, P=0.034), but not in functional outcome at discharge or hospital length of stay. Pregnant and postpartum women treated with MT did not experience mortality or miscarriage during hospitalization. CONCLUSIONS This large-scale analysis utilizing national claims data suggests that MT is a safe and efficacious therapy for AIS during pregnancy and the postpartum period. In the absence of prospective clinical trials, population-based cross-sectional analyses such as the present study provide valuable clinical insight.
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Affiliation(s)
| | - Tolga Sursal
- Department of Neurosurgery (T.S., C.D.G.), Westchester Medical Center, Valhalla, NY
| | - Catherine A Morse
- School of Medicine, New York Medical College, Valhalla, (A.L.D., C.A.M., C.B.)
| | - Camille Briskin
- School of Medicine, New York Medical College, Valhalla, (A.L.D., C.A.M., C.B.)
| | - Katarina Dakay
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Christeena Kurian
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Gurmeen Kaur
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Ramandeep Sahni
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.)
| | - Chirag D Gandhi
- Department of Neurosurgery (T.S., C.D.G.), Westchester Medical Center, Valhalla, NY
| | - Stephan A Mayer
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Fawaz Al-Mufti
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
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19
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Abstract
Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. Hypertensive disorders of pregnancy and gestational hypercoagulability are important contributors to obstetric stroke. Preeclampsia and eclampsia confer risk for future cardiovascular disease. Hemorrhagic stroke is the most common type of obstetric stroke. Ischemic stroke can result from cardiomyopathy, paradoxical embolism, posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and dissections. Cerebral venous sinus thrombosis is a frequent complication of pregnancy.
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Affiliation(s)
- Erica C Camargo
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 729-C, Boston, MA 02114, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 729-C, Boston, MA 02114, USA.
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20
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Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin 2021; 39:649-670. [PMID: 33896537 DOI: 10.1016/j.ncl.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article serves as a comprehensive review of neurologic emergencies in pregnancy. Common initial presentations of neuroemergencies are reviewed with a clinical algorithm. Neurovascular disorders in pregnancy are reviewed, including acute ischemic strokes with data on tPA and thrombectomy; cerebral venous sinus thrombosis diagnosis and management; posterior reversible encephalopathy syndrome management; reversible cerebral vasoconstriction syndrome; and intracerebral hemorrhage. Attention is paid to management of cerebral edema and safety of osmotic therapies. A review of seizures in pregnancy is provided, including new-onset causes and decreased seizure thresholds. For status epilepticus, a low teratogenicity risk medication protocol in pregnancy is provided.
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Affiliation(s)
- Elizabeth Macri
- Department of Neurology, University of New Mexico, MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131, USA. https://twitter.com/SportsDoc2009
| | - Diana Greene-Chandos
- Neurosciences Critical Care Fellowship, Department of Neurology, University of New Mexico; MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131, USA.
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21
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Blondon M, Martinez de Tejada B, Glauser F, Righini M, Robert-Ebadi H. Management of high-risk pulmonary embolism in pregnancy. Thromb Res 2021; 204:57-65. [PMID: 34146979 DOI: 10.1016/j.thromres.2021.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022]
Abstract
Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Frederic Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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22
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Hanson R, Brown P, Temple-Cooper M, Hoyt M. Puerperium Stroke and Subsequent Tissue-Type Plasminogen Activator-Induced Hemorrhage: A Case Report. A A Pract 2021; 15:e01459. [PMID: 33955867 DOI: 10.1213/xaa.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of ischemic stroke in an apparently healthy 35-year-old gravida 2 para 1 who was treated with tissue-type plasminogen activator (tPA) 9 hours after vaginal delivery that resulted in severe hemorrhage. Limited data suggest use of thrombolytics in pregnancy is safe, but there is a paucity of evidence assessing their use immediately postpartum. We describe successful combination of tPA with endovascular mechanical thrombectomy (EMT) for treatment of postpartum stroke, which was followed by extensive uterine bleeding.
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Affiliation(s)
| | - Peter Brown
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mary Temple-Cooper
- Department of Pharmacy, Hillcrest Hospital, Cleveland Clinic Health System, Mayfield Heights, Ohio
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23
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Karjalainen L, Tikkanen M, Rantanen K, Aarnio K, Korhonen A, Saaros A, Laivuori H, Gissler M, Ijäs P. Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987-2016. Neurology 2021; 96:e2564-e2575. [PMID: 33827961 DOI: 10.1212/wnl.0000000000011990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS. METHODS We performed a retrospective population-based cohort study and nested case-control study in Finland from 1987 to 2016. The Medical Birth Register (MBR) was linked to the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period in 5-year age groups and pregnancy/postpartum period was calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors. RESULTS After chart review, 29.6% (257 of 868) of cases were PAS. The incidence of PAS was 14.5 (95% confidence interval [CI] 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987 to 1991 to 2012 to 2016 (p < 0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from 20 to 24 years to >40 years of age (p < 0.0001). During the early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable-adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95% CI 1.2-2.7), migraine (OR 16.3, 95% CI 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95% CI 2.5-6.3) were the most important risk factors for PAS. CONCLUSION PAS incidence is increasing, stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine, and hypertensive disorders of pregnancy are associated with an increased risk of PAS.
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Affiliation(s)
- Liisa Karjalainen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
| | - Minna Tikkanen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Kirsi Rantanen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Karoliina Aarnio
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Aino Korhonen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Anna Saaros
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Hannele Laivuori
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Mika Gissler
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Petra Ijäs
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
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24
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Bojda M, Cimprichová A, Vavríková B, Filipková A, Gdovinová Z. Intravenous thrombolysis for stroke in pregnancy should be administered if the benefit outweighs the risk: A case report and recommended diagnostic workup. WOMENS HEALTH 2021; 17:1745506521999495. [PMID: 33710947 PMCID: PMC7958154 DOI: 10.1177/1745506521999495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction: There is an ongoing debate about the use of recombinant tissue plasminogen activator in
acute stroke during pregnancy. The aim of our case report is to present that even in a
small stroke centre intravenous thrombolysis can be used on a pregnant woman if the
benefit outweighs the risk and to summarize the diagnostic workup in a pregnant woman
with stroke. Case report: Our case describes a 31-year-old woman presenting in her third trimester with a sudden
onset of slurred speech, severe right hemiparesis, facial nerve central palsy, eyes
deviation to the left, right side hemianopia, hemisensory loss, psychomotor agitation
and pain in the right lower limb. She was successfully treated with recombinant tissue
plasminogen activator with almost complete recovery (NIHSS 1 after 10 days), and 23 days
after intravenous thrombolysis, she delivered in the 37th week a healthy male infant.
The first documented successful outcome from thrombolysis for this condition in Slovakia
supports the notion of giving intravenous recombinant tissue plasminogen activator to
pregnant patients with disabling ischaemic stroke who meet the criteria for
thrombolysis. Discussion: At the end of case study, a recommended diagnostic workup for acute treatment of stroke
in pregnant women is presented.
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Affiliation(s)
- Marek Bojda
- Department of Neurology, Faculty Hospital Trenčín, Trencin, Slovakia
| | | | - Bibiana Vavríková
- Department of Neurology, Faculty Hospital Trenčín, Trencin, Slovakia
| | - Alena Filipková
- Department of Neurology, Faculty Hospital Trenčín, Trencin, Slovakia
| | - Zuzana Gdovinová
- Department of Neurology, Faculty of Medicine, P.J. Šafarik University and University Hospital L. Pasteur, Košice, Slovakia
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25
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Abstract
Maternal mortality rates have been steadily increasing in the United States, and cardiovascular mortality is the leading cause of death among pregnant and postpartum women. Maternal stroke accounts for a significant burden of cardiovascular mortality. Data suggest that rates of maternal stroke have been increasing in recent years. Advancing maternal age at the time of birth and the increasing prevalence of traditional cardiovascular risk factors, and other risk factors, as well, such as hypertensive disorders of pregnancy, migraine, and infections, may contribute to increased rates of maternal stroke. In this article, we provide an overview of the epidemiology of maternal stroke, explore mechanisms that may explain increasing rates of stroke among pregnant women, and identify key knowledge gaps for future investigation in this area.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha (I.Y.E.)
| | - Syed Bukhari
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (S.B., A.F.B.)
| | - Amr F Barakat
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (S.B., A.F.B.)
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville (C.J.P.)
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, MO (K.J.L.)
| | - Eliza C Miller
- Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (E.C.M.)
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26
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Kumar A, McCullough L. Cerebrovascular disease in women. Ther Adv Neurol Disord 2021; 14:1756286420985237. [PMID: 33552237 PMCID: PMC7844450 DOI: 10.1177/1756286420985237] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/16/2020] [Indexed: 12/20/2022] Open
Abstract
Cerebrovascular disease is a major cause of morbidity, mortality, and disability in women. The spectrum of disease differs between men and women, with women being particularly vulnerable to certain conditions, especially during specific periods of life such as pregnancy. There are several unique risk factors for cerebrovascular disease in women, and the influence of some traditional risk factors for stroke is stronger in women. Moreover, disparities persist in representation of women in clinical trials, acute intervention, and stroke outcomes. In this review, we aimed to explore the epidemiology, etiologies, and management of cerebrovascular disease in women, highlighting some of these differences and the growing need for sex-specific management guidelines and health policies.
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Affiliation(s)
- Aditya Kumar
- Department of Neurology, 6431 Fannin Street, Houston, TX 77030, USA
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27
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Dinehart E, Leon Guerrero C, Pham A, Chandra S, Petersen SM, Bathgate S, Ahmadzia H. Extending the window for thrombolysis for treatment of acute ischaemic stroke during pregnancy: a review. BJOG 2020; 128:516-520. [PMID: 32920999 DOI: 10.1111/1471-0528.16495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 11/29/2022]
Abstract
Historically, safety of intravenous recombinant tissue plasminogen activator (IV rt-PA) for the treatment of acute ischaemic stroke (AIS) is limited to use within 4.5 hours from symptom onset. Recent studies suggest the treatment window may be extended when patients have salvageable brain tissue on advanced neuroimaging. This paper describes a novel use of IV rt-PA for treatment of AIS in a pregnant patient within an extended-time window (>4.5 hours, and <9 hours) based on advanced neuroimaging with a favourable outcome. TWEETABLE ABSTRACT: Novel use of IV rt-PA for treatment of AIS in pregnancy within an extended-time window based on advanced imaging with a favourable outcome.
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Affiliation(s)
- E Dinehart
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - C Leon Guerrero
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - A Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - S Chandra
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - S M Petersen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - S Bathgate
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H Ahmadzia
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Elgendy IY, Gad MM, Mahmoud AN, Keeley EC, Pepine CJ. Acute Stroke During Pregnancy and Puerperium. J Am Coll Cardiol 2020; 75:180-190. [PMID: 31948647 DOI: 10.1016/j.jacc.2019.10.056] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/17/2019] [Accepted: 10/28/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Acute stroke during pregnancy or within 6 weeks of childbirth is devastating for the mother and her family, yet data regarding incidence and contemporary trends are very limited. OBJECTIVES This study sought to investigate the incidence and outcomes of acute stroke and transient ischemic attack during pregnancy or within 6 weeks of childbirth in a large database. METHODS The National Inpatient Sample was queried to identify women age ≥18 years in the United States with pregnancy-related hospitalizations from January 1, 2007, to September 30, 2015. Temporal trends in acute stroke (ischemic and hemorrhagic)/transient ischemic attack incidence and in-hospital mortality were extracted. RESULTS Among 37,360,772 pregnancy-related hospitalizations, 16,694 (0.045%) women had an acute stroke. The rates of acute stroke did not change (42.8 per 100,000 hospitalizations in 2007 vs. 42.2 per 100,000 hospitalizations in 2015; ptrends = 0.10). Among those with acute stroke, there were increases in prevalence of obesity, smoking, hyperlipidemia, migraine, and gestational hypertension. Importantly, in-hospital mortality rates were almost 385-fold higher among those who had a stroke (42.1 per 1,000 pregnancy-related hospitalizations vs. 0.11 per 1,000 pregnancy-related hospitalizations; p < 0.0001). The rates of in-hospital mortality among pregnant women with acute stroke decreased (5.5% in 2007 vs. 2.7% in 2015; ptrends < 0.001). CONCLUSIONS In this contemporary analysis of pregnancy-related hospitalizations, acute stroke occurred in 1 of every 2,222 hospitalizations, and these rates did not decrease over approximately 9 years. The prevalence of most stroke risk factors has increased. Acute stroke during pregnancy and puerperium was associated with high maternal mortality, although it appears to be trending downward. Future studies to better identify mechanisms and approaches to prevention and management of acute stroke during pregnancy and puerperium are warranted.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Mohamed M Gad
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmed N Mahmoud
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
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Barghouthi T, Lemley R, Figurelle M, Bushnell C. Epidemiology of neurologic disease in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:119-141. [PMID: 32736746 DOI: 10.1016/b978-0-444-64239-4.00006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.
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Affiliation(s)
- Tamara Barghouthi
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Regan Lemley
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Morgan Figurelle
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Cheryl Bushnell
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States.
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31
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Grammatis AL, Catton HL, Hilton D. Ischaemic stroke and pre-eclampsia in the third trimester of pregnancy: a diagnostic and therapeutic challenge. BMJ Case Rep 2019; 12:12/12/e229635. [PMID: 31811103 PMCID: PMC6904148 DOI: 10.1136/bcr-2019-229635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
A 23-year-old low-risk primiparous patient, who was 35 weeks pregnant, presented in the emergency department after collapsing at home. Her observations showed severe hypertension with proteinuria. On examination, she had left hemiparesis and was aphasic. Fetal monitoring was reassuring. Initial CT did not reveal any evidence of intracranial pathology. She was stabilised and delivered via emergency caesarean section. Subsequent MRI and CT showed an acute right-sided infarct involving the right middle cerebral artery territory, frontal and parietal regions, and increased mass effect. She was transferred to the nearest neurosurgical centre where she was conservatively managed and discharged home 3 weeks later for continuing rehabilitation. She achieved a good recovery.
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32
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Kozberg MG, Camargo EC. Management of Maternal Stroke and Mitigating Risk. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:72. [DOI: 10.1007/s11936-019-0770-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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33
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Abstract
Pregnancy confers a substantially increased risk of stroke in women. The period of highest risk of stroke is the peripartum/postpartum phase, coinciding with the highest risk for hypertensive disorders of pregnancy and peak gestational hypercoagulability. Hemorrhagic stroke is the most common type of obstetric stroke. Hypertensive disorders of pregnancy are important contributors to obstetric stroke and predispose women to premature cardiovascular disease. The rate of stroke associated with hypertensive disorders of pregnancy has increased in the United States. Other conditions associated with obstetric stroke include posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis.
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Affiliation(s)
- Erica C Camargo
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Steven K Feske
- Stroke Division, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 729-C, Boston, MA 02114, USA.
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34
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Ryman KM, Pace WD, Smith S, Fontaine GV. Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature. Pharmacotherapy 2019; 39:767-774. [PMID: 31077601 DOI: 10.1002/phar.2278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute ischemic stroke (AIS) during pregnancy is a rare but serious complication. Intravenous alteplase is the only medication approved for hyperacute treatment of AIS; however, it has not been evaluated prospectively in pregnancy. Pregnancy was an exclusion criterion in prospective AIS studies and was only recently removed as a relative contraindication in the 2018 American Heart Association/American Stroke Association Stroke guidelines. Due to the exclusion of pregnant women from randomized controlled trials, the safety of fibrinolytic therapy in pregnant patients is not well established. In this review, we report the use of intravenous alteplase for AIS in two pregnant patients, with temporally associated clinical improvement and without complications to either the mother or fetus. Additionally, we summarize a systematic review of the literature for both intravenous and intra-arterial alteplase use for AIS in pregnant patients. A total of 31 cases met inclusion criteria for this review of assessment of safety and efficacy of alteplase use in pregnancy. Existing case reports and guidelines support the use of alteplase for AIS in pregnant patients without contraindications.
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Affiliation(s)
- Klayton M Ryman
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
- Department of Pharmacy, Baylor University Medical Center, Dallas, Texas
| | - Wilson D Pace
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
| | - Shawn Smith
- Department of Neurology, Intermountain Medical Center, Murray, Utah
- Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Gabriel V Fontaine
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
- Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah
- Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
- Roseman University College of Pharmacy, South Jordan, Utah
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35
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Hong JH. Cerebrovascular complications during pregnancy and postpartum. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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36
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Abstract
PURPOSE OF THE REVIEW Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence. RECENT FINDINGS The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.
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Affiliation(s)
- Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
- Neurological Institute of New York, 710 West 168th Street, 6th floor, New York, NY, 10032, USA.
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37
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Karjalainen L, Tikkanen M, Rantanen K, Laivuori H, Gissler M, Ijäs P. Pregnancy-associated stroke -a systematic review of subsequent pregnancies and maternal health. BMC Pregnancy Childbirth 2019; 19:187. [PMID: 31138152 PMCID: PMC6540366 DOI: 10.1186/s12884-019-2339-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 05/13/2019] [Indexed: 01/29/2023] Open
Abstract
Background Pregnancy-associated stroke is a rare but life-threatening event, with an estimated incidence of 30/100000 deliveries. Data on the risk of stroke recurrence and the risk of other adverse pregnancy outcomes are essential for adequate counselling and surveillance in subsequent pregnancies. The aim of this systematic review is to describe the implications of a pregnancy-associated stroke for the future health of these women. Methods We searched Ovid Medline, PubMed, Cochrane Library and CINAHL for articles published in 1980–2018. Articles including women with pregnancy-associated stroke and information on at least one of the following outcomes were included: 1) recurrence of stroke during subsequent pregnancy, 2) number and course of subsequent pregnancies and their outcomes and 3) subsequent cardiovascular health. Results Twelve articles were included in the review, with six providing information on subsequent pregnancies, four on subsequent maternal health and two on both. The included articles varied greatly in terms of study design, length of follow up and reported outcomes. We found 252 women with pregnancy-associated stroke for whom the outcomes of interest were reported: 135 women with information on subsequent pregnancies and 123 women with information on future health. In total, 55 pregnancies after stroke were found. In the majority of studies, the incidence of pregnancy complications was comparable to that of the general population. The risk of stroke recurrence during pregnancy was 2%. Data on subsequent health of these women were limited, and the quality of the data varied between the studies. Conclusions Data on subsequent pregnancies and health of women with a history of pregnancy-associated stroke are limited. Further research on this topic is essential for adequate counselling and secondary prevention. Electronic supplementary material The online version of this article (10.1186/s12884-019-2339-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liisa Karjalainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, P.O. Box 700, FI-00029 HUS, Helsinki, Finland.
| | - Minna Tikkanen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, P.O. Box 700, FI-00029 HUS, Helsinki, Finland
| | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital and Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland.,Department of Obstetrics and Gynaecology, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Mika Gissler
- Department of Information Services, National Institute of Health and Welfare, Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, P.O. Box 700, FI-00029 HUS, Helsinki, Finland
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38
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Abstract
Venous thromboembolism (VTE), referring to both deep vein thrombosis and pulmonary embolism, is a leading cause of death in the developed world during pregnancy. This increased risk is attributed to the Virchow triad, inherited thrombophilias, along with other standard risk factors, and continues for up to 6 to 12 weeks postpartum. During the peripartum period, women should be risk stratified and preventive measures should be initiated based on their risk. Diagnostic tests and treatment strategies commonly used in VTE differ in pregnancy. An understanding of these differences is imperative to diagnose with confidence and to treat appropriately.
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Affiliation(s)
- Christopher Deeb Dado
- Pulmonary and Critical Care Fellowship, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Andrew Tobias Levinson
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 164 Summit Avenue, Providence, RI 02904, USA
| | - Ghada Bourjeily
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 146 West River Street, Suite 11C, Providence, RI 02904, USA.
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39
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Peksa GD, Ostrem J, Davis T. Intravenous tissue plasminogen activator for ischemic stroke in early pregnancy dosed by actual body weight. SAGE Open Med Case Rep 2019; 7:2050313X19828247. [PMID: 30800307 PMCID: PMC6378419 DOI: 10.1177/2050313x19828247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/10/2019] [Indexed: 11/20/2022] Open
Abstract
Introduction: Few published reports highlight intravenous tissue plasminogen activator use during the first trimester of pregnancy and provide outcomes for mother and fetus. Little guidance is available regarding body weight dosing of intravenous tissue plasminogen activator during pregnancy. Methods: Here, we present a patient who received intravenous tissue plasminogen activator in the emergency department during her first trimester of pregnancy for the treatment of an acute ischemic stroke. Outcomes are presented for mother and fetus, as well as discussion about the dosing weight utilized for the intravenous tissue plasminogen activator dose calculation. Results: A 35-year-old, Gravida 7 Para 6, presented to the emergency department at 9 weeks gestation with acute stroke symptoms. Her initial National Institutes of Health Stroke Scale was 7. Imaging revealed a hyperdense right middle cerebral artery sign. Intravenous tissue plasminogen activator was administered 57 min after her arrival and based on her actual body weight during pregnancy. Post tissue plasminogen activator imaging revealed recanalization of the vessel and the patient’s National Institutes of Health Stroke Scale was 0. The patient progressed to delivery of a healthy female infant. The patient did not experience any bleeding complications throughout pregnancy. Conclusion: We present positive outcomes of a mother and fetus after receipt of intravenous tissue plasminogen activator using actual body weight during the first trimester of pregnancy for an acute ischemic stroke. Additional information is necessary to provide recommendations for the application to future patients in early pregnancy.
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Affiliation(s)
- Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA.,Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jamie Ostrem
- Department of Pharmacy, Emory University Hospital, Atlanta, GA, USA
| | - Teresa Davis
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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40
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Abstract
Stroke risk is 3 times higher in pregnancy than in the general young adult population and carries high morbidity and mortality risks. The recognition of signs and symptoms of stroke and other serious cerebrovascular disorders in pregnant and postpartum patients is important for the obstetrician to be able to initiate urgent evaluation and management. The objective of this review is to provide an evidence-based summary of stroke incidence, risk factors, prevention, and treatment of stroke in pregnancy. The impact of postpartum contraceptive use can on stroke risk is summarized.
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Affiliation(s)
- Tamara Barghouthi
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, North Carolina
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41
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Szuchy Kristiansen E, Holm Vestergaard H, Modrau B, Oppel LM. Acute Ischemic Stroke in Late Pregnancy Treated with Intravenous Thrombolysis and Endovascular Therapy. Case Rep Neurol 2019; 11:41-46. [PMID: 31043957 PMCID: PMC6477488 DOI: 10.1159/000496084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/07/2018] [Indexed: 01/12/2023] Open
Abstract
Pregnancy has usually been an exclusion criterion in clinical trials with thrombolysis and endovascular therapy in acute ischemic stroke. For that reason, these therapies are not recommended causing lack of evidence and vice versa. In this case report, we describe a pregnant woman in week 33 + 3 presenting with acute ischemic stroke, which was successfully treated with systemic thrombolysis and endovascular therapy, resulting in a good clinical outcome for both mother and child. The altered fibrinolytic system and the risk factors related to pregnancy constitute a challenge for clinicians when choosing the most suitable treatment modality for treating acute ischemic stroke in pregnancy. It is still uncertain whether thrombolysis in combination with endovascular therapy or endovascular therapy alone is the most appropriate treatment option. However, there is slowly growing evidence that thrombolysis and thrombectomy in pregnancy are feasible and safe with a good clinical outcome for both the mother and the child.
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Affiliation(s)
- Eva Szuchy Kristiansen
- Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Neurology, University Hospital, Aalborg, Denmark
| | | | - Boris Modrau
- Department of Neurology, University Hospital, Aalborg, Denmark
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42
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Shah SS, Snelling BM, Brunet MC, Sur S, McCarthy DJ, Stein A, Khandelwal P, Starke RM, Peterson EC. Transradial Mechanical Thrombectomy for Proximal Middle Cerebral Artery Occlusion in a First Trimester Pregnancy: Case Report and Literature Review. World Neurosurg 2018; 120:415-419. [DOI: 10.1016/j.wneu.2018.09.095] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 11/16/2022]
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43
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Cauldwell M, Rudd A, Nelson-Piercy C. Management of stroke and pregnancy. Eur Stroke J 2018; 3:227-236. [PMID: 31008353 PMCID: PMC6453206 DOI: 10.1177/2396987318769547] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/10/2018] [Indexed: 11/17/2022] Open
Abstract
Stroke continues to be one of the main causes of death in the developed countries and the incidence in pregnancy appears to be increasing. Pregnancy-related stroke has a relatively high mortality rate of 10% and so clinicians need to be mindful of appropriate investigations and referral of a pregnant woman with suspected stroke, so they can receive timely treatment. In this review we address the risk factors associated with stroke, diagnosis and appropriate management of the different stroke types. We also discuss implications for care around pregnancy and delivery as well as reviewing how a pregnancy with previous stroke should be managed.
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Remote Intracerebral Hemorrhage Following Intravenous Thrombolysis in Pregnancy at 31 Weeks Gestation: A Case Report and Review of the Literature. Neurologist 2018; 23:19-22. [PMID: 29266040 DOI: 10.1097/nrl.0000000000000165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Intravenous recombinant tissue-type plasminogen activator thrombolysis in pregnancy for acute ischemic stroke is infrequent. As a rare complication of thrombolysis, remote intracerebral hemorrhage (rICH) whose mechanisms are unclear has not gained enough attention until now. CASE REPORT We present here a case of 26-year-old pregnant woman at 31 weeks gestation who suffered from sudden onset right-sided hemiparesis and slurred speech. She successfully received intravenous recombinant tissue-type plasminogen activator thrombolysis within 2.5 hours from stroke onset. Further workup demonstrated multiple and bilateral acute cerebral infarcts due to cardioembolism. At 6 hours after thrombolysis, multifocal intracerebral hemorrhages were developed in her left cerebellum and right temporal cortex, remote from the initial infarct areas. However, the patient achieved a final complete recovery of symptoms. Despite diffusion-weighted imaging could not confirm infarct in the areas of hemorrhages, multiple cerebral embolism was suggested to be involved in the etiology of rICH. CONCLUSIONS rICH is different from local intracerebral hemorrhage in its risk factors, neurological outcomes, and underlying mechanisms. Patients with rICH may have favorable outcomes and multiple cerebral embolism is still one of the important mechanisms for postthrombolytic rICH.
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45
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Terón I, Eng MS, Katz JM. Causes and Treatment of Acute Ischemic Stroke During Pregnancy. Curr Treat Options Neurol 2018; 20:21. [PMID: 29785465 DOI: 10.1007/s11940-018-0506-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Treatment recommendations for pregnancy associated ischemic stroke are scarce. This may be due to the fact that, in general, obstetricians tend not to make recommendations for stroke patients and neurologists are not commonly involved in the care of pregnant women. Herein, we review the multiple etiologies of ischemic stroke during pregnancy, considerations for diagnostic testing, and acute treatment and prevention options, including associated risks specific to the pregnant and puerperal state. RECENT FINDINGS Intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy have been used successfully to treat pregnant women with acute ischemic stroke. Recent national guidelines recommend considering tPA use during pregnancy for moderate and severe strokes if the potential benefits offset the risks of uterine hemorrhage. Pregnancy-associated ischemic stroke is rare, but can be devastating, and recanalization therapy should not be systematically withheld. Women who are at risk for stroke should be followed carefully, and providers caring for pregnant women should be educated regarding stroke signs and symptoms. Many of the standard post stroke diagnostic modalities may be used safely in pregnancy, and primary and secondary stroke prevention therapy must be tailored to avoid fetal toxicity.
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Affiliation(s)
- Ina Terón
- Department of Neurology, North Shore University Hospital and Zucker School of Medicine at Hofstra/Northwell, and Feinstein Institute for Medical Research, 300 Community Drive, 9 Tower, Manhasset, NY, 11030, USA.
| | | | - Jeffrey M Katz
- Department of Neurology, North Shore University Hospital and Zucker School of Medicine at Hofstra/Northwell, and Feinstein Institute for Medical Research, 300 Community Drive, 9 Tower, Manhasset, NY, 11030, USA.,Department of Radiology, North Shore University Hospital and Zucker School of Medicine at Hofstra/Northwell, and Feinstein Institute for Medical Research, Hempstead, NY, 11549, USA
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46
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Bodenant M, Leys D. Infarti cerebrali del soggetto giovane. Neurologia 2018. [DOI: 10.1016/s1634-7072(18)41288-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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47
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Sousa Gomes M, Guimarães M, Montenegro N. Thrombolysis in pregnancy: a literature review. J Matern Fetal Neonatal Med 2018; 32:2418-2428. [DOI: 10.1080/14767058.2018.1434141] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Marina Sousa Gomes
- Department of Obstetrics and Gynecology, Alto Minho Local Healthcare Unit, Viana do Castelo, Portugal
| | - Mariana Guimarães
- Department of Obstetrics and Gynecology, São João Hospital Center, Porto, Portugal
| | - Nuno Montenegro
- Department of Obstetrics and Gynecology, São João Hospital Center, Porto, Portugal
- Medicine Faculty, University of Porto, Porto, Portugal
- Institute of Public Health of the University of Porto, Porto, Portugal
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49
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Khan A, Hosseini P, Nevajda B, Khan S. Lesson of the month 2: Use of thrombolysis for ischaemic stroke in pregnancy - a case report and review of literature. Clin Med (Lond) 2017; 17:581-583. [PMID: 29196364 PMCID: PMC6297686 DOI: 10.7861/clinmedicine.17-6-581] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A nine-week pregnant 33-year-old female presented with sudden-onset right-sided hemiparesis, hemisensory loss, dysarthria and homonymous hemianopia. She was known to have eleven previous miscarriages and used recreational drugs. A CT-head was unremarkable. The patient was subsequently diagnosed with an acute thromboembolic infarct and chose alteplase after counselling. During thrombolysis an ultrasound identified a foetus with no concerning features. A post-thrombolysis CT revealed a left-sided posterior cerebral infarct. CT-venography, carotid Doppler, 72-hour Holter monitor, thrombophilia and an autoimmune screen were all normal. A transthoracic echocardiogram demonstrated a mobile intra-atrial septum with a patent foramen ovale confirmed on bubble echocardiogram. Three days post-thrombolysis the patient requested a termination of pregnancy. A subsequent transvaginal ultrasound demonstrated a missed miscarriage for which the patient underwent evacuation of retained products of conception. Multidisciplinary care ensured that her sensorimotor deficit resolved grossly with only mild dysarthria and right-hand fine motor incoordination.
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Affiliation(s)
- Asim Khan
- Basildon University Hospital, Basildon and Thurrock NHS Foundation Trust
| | - Paris Hosseini
- University College London Medical School, University College London
| | - Branimir Nevajda
- Basildon University Hospital, Basildon and Thurrock NHS Foundation Trust
| | - Sami Khan
- Basildon University Hospital, Basildon and Thurrock NHS Foundation Trust
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50
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Abstract
Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke - including diabetes mellitus and atrial fibrillation - are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials - despite governmental actions highlighting the need to include both men and women in clinical trials - resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women.
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