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Segherlou ZH, Shakeri-Darzekonani M, Khavandegar A, Stephenson S, Ciccone K, Masheghati F, Hosseini Siyanaki MR, Lyerly M, Lucke-Wold B. Hormonal influences on cerebral aneurysms: unraveling the complex connections. Expert Rev Endocrinol Metab 2024; 19:207-215. [PMID: 38712738 DOI: 10.1080/17446651.2024.2347275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Intracranial aneurysms (IAs) occur in 3-5% of the general population and are characterized by localized structural deterioration of the arterial wall with loss of internal elastic lamina and disruption of the media. The risk of incidence and rupture of aneurysms depends on age, sex, ethnicity, and other different factors, indicating the influence of genetic and environmental factors. When an aneurysm ruptures, there is an estimated 20% mortality rate, along with an added 30-40% morbidity in survivors. The alterations in hormonal levels can influence IAs, while the rupture of an aneurysm can have various impacts on endocrine pathways and affect their outcome. AREA COVERED This review explores the reciprocal relationship between endocrinological changes (estrogen, growth hormone, and thyroid hormones) and IAs, as well as the effects of aneurysm ruptures on endocrine fluctuations. EXPERT OPINION Based on the data presented in this paper, we recommend further exploration into the influence of hormones on aneurysm formation and rupture. Additionally, we propose conducting endocrine assessments for patients who have experienced a rupture of IAs. Monitoring hormonal changes in patients with IAs could serve as a potential risk factor for rupture, leading to interventions in the approach to managing IAs.
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Affiliation(s)
| | | | - Armin Khavandegar
- College of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Stephenson
- Biotechnology Department, Krieger School of Arts and Sciences, John Hopkins University, Baltimore, MD, USA
| | - Kimberly Ciccone
- Department of Behavioral Neuroscience, College of Arts and Sciences, University of North Florida, Jacksonville, FL, USA
| | - Forough Masheghati
- College of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mac Lyerly
- School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
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Hanna M, Wabnitz A, Grewal P. Sex and stroke risk factors: A review of differences and impact. J Stroke Cerebrovasc Dis 2024; 33:107624. [PMID: 38316283 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107624] [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: 09/01/2023] [Revised: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors. METHODS We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review. RESULTS Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels. CONCLUSIONS By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.
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Affiliation(s)
- Mckay Hanna
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ashley Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Parneet Grewal
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States.
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Ilyas Y, Öncü K, İlyas K, Beşi R A. Moyamoya Disease Diagnosed With Intracranial Hemorrhage After Cesarean Section Under Spinal Anesthesia: A Case Report. Cureus 2024; 16:e56436. [PMID: 38638714 PMCID: PMC11024794 DOI: 10.7759/cureus.56436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Moyamoya disease (MMD) is a rare non-inflammatory cerebral vasculopathy characterized by progressive stenosis of the internal carotid arteries, often bilaterally, and the formation of abnormal collateral vascular structures at the cranial base. A patient who underwent elective cesarean section (C/S) twice under spinal anesthesia and was diagnosed with MMD as a result of recurrent intracranial hemorrhage in the postpartum periods is presented. A 41-year-old female patient without any systemic comorbidity, gravida 2, parity 2, had her second cesarean section (C/S) operation under spinal anesthesia and was discharged on the third postoperative day without any problems. The patient had a mild headache that started from the occipital region and spread to the entire cranium on the same day. After applying to the emergency department at different times, she was discharged with conservative treatment. The patient had a severe headache and was admitted to the emergency room on the ninth postoperative day. The patient, who was diagnosed with intracranial hemorrhage after cranial imaging, was referred. Cranial angiography revealed advanced bilateral internal carotid artery symmetric occlusion and the basilar artery was preserved. According to the angiographic image, the patient was diagnosed with moyamoya disease and was followed up in the intensive care unit. The muscle strength of the patient, who had no cranial nerve pathology or lateralization findings, was evaluated as normal. Conservative management was applied in the intensive care unit. The patient was discharged with recommendations for neurosurgery and cardiovascular surgery after 12 days. In the postpartum period, especially in cases of headache that persists for a long time after dural puncture and does not have a postdural feature, intracranial hemorrhage should be considered until proven otherwise, and moyamoya disease also be considered in the differential diagnosis of intracranial hemorrhage. The approach to the patient in the perioperative period should focus on providing normotension, normocapnia, normothermia, and effective analgesia.
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Affiliation(s)
- Yasir Ilyas
- Anesthesiology and Reanimation, Trabzon Fatih State Hospital, Trabzon, TUR
| | - Kıvanç Öncü
- Anaesthesia and Reanimation, Sinop Atatürk State Hospital, Sinop, TUR
| | - Kübra İlyas
- Anesthesiology and Reanimation, Karadeniz Technical University, Trabzon, TUR
| | - Ahmet Beşi R
- Anesthesiology and Reanimation, Karadeniz Technical University, Trabzon, TUR
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Frimat M, Gnemmi V, Stichelbout M, Provôt F, Fakhouri F. Pregnancy as a susceptible state for thrombotic microangiopathies. Front Med (Lausanne) 2024; 11:1343060. [PMID: 38476448 PMCID: PMC10927739 DOI: 10.3389/fmed.2024.1343060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
Pregnancy and the postpartum period represent phases of heightened vulnerability to thrombotic microangiopathies (TMAs), as evidenced by distinct patterns of pregnancy-specific TMAs (e.g., preeclampsia, HELLP syndrome), as well as a higher incidence of nonspecific TMAs, such as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, during pregnancy. Significant strides have been taken in understanding the underlying mechanisms of these disorders in the past 40 years. This progress has involved the identification of pivotal factors contributing to TMAs, such as the complement system, ADAMTS13, and the soluble VEGF receptor Flt1. Regardless of the specific causal factor (which is not generally unique in relation to the usual multifactorial origin of TMAs), the endothelial cell stands as a central player in the pathophysiology of TMAs. Pregnancy has a major impact on the physiology of the endothelium. Besides to the development of placenta and its vascular consequences, pregnancy modifies the characteristics of the women's microvascular endothelium and tends to render it more prone to thrombosis. This review aims to delineate the distinct features of pregnancy-related TMAs and explore the contributing mechanisms that lead to this increased susceptibility, particularly influenced by the "gravid endothelium." Furthermore, we will discuss the potential contribution of histopathological studies in facilitating the etiological diagnosis of pregnancy-related TMAs.
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Affiliation(s)
- Marie Frimat
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
- Inserm, Institut Pasteur de Lille, Univ. Lille, Lille, France
| | | | | | - François Provôt
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, CHUV and University of Lausanne, Lausanne, Switzerland
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Casey A, Jeyaseelan A, Byrne L, Reardon MF. Presentation of basilar artery stroke secondary to patent foramen ovale: a diagnosis made with a 'selfie'. BMJ Case Rep 2024; 17:e256223. [PMID: 38182167 PMCID: PMC10773335 DOI: 10.1136/bcr-2023-256223] [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] [Indexed: 01/07/2024] Open
Abstract
We report the case of a woman in her late 20s, with no significant medical history, who was found unresponsive at home. Her mother revealed a 'selfie' sent to her by the patient 30 min prior to collapse which revealed bilateral ptoses. Initial brain imaging with non-contrast CT of the brain revealed nil of note. A multiphase CT angiogram revealed an acute basilar artery thrombosis. She underwent timely thrombolysis and was transferred for endovascular thrombectomy. Further evaluation with an aim to define the aetiology revealed the diagnosis of patent foramen ovale with a resultant paradoxical embolism. The differential diagnoses of unexplained rapidly evolving neurology with reduced Glasgow coma scale, and relevant appropriate investigations are discussed in this case report.
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Affiliation(s)
- Aoife Casey
- Medicine, Wexford General Hospital, Newtown Road, Carricklawn, Wexford, Ireland
| | - Arveen Jeyaseelan
- Medicine, Wexford General Hospital, Newtown Road, Carricklawn, Wexford, Ireland
| | - Luke Byrne
- Medicine, Wexford General Hospital, Newtown Road, Carricklawn, Wexford, Ireland
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Yajima H, Miyawaki S, Sayama S, Kumasawa K, Ikemura M, Imai H, Hongo H, Hirano Y, Ishigami D, Torazawa S, Kiyofuji S, Koizumi S, Saito N. Hypertensive disorders of pregnancy in moyamoya disease: A single institution experience. J Stroke Cerebrovasc Dis 2023; 32:107377. [PMID: 37742384 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107377] [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: 05/23/2023] [Revised: 08/21/2023] [Accepted: 09/16/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE The characteristics of pregnancy and delivery in patients with moyamoya disease (MMD) remain unclear. We retrospectively investigated perinatal outcomes in patients with MMD to evaluate the risks associated to this condition. MATERIALS AND METHODS Clinical data of women with MMD who delivered at the University of Tokyo Hospital between 2000 and 2021 were collected. Maternal characteristics including genetic data, obstetric complications, method of delivery and anesthesia, neonatal outcomes, neurological events during pregnancy, delivery, and postpartum course, were reviewed. RESULTS Thirteen pregnancies with MMD were identified. The median maternal age was 30 years. The initial clinical symptoms were identified as transient ischemic attack, infarction, and headache. Eight patients had a history of bypass surgery. The median gestational age at delivery was 37 weeks. DNA samples were collected from five patients, responsible for six pregnancies. Of these six cases, five had the RNF213 c.14429G > A (p.Arg4810Lys) heterozygous variant. Of the 13 pregnancies, seven had hypertensive disorder of pregnancy (HDP). Additionally, three of five pregnancy cases with RNF213 p.Arg4810Lys heterozygous variant presented with HDP. Nine patients underwent cesarean section, and four delivered vaginally with epidural anesthesia. One case of ischemic stroke was confirmed during the postpartum period. Regarding newborns, neither Apgar scores lower than 7 nor neonatal intensive care unit admissions were reported. CONCLUSIONS This study suggests that the frequency of HDP is higher in patients with MMD compared to those with normal pregnancies. Strict blood pressure control should be performed in patients with MMD during pregnancy and postpartum period.
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Affiliation(s)
- Hirohisa Yajima
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan.
| | - Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masako Ikemura
- Department of Pathology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideaki Imai
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan; Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Yudai Hirano
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Daiichiro Ishigami
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Seiei Torazawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Satoshi Kiyofuji
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
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Christopher KM, Gao X, Abdelsalam A, Miremadi B, Scott J, Ilorah C, Xaverius P, Linares G. Stroke-related risk factors during pregnancy in women who underwent metabolic and bariatric surgery compared with women who have not undergone metabolic and bariatric surgery. Surg Obes Relat Dis 2023; 19:1142-1147. [PMID: 37150625 DOI: 10.1016/j.soard.2023.03.017] [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: 08/19/2022] [Revised: 02/20/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Stroke during pregnancy is rare, occurring in 30 of 100,000 pregnancies and accounting for 7% of maternal deaths in the United States from 2016 to 2018. Metabolic and bariatric surgery (MBS) has been shown to reduce symptoms of chronic conditions that are risk factors for stroke, including hypertension, hypercholesterolemia, and diabetes in women. However, little is known about the impact of MBS on stroke risk during pregnancy. OBJECTIVES To examine stroke and stroke risk factors including preeclampsia, eclampsia, gestational hypertension, and embolism/thrombosis in women of reproductive age who have had MBS. SETTING We used the National Inpatient Sample, a publicly available data set from the Healthcare Cost and Utilization Project that samples 20% of hospital discharges in the United States. METHODS This cross-sectional study included women between the ages of 20 and 44 years who had a maternal admission code. Weighted logistic regression was conducted to assess the odds of stroke and stroke risk factors in women with a history of MBS compared with other women of reproductive age. RESULTS Women with a history of MBS have 12% lower adjusted odds of developing preeclampsia/eclampsia and 10% lower adjusted odds of gestational hypertension than women who did not undergo MBS. When stratified by race, the difference was significant in White women (preeclampsia/eclampsia: adjusted odds ratio [aOR] = .89; 95% confidence interval [CI], .81-.98; gestational hypertension: aOR = .91; 95% CI, .83-1.00). Latinas with MBS had significantly lower odds of preeclampsia/eclampsia (aOR = .75; 95% CI, .64-.90). CONCLUSIONS MBS helps women lose weight and decrease the incidence of some pregnancy-related risk factors for stroke. However, there is a notable racial health disparity.
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Affiliation(s)
- Kara M Christopher
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri.
| | - Xiaoyi Gao
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Ahmed Abdelsalam
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Brian Miremadi
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Jordan Scott
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Chike Ilorah
- Brookwood Baptist Health Specialty Services, Neurology, Birmingham, Alabama
| | - Pamela Xaverius
- University of Health Sciences and Pharmacy, St. Louis, Missouri
| | - Guillermo Linares
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri
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Tombak Y, Karaahmet OZ, Umay E, Tombak A, Gurcay E. Factors influencing the willingness to participate in rehabilitation in patients with subacute stroke. J Clin Neurosci 2023; 116:99-103. [PMID: 37678057 DOI: 10.1016/j.jocn.2023.09.001] [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: 06/27/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The aim of this study was to examine the parameters that may influence the willingness of patients to participate in post-stroke rehabilitation. METHODS Patients in the subacute phase of stroke who underwent inpatient rehabilitation for one month were included in this study. The primary outcome measure was the level of rehabilitation participation as measured on the Pittsburgh Rehabilitation Participation Scale (PRPS). Other outcome measures evaluated were Mini-Mental State Examination (MMSE) for cognitive functions, Brunnstrom stage for motor recovery, modified Rankin Scale (mRS) for disability, Functional Independence Measure for functionality, Pittsburgh Sleep Quality Index for sleep quality, and Beck Depression Inventory for emotional state. RESULTS A total of 38 patients with first-time stroke were studied. A negative correlation was found between the participation in rehabilitation and body mass index (BMI) (r: -0.398p = 0.012), myocardial infarction (MI) history (r: -0.387p = 0.015) and mRS (r: -0.351p = 0.031), while a positive correlation was determined with MMSE (r: 0.432P = 0.007). A 1-unit increase in BMI, MI history, and mRS resulted in a 0.176, 0.673, and 0.294-unit decrease in participation in rehabilitation, respectively. In addition, a 1-unit increase in MMSE provided an increase of 0.606-unit in participation. CONCLUSION BMI within normal limits, prevention/treatment of cardiovascular diseases, and well-being of physical and cognitive functions might be the factors that positively influence participation in rehabilitation process. We consider that it would be appropriate to evaluate these parameters with particular emphasis in stroke patients in the subacute period to be rehabilitated.
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Affiliation(s)
- Yasemin Tombak
- Department of Physical Medicine & Rehabilitation, Ankara Etlik City Hospital, Ankara, Turkey.
| | - Ozgur Zeliha Karaahmet
- Department of Physical Medicine & Rehabilitation, Ankara Etlik City Hospital, Ankara, Turkey
| | - Ebru Umay
- Department of Physical Medicine & Rehabilitation, Ankara Etlik City Hospital, Ankara, Turkey
| | - Aysegul Tombak
- Department of Physical Medicine & Rehabilitation, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Eda Gurcay
- Department of Physical Medicine & Rehabilitation, University of Health Sciences, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
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Khoromi S. Secondary headaches in pregnancy and the puerperium. Front Neurol 2023; 14:1239078. [PMID: 37840942 PMCID: PMC10569305 DOI: 10.3389/fneur.2023.1239078] [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: 06/12/2023] [Accepted: 08/30/2023] [Indexed: 10/17/2023] Open
Abstract
Headache during pregnancy can be due to primary causes such as migraine but can also be a presenting symptom of secondary causes including life threatening conditions. This is a minireview of secondary causes of headache during pregnancy and the puerperium. Unique alterations in physiological and vascular functions as well as in the coagulation pathway which occur during pregnancy increase the risk of most of these secondary conditions which include preeclampsia, eclampsia, hemorrhagic stroke, cerebral venous, sinus thrombosis, reversible cerebral vascular syndrome, and posterior reversible encephalopathy. Marked increase in progesterone level in pregnancy is also associated with the growth of tumors such as meningiomas, as 70% of these tumors are positive for progesterone receptors and increase in size can lead to headache along with other neurological symptoms. Hemodynamic changes can lead to the growth of meningiomas as well. Although hormone producing pituitary tumors are usually not conducing to pregnancy, women with known pituitary tumors who do get pregnant may become symptomatic during pregnancy and develop secondary headache. Another rare cause of secondary headache during pregnancy is pituitary apoplexy. Although its occurrence is uncommon, it needs to be properly recognized and treated to avoid endocrine and visual complications. Other rare entities with increased incidence during the puerperium such postdural puncture headache will be also discussed. In summary, new onset headache during pregnancy deserves special attention because in the absence of proper recognition and treatment, secondary headache disorders can endanger the life of the mother and the fetus.
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Affiliation(s)
- Suzan Khoromi
- University of California, San Diego, La Jolla, CA, United States
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Qu H, He C, Xu H, Sun X. Investigating the association of breast cancer and stroke: A two-sample Mendelian randomization study. Medicine (Baltimore) 2023; 102:e35037. [PMID: 37747009 PMCID: PMC10519452 DOI: 10.1097/md.0000000000035037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/26/2023] Open
Abstract
We conducted a two-sample Mendelian randomization (MR) design to evaluate the causal relation between breast cancer and stroke. Genetic variants associated with breast cancer and stroke were both obtained from genome-wide association study summary data. The single nucleotide polymorphisms were selected as instrumental variables. Effect estimates were primarily evaluated using standard inverse variance weighted. Finally, sensitivity analyses were performed for the detection of potential pleiotropy and heterogeneity in the cause-effect evaluation. There was a causal association of ER-positive breast cancer (odds ratio = 0.11, 95% confidence interval: 0.08-0.16, P < .001), and ER-negative breast cancer (odds ratio = 1.04, 95% confidence interval: 1.00-1.07, P = .045) with stroke. MR-egger regression revealed that the cause-effect of ER-positive breast cancer (P < .001) is drove by the directional horizontal pleiotropy, while there was no directional pleiotropy in the cause-effect of ER-negative breast cancer (P = .82). Cochran Q-derived P-value from inverse variance weighted (P = .27) shown that the cause-effect of ER-negative breast cancer on stroke do not need to consider the effect of heterogeneity. In addition, the leave-one-out analysis showed no influential instruments driving the associations, suggesting robust results for all outcomes. The present MR study reveals that ER negative breast cancer increase the risk of stroke.
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Affiliation(s)
- Huiling Qu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Chao He
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Haichun Xu
- Department of Psychiatry, Shenyang Jing'an Mental Health Hospital, Shenyang, Liaoning, P.R. China
| | - Xiaoyu Sun
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
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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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Bitar G, Sibai BM, Chen HY, Neff N, Blackwell S, Chauhan SP, Bartal MF. Pregnancy-Associated Stroke and Outcomes Related to Timing and Hypertensive Disorders. Obstet Gynecol 2023:00006250-990000000-00811. [PMID: 37411017 DOI: 10.1097/aog.0000000000005249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To estimate temporal trends of stroke in the peripartum period and to assess the relationship between stroke and maternal adverse outcomes vis-à-vis timing and hypertension. METHODS We conducted a retrospective, cross-sectional study using the National Inpatient Sample to identify hospitalizations with pregnancy-associated stroke in the United States (2016-2019). Temporal trends in pregnancy-associated stroke were examined according to timing of stroke (antepartum vs postpartum) and both prepregnancy and pregnancy hypertensive disorders (yes vs no). Multivariable Poisson regression models with robust error variance were used to examine the association among maternal adverse outcomes, timing of stroke, and hypertensive disorders. RESULTS Among 15,977,644 pregnancy hospitalizations, 6,100 hospitalizations (38.2/100,000 hospitalizations) were with pregnancy-associated stroke. Of these, 3,635 (59.6%) had antepartum pregnancy-associated stroke and 2,465 (40.4%) had postpartum pregnancy-associated stroke; alternatively, 2,640 (43.3%) had hypertensive disorders, and 3,460 (56.7%) were without hypertensive disorders. From 2016 to 2019, the overall rate of pregnancy-associated stroke (37.5 to 40.8/100,000 pregnancy hospitalizations, P=.028), rate of postpartum pregnancy-associated stroke (14.6 to 17.6/100,000 pregnancy hospitalizations, P=.005), and rate of pregnancy-associated stroke with hypertensive disorders (14.9 to 17.2/100,000 pregnancy hospitalizations, P=.013) increased. Antepartum pregnancy-associated stroke and pregnancy-associated stroke without hypertensive disorders, however, remained stable. Despite higher risk of maternal morbidity in postpartum stroke hospitalizations, including mechanical ventilation and pneumonia, there was no significant difference in in-hospital mortality between antepartum and postpartum stroke. Similarly, between pregnancy-associated stroke with hypertensive disorders and stroke without hypertensive disorders, an increased risk of mechanical ventilation, seizure, and prolonged hospital stay was seen for stroke with hypertensive disorders without an increase in mortality. CONCLUSION A nationally representative sample of hospitalizations in the United States indicates an increasing trend in the rate of postpartum stroke. Almost half of hospitalizations with pregnancy-associated stroke have concomitant hypertensive disorders. Risk of adverse outcomes, but not mortality, is elevated in patients with stroke occurring in the postpartum period and stroke associated with hypertensive disorders.
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Affiliation(s)
- Ghamar Bitar
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; and the Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
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Menon G, Macharla A, Srinivasan S, Santosh S, Pai A, Nair R, Hegde A. Spontaneous Intracerebral Hemorrhage in the Young: An Institutional Registry Analysis. Ann Indian Acad Neurol 2023; 26:502-506. [PMID: 37970280 PMCID: PMC10645210 DOI: 10.4103/aian.aian_76_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: 01/28/2023] [Revised: 05/08/2023] [Accepted: 05/18/2023] [Indexed: 11/17/2023] Open
Abstract
Background Spontaneous intracerebral hemorrhage (SICH) accounts for about 10-15% of all strokes. Generally, it is a disease of the elderly; worldwide, the incidence of SICH in the young is showing an increasing trend, especially in India and the Asian continent. An attempt is also made to analyze the presence of factors, which may predict the risk of SICH among young hypertensives. Methods A six-year retrospective review of patients aged below 50 years who presented with SICH was included in the study. Patients with bleeds secondary to an identifiable cause such as tumor, trauma, vascular malformations, and coagulopathy-induced bleeds were excluded from the study. The outcome was measured at 90 days using the modified ranking scale, and predictors of outcome (good outcome modified ranking score (mRS): 0-3; poor outcome mRS: 4-6) were analyzed. Results SICH in the young accounted for 28.4% of all intracerebral hemorrhage (ICH) patients admitted during the study period (344/1210). The mean age of our male-dominant (78.5%) cohort was 42.9 ± 6.24 years, and the median Glasgow coma score (GCS) on presentation was 11 (IQR: 8-14). A prior history of hypertension (HTN) was obtained in 51.2% (176), and left ventricular hypertrophy (LVH) was documented in 237 (68.9%) patients. The basal ganglia was the most common location of the bleed (62.2%). At 90 days, 200 patients (58.1%) had good outcome and 144 (41.9%) had poor outcome with an overall mortality of 75 (21.8%). Independent predictors of poor outcome were poor GCS, larger volume, and high serum creatinine values. Conclusion The incidence of SICH among the young accounts for nearly 30% of admitted ICH. Poor outcome and mortality are high with HTN being the single most important modifiable risk factor in the cohort.
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Affiliation(s)
- Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Aparna Macharla
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Siddharth Srinivasan
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sonin Santosh
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ashwin Pai
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rajesh Nair
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Ananth CV, Brandt JS, Keyes KM, Graham HL, Kostis JB, Kostis WJ. Epidemiology and trends in stroke mortality in the USA, 1975-2019. Int J Epidemiol 2023; 52:858-866. [PMID: 36343092 PMCID: PMC10244057 DOI: 10.1093/ije/dyac210] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/18/2022] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Whether changes in stroke mortality are affected by age distribution and birth cohorts, and if the decline in stroke mortality exhibits heterogeneity by stroke type, remains uncertain. METHODS We undertook a sequential time series analysis to examine stroke mortality trends in the USA among people aged 18-84 years between 1975 and 2019 (n = 4 332 220). Trends were examined for overall stroke and by ischaemic and haemorrhagic subtypes. Mortality data were extracted from the US death files, and age-sex population data were extracted from US census. Age-standardized stroke mortality rates and incidence rate ratio (IRR) with 95% confidence interval [CI] were derived from Poisson regression models. RESULTS Age-standardized stroke mortality declined for females from 87.5 in 1975 to 30.9 per 100 000 in 2019 (IRR 0.27, 95% CI 0.26, 0.27; average annual decline -2.78%, 95% CI -2.79, -2.78). Among males, age-standardized mortality rate declined from 112.1 in 1975 to 38.7 per 100 000 in 2019 (RR 0.26, 95% CI 0.26, 0.27; average annual decline -2.80%, 95% CI -2.81, -2.79). Stroke mortality increased sharply with advancing age. Decline in stroke mortality was steeper for ischaemic than haemorrhagic strokes. CONCLUSIONS Stroke mortality rates have substantially declined, more so for ischaemic than haemorrhagic strokes.
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Affiliation(s)
- Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Katherine M Keyes
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Hillary L Graham
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John B Kostis
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - William J Kostis
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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15
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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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Hemorrhagic Stroke in Pregnancy. Clin Obstet Gynecol 2023; 66:223-230. [PMID: 36044629 DOI: 10.1097/grf.0000000000000739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Hemorrhagic stroke carries a high risk of disability and mortality. The obstetrical population is at increased risk. Prompt diagnosis and maternal stabilization with a multidisciplinary approach are the mainstays in management. Computed tomography head is the diagnostic imaging of choice and is considered safe in pregnancy. Fetal status optimization before neurosurgery and delivery should be considered if the fetus is viable or if worsening maternal condition. Obstetric indications guide the mode of delivery. Cesarean delivery may be indicated to reduce increasing intracranial pressure. Neuraxial anesthesia should be considered to minimize catecholamine surges, reduce sedation, and control blood pressures.
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17
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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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18
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Choudhary D, Mohan V, Varsha AS, Hegde A, Menon G. Neurosurgical emergencies during pregnancy - Management dilemmas. Surg Neurol Int 2023; 14:151. [PMID: 37151438 PMCID: PMC10159311 DOI: 10.25259/sni_1076_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Background Neurosurgical emergencies in the obstetric setting pose considerable challenges. Decision-making involves deliberations on the gestational age, critical nature of the illness, timing of surgery, maternal positioning during neurosurgery, anesthesiologic strategies, monitoring of the pregnancy during surgery, and the mode of delivery. The present study discusses the management and ethical dilemmas encountered during the management of six obstetric patients with neurosurgical emergencies. Methods A retrospective review of all neurosurgical operations performed between January 2016 and December 2022 were included in the study. Results This study includes a series of six pregnant women who presented with neurosurgical emergencies, secondary to freshly diagnosed pathologies in the period 2016-2022. The mean maternal age was 31.33 years. Four of the six patients were in the third semester and two were in the second trimester. The underlying etiologies were as follows: spontaneous intracerebral hypertensive hemorrhage (1), obstructive hydrocephalus due to shunt malfunction (1), brain tumor (02), and compressive spinal cord myelopathy due to tumors (02). Three patients who were near term underwent lower cesarean section followed by emergency neurosurgical procedure in the same sitting. Two second trimester patients continued their pregnancy after the emergency neurosurgical operation. In one patient, in whom a brain tumor was diagnosed near term, underwent neurosurgery 1 week after successful cesarean section. All the six mothers and fetus recovered well, ex3cept two patients who have persisting residual deficits. Conclusion Treatment of neurosurgical emergencies during pregnancy needs to be customized depending on the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. With careful planning, timely intervention, consultative decision making and it is possible to achieve the ultimate goal - which is to protect and safeguard the mother and preserve and deliver a viable fetus.
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Affiliation(s)
| | | | | | | | - Girish Menon
- Corresponding author: Girish Menon, Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India.
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Khatibi K, Saber H, Patel S, Mejia LLP, Kaneko N, Szeder V, Nour M, Jahan R, Tateshima S, Colby G, Duckwiler G, Afshar Y. Aneurysmal subarachnoid hemorrhage in pregnancy: National trends of treatment, predictors, and outcomes. PLoS One 2023; 18:e0285082. [PMID: 37141265 PMCID: PMC10159186 DOI: 10.1371/journal.pone.0285082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/16/2023] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is a rare event associated with significant pregnancy-associated maternal and neonatal morbidity and mortality. The optimal treatment strategy and clinical outcome of aSAH in pregnancy remains unclear. We aimed to investigate the treatment utilizations and outcomes of aSAH in pregnant people. METHODS Using the 2010-2018 National Inpatient Sample, we identified all birth hospitalizations of women between ages of 18 to 45 associated with subarachnoid hemorrhage and aneurysm treatment were included. Multivariate analyses were used to evaluate the effect of pregnancy state, mode of treatment of aneurysms, severity of subarachnoid hemorrhage on mortality and discharge destination of this cohort. Trends in mode of treatment utilized for aneurysmal treatment in this time interval was evaluated. RESULTS 13,351 aSAH with treatment were identified, of which 440 were associated with pregnancy. There was no significant difference in mortality or rate of discharge to home in pregnancy related hospitalization. Worse aSAH severity, chronic hypertension, and smaller hospital size was associated with significantly higher rate of mortality from aSAH during pregnancy. Worse aSAH severity was associated with lower rate of discharge to home. Like the non-pregnant cohort, the treatment of ruptured aneurysms in pregnancy are increasingly through endovascular approaches. The mode of treatment does not change the mortality or discharge destination. CONCLUSIONS Pregnancy does not alter mortality or the discharge destination for aSAH. Ruptured aneurysms during pregnancy are increasingly treated endovascularly. Mode of aneurysm treatment does not affect mortality or discharge destination in pregnancy.
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Affiliation(s)
- Kasra Khatibi
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, United States of America
| | - Hamidreza Saber
- Department of Neurology, University of Texas at Austin, Austin, TX, United States of America
| | - Smit Patel
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, United States of America
| | | | - Naoki Kaneko
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Viktor Szeder
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - May Nour
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, United States of America
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Reza Jahan
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Satoshi Tateshima
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Geoffrey Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Gary Duckwiler
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA, United States of America
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Abdelnour LH, Kurdy M, Idris A. Systematic review of postpartum and pregnancy-related cervical artery dissection. J Matern Fetal Neonatal Med 2022; 35:10287-10295. [PMID: 36176066 DOI: 10.1080/14767058.2022.2122799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cervical artery dissection (CeAD) is responsible of one fifth of cases of ischemic stroke, but is uncommon during pregnancy or the early postpartum period and evidence is derived from published case reports and case series. OBJECTIVES This systematic review with a prospectively registered protocol was conducted to study the clinical presentation, management and prognosis of this condition. METHODS Ovid-Medline, PubMed Central, and CINAHL were searched without language restriction. RESULTS Fifty-seven articles (50 case reports and seven case series) reporting on 77 patients were included. The mean age was 33.7 years. The main possible risk factors identified were migraine, hyperlipidemia, connective tissue disorders, preeclampsia and eclampsia, HELLP syndrome and prolonged second stage of labor. Headache was the most frequent symptom, followed by neck pain. Acute medical treatments included anticoagulation, antiplatelets, and endovascular therapy. No patients received thrombolysis. The overall prognosis was good with 77.8% of patients making full clinical recovery. CONCLUSIONS Cervical artery dissection is a rare, but an important complication of pregnancy and puerperium. Diagnosis requires a high index of suspicion. The strong association with hypertensive and connective tissue disorders requires further research.
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Impact of preeclampsia/eclampsia on hemorrhagic and ischemic stroke risk: A 17 years follow-up nationwide cohort study. PLoS One 2022; 17:e0276206. [DOI: 10.1371/journal.pone.0276206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
Background and purposes
The long-term risk of stroke in women with preeclampsia/eclampsia is a concerning issue. In this study we further investigated different stroke subtypes and differentiated follow-up time intervals.
Methods
Between 2000 and 2017, 1,384,427 pregnant women were registered in the National Health Insurance Research Database in Taiwan. After excluding women with previous stroke history and exact matching with all confounders, 6,053 women with preeclampsia/eclampsia and 24,212 controls were included in the analysis sample.
Results
Over the 17-year follow-up, the adjusted hazard ratio (aHR) for stroke in women with preeclampsia/eclampsia was 2.05 (95% confidence interval, CI = 1.67–2.52, p<0.001). The 17 years overall aHR of both ischemic and hemorrhagic stroke were 1.98 and 3.45, respectively (p<0.001). The stroke subtypes, hemorrhagic and ischemic, had different time trend risks, and hemorrhagic stroke risks kept higher than that of ischemic stroke. The aHR of ischemic stroke reached a peak during 1–3 years after childbirth (aHR = 3.09). The aHR of hemorrhagic stroke reached a peak during 3–5 years (aHR = 7.49).
Conclusions
Stroke risk persisted even after decades, for both ischemic and hemorrhagic subtypes. Women with preeclampsia/eclampsia history should be aware of the long-term risk of stroke.
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22
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Hsu JL, Chin SC, Cheng MH, Wu YR, Ro A, Ro LS. Postpartum Spinal Cord Infarction: A Case Report and Review of the Literature. MEDICINES (BASEL, SWITZERLAND) 2022; 9:54. [PMID: 36355059 PMCID: PMC9698876 DOI: 10.3390/medicines9110054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
Background: Postpartum spinal cord infarction is a very rare disease. Only two cases have been reported in the English literature. Methods: We reported a 26 year old female who received second doses of the mRNA-1273 vaccine 52 days before delivery. She presented as sudden onset of paraplegia, sensory level, and sphincter incontinence at postpartum period. No history of heparin exposure was noted. Imaging findings confirmed the T10-11 level infarction and her anti-human heparin platelet factor 4 (anti-PF4) antibody was positive. After 7 days of dexamethasone therapy, her paraplegia and urinary incontinence gradually improved. Results: The CT angiography (CTA) of the artery of Adamkiewicz (Aka) showed tandem narrowing, most conspicuous at the T10-11 level, which was presumably due to partial occlusion of the arteriolar lumen. The thoracolumbar spine magnetic resonance imaging with contrast medium showed owl's eyes sign at the T10 and T11 levels. We compared our case with two other case reports from the literature. Conclusions: Post-partum spinal cord infarction with positive anti-PF4 antibody and relatively thrombocytopenia are the characteristics of our case.
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Affiliation(s)
- Jung-Lung Hsu
- Department of Neurology, New Taipei Municipal TuCheng Hospital, Chang Gung Memorial Hospital and Chang Gung University, New Taipei City 236, Taiwan
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Humanities in Medicine and Research Center for Brain and Consciousness, Shuang Ho Hospital, Taipei Medical University, Taipei 110, Taiwan
| | - Shy-Chyi Chin
- Department of Medical Imaging and Intervention, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Yih-Ru Wu
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan
| | - Aileen Ro
- Department of Obstetrics and Gynecology, College of Medicine, Linkou Chang Gung Memorial Hospital and Chang-Gung University, Taoyuan 333, Taiwan
| | - Long-Sun Ro
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan
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Jeong Y, Jung YJ, Noh E, Ha S, Hwang J, Cho GJ, Oh MJ, Kim YH. The risk for future cerebrovascular disease in pregnant women with Moyamoya disease: a nationwide population-based study in South Korea. BMC Pregnancy Childbirth 2022; 22:433. [PMID: 35610618 PMCID: PMC9128146 DOI: 10.1186/s12884-022-04718-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 04/22/2022] [Indexed: 11/12/2022] Open
Abstract
Background Physiologic changes during pregnancy affect the development of postpartum cerebrovascular disease (CVD) in women with Moyamoya disease. Due to the rare prevalence of Moyamoya disease and its large regional variations, large-scale based studies on the risk of CVD after delivery have not been conducted. This study aimed to evaluate whether women with Moyamoya disease have an increased risk of CVD after delivery. Methods Research data was collected from the National Health Insurance Claims Database of the Health Insurance Review and Assessment Service. Patients who delivered in Korea from 2007 to 2014 were enrolled in this study. We classified women as having CVD if they were diagnosed with any of the following conditions between delivery and December 31, 2016; cerebral infarction (I63.X in the International Classification of Diseases-10th Revision [ICD-10]) and/or intracranial hemorrhage (I61.X, I62.X in ICD-10) and/or subarachnoid hemorrhage (I60.X in ICD-10). Women with Moyamoya disease were identified as having I67.5 in ICD-10. We matched the study cohort by the ratio of 1:10 to analyze the risk CVD occurrence. The matching technique applied in this study was based on the variables of age and parity. To evaluate the adjusted hazard ratio (HR) for CVD in women with Moyamoya disease, we used multivariate Cox proportional hazard regression. Results Among a total of 3,611,216 Korean women who underwent delivered, we identified 412 women with Moyamoya disease diagnosis and 1420 age- and parity-matched women without Moyamoya disease (control). Compared to the control group, women with Moyamoya disease had a significantly higher rate of Cesarean section, overt DM, and essential hypertension (all p < 0.0001). Among women with Moyamoya disease, 55 (13.35%) women developed CVD within the follow-up postpartum period. The presence of Moyamoya disease was associated with an increased risk of CVD after delivery (adjusted HR 37.42; 95% confidence interval (CI) 17.50-80.02 within 2.3 years) after adjusting for pregnancy-induced hypertension, gestational diabetes mellitus, pregestational diabetes, chronic hypertension. Conclusion This population based study showed that the occurrence rate of CVD after delivery was higher in women with Moyamoya disease than in those without. Therefore, careful and long-term postpartum surveillance is required for women with Moyamoya disease.
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Affiliation(s)
- Yeonseong Jeong
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Yun Ji Jung
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Eunjin Noh
- Korea University Guro Hospital Smart Healthcare Center, Seoul, Republic of Korea
| | - Sungyeon Ha
- Graduate School of Statistics, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jeongeun Hwang
- Department of Biomedical Research Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Min-Jeong Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea.
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Mayorga-Corvacho J, Vergara-Garcia D, Benavides C, Riveros WM. Ruptured brain arteriovenous malformation in a pregnant woman: a case report. Br J Neurosurg 2022:1-4. [PMID: 35510560 DOI: 10.1080/02688697.2022.2064426] [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: 01/14/2021] [Revised: 11/24/2021] [Accepted: 04/06/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) are vascular lesions that commonly present with intracranial haemorrhage. Pregnancy has been associated with an increased risk of bAVM rupture. However, their natural history in pregnant women is uncertain. CASE DESCRIPTION A 27-year-old female at 28 weeks of gestation presented with a compromised neurological status secondary to a ruptured left frontal Spetzler-Martin scale (SM) III + bAVM. An emergent caesarean section was performed due to the high risk of foetal distress. Endovascular treatment successfully controlled the bleeding site, and stereotactic radiosurgery was offered as a subsequent treatment option. CONCLUSION bAVMs should be considered in pregnant women with intracranial haemorrhage. The management of these lesions during pregnancy is controversial. Surgical risk and foetal development should be considered when selecting a management strategy.
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Affiliation(s)
- Juliana Mayorga-Corvacho
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - David Vergara-Garcia
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - Camilo Benavides
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - William Mauricio Riveros
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
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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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Aneurysmal and arteriovenous malformation hemorrhage during pregnancy: An update on the epidemiology, risk factors and prognosis. Clin Neurol Neurosurg 2021; 208:106897. [PMID: 34455403 DOI: 10.1016/j.clineuro.2021.106897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Intracranial hemorrhage (ICH) is a devastating condition with a high rate of morbidity and mortality. Aneurysm or arteriovenous malformation (AVM) rupture are two common etiologies leading to ICH. Here we provide an update on ICH during pregnancy with a focus on those caused by aneurysm or AVM rupture. METHODS Here we systematically review 25 studies reported in the literature to provide an update on ICH during pregnancy focusing on aneurysm or AVM rupture. We also reviewed the prognosis of ICH during puerperium. RESULTS Discrepancies exist between studies supporting or refuting the hypothesis of a higher rate of ICH during pregnancy, obscuring the overall rate of aneurysm and AVM rupture in pregnant ICH patients. However, risk factors such as maternal age and hypertension have shown to increase the frequency of ICH in pregnant patients. We also show increased morbidity and mortality in patients suffering from preeclampsia/eclampsia. DISCUSSION ICH is rare, but the various studies demonstrating its increased frequency, morbidity, and mortality during pregnancy should raise our awareness of this condition. The management and treatment decisions for a pregnant ICH patient should follow the same principles as nonpregnant patients, but with the knowledge that not all medications are appropriate for use in the pregnant patient. Although there seems to be a higher frequency of AVM rupture, further research must be conducted in order to fully determine the effects of pregnancy on aneurysm and AVM ruptures.
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Risk of Incident Stroke among Vegetarians Compared to Nonvegetarians: A Systematic Review and Meta-Analysis of Prospective Cohort Studies. Nutrients 2021; 13:nu13093019. [PMID: 34578897 PMCID: PMC8471883 DOI: 10.3390/nu13093019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 01/17/2023] Open
Abstract
Vegetarian dietary patterns provide health benefits for cardiovascular health; however, the studies examining the association of vegetarian diets with stroke incidence showed inconsistent findings. We systematically evaluated the risk of incident stroke among vegetarians (diets excluding meat, poultry, fish, and seafood) compared among nonvegetarians. A systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science was performed until 20 May 2021. Prospective cohort studies comparing the risk estimates for incident stroke between vegetarians and nonvegetarians were included. Of 398 articles identified in the database search, data from seven cohort studies (408 total stroke cases in 29,705 vegetarians and 13,026 total stroke cases in 627,728 nonvegetarians) were included. The meta-analysis revealed no significant association between adhering to the vegetarian dietary patterns and the risk of incident stroke (HR = 0.86; 95% CI = 0.67-1.11; I2 = 68%, n = 7). Subgroup analyses suggested that studies conducted in Asia and those with a mean baseline age of participants 50-65 years showed a lower risk of stroke in vegetarians. Moreover, no significant association between vegetarian diets and the risk of ischemic stroke (HR = 0.56; 95% CI = 0.22-1.42; I2 = 82%, n = 3) or hemorrhagic stroke (HR = 0.77; 95% CI = 0.19-3.09; I2 = 85%, n = 2) was found. To be conclusive, no strong relationship between vegetarian diets and the incidence of stroke was observed. Given the limited certainty of evidence from NutriGrade, future well-designed studies are warranted to provide solid evidence on this topic.
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Al-Mufti F, Schirmer CM, Starke RM, Chaudhary N, De Leacy R, Tjoumakaris SI, Haranhalli N, Abecassis IJ, Amuluru K, Bulsara KR, Hetts SW. Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2021; 14:1033-1041. [PMID: 34244337 DOI: 10.1136/neurintsurg-2021-017888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis. METHODS We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence. RESULTS MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery & Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neil Haranhalli
- Department of Neurosurgery, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Krishna Amuluru
- Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, Indiana, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Department of Radiology, UCSF, San Francisco, California, USA
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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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Liew J, Feghali J, Huang J. Intracerebral and subarachnoid hemorrhage in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 172:33-50. [PMID: 32768093 DOI: 10.1016/b978-0-444-64240-0.00002-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maternal stroke occurs in around 34 out of every 100,000 deliveries and is responsible for around 5%-12% of all maternal deaths. It is most commonly hemorrhagic, and women are at highest risk for developing pregnancy-related hemorrhage during the early postpartum period through 6 weeks following the delivery. The most common causes of hemorrhagic stroke in pregnant patients are arteriovenous malformations and cerebral aneurysms. Management is similar to that for acute hemorrhagic stroke in the nonpregnant population with standard use of computed tomography and judicious utilization of intracranial vessel imaging and contrast. The optimal delivery method is evaluated on a case-by-case basis, and cesarean delivery is not always required. As most current studies are limited by retrospective design, relatively small sample sizes, and heterogeneous study term definitions, strong and comprehensive evidence-based guidelines on the management of acute hemorrhagic stroke in pregnant patients are still lacking. In the future, multicenter registries and prospective studies with uniform definitions will help improve management strategies in this complex patient population.
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Affiliation(s)
- Jason Liew
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Gokina NI, Fairchild RI, Prakash K, DeLance NM, Bonney EA. Deficiency in CD4 T Cells Leads to Enhanced Postpartum Internal Carotid Artery Vasoconstriction in Mice: The Role of Nitric Oxide. Front Physiol 2021; 12:686429. [PMID: 34220551 PMCID: PMC8242360 DOI: 10.3389/fphys.2021.686429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
The risk of postpartum (PP) stroke is increased in complicated pregnancies. Deficiency in CD4 T cell subsets is associated with preeclampsia and may contribute to PP vascular disease, including internal carotid artery (ICA) stenosis and stroke. We hypothesized that CD4 T cell deficiency in pregnancy would result in ICA dysregulation, including enhanced ICA vasoconstriction. We characterized the function, mechanical behavior, and structure of ICAs from C57BL/6 (WT) and CD4 deficient (CD4KO) mice, and assessed the role of NO in the control of ICA function at pre-conception and PP. WT and CD4KO mice were housed under pathogen-free conditions, mated to same-strain males, and allowed to litter or left virgin. At 3 days or 4 weeks PP, mice were euthanized. The responses to phenylephrine (PE), high K+ and acetylcholine (ACh) were assessed in pressurized ICAs before and after NOS inhibition. Passive lumen diameters were measured at 3–140 mmHg. eNOS and iNOS expression as well as the presence of T cells were evaluated by immunohistochemistry. Constriction of WT ICAs to PE was not modified PP. In contrast, responses to PE were significantly increased in ICAs from PP as compared to virgin CD4KO mice. Constriction to high K+ was not enhanced PP. ICAs from WT and CD4KO mice were equally sensitive to ACh with a significant rightward shift of dose-response curves after L-NNA treatment. NOS inhibition enhanced PE constriction of ICAs from WT virgin and PP mice. Although a similar effect was detected in ICAs of virgin CD4KO mice, no such changes were observed in vessels from PP CD4KO mice. Passive arterial distensibility at physiological levels of pressure was not modified at PP. ICA diameters were significantly increased in PP with no change in vascular wall thickness. Comparison of eNOS expression in virgin, 3 days and 4 weeks PP revealed a reduced expression in ICA from CD4 KO vs. WT PP vessels which reached significance at 4 weeks PP. iNos expression was similar and decreased over the PP period in vessels from WT and CD4KO mice. Dysregulation of the CD4 T cell population in pregnancy may make ICA vulnerable to vasospasm due to decreased NO-dependent control of ICA constriction. This may lead to cerebral hypoperfusion and increase the risk of maternal PP stroke.
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Affiliation(s)
- Natalia I Gokina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Rebecca I Fairchild
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Kirtika Prakash
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Nicole M DeLance
- Microscopy Imaging Center, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Elizabeth A Bonney
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
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Bajko Z, Motataianu A, Stoian A, Barcutean L, Andone S, Maier S, Drăghici IA, Balasa R. Postpartum Cerebral Venous Thrombosis-A Single-Center Experience. Brain Sci 2021; 11:brainsci11030327. [PMID: 33806706 PMCID: PMC7998769 DOI: 10.3390/brainsci11030327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Cerebral venous thrombosis (CVT) is a rare variant of stroke in the general population, but an important subtype among pregnancy- and puerperium-related cases. Studies describing its risk factors and clinical characteristics are limited. The aim of our study is to disclose these aspects and compare with cases unrelated to pregnancy and puerperium. Materials and Methods: We performed a retrospective analysis including 88 consecutive cases from a tertiary neurology clinic with a diagnosis of CVT. Ten of the 88 cases (11.3%) appeared during the postpartum period. Results: The mean age of the puerperal CVT cases was 26.5 years. The main pregnancy-related risk factors besides puerperium were cesarean delivery (5/10), preeclampsia (2/10), and stillbirth (1/10). General risk factors for thrombosis, i.e., infection, smoking, and primary hypercoagulability, were identified in 50% of cases. Onset was in the first 3 weeks after delivery, with a mean value of 9.6 ± 5.6 days. Headache was present in 90% of postpartum CVT cases and in 76.1% of non-postpartum female cases. Seizures were more frequent in the postpartum group (60% vs. 34.8%). Onset was acute (<48 h) in 50% of postpartum cases and in 30.4% of the non-postpartum female group. The Rankin score at discharge was significantly lower in the postpartum group (0.22 vs. 0.7, p = 0.02), suggesting a more favorable short-term outcome. Conclusions: The early postpartum period represents an important risk for the development of CVT. Cesarean delivery and preeclampsia, besides general risk factors such as infection, smoking, and primary thrombophilia, contribute to enhanced risk. Puerperium-related CVT presents a more favorable outcome compared with CVT with other etiologies.
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Affiliation(s)
- Zoltan Bajko
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Anca Motataianu
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Adina Stoian
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
- Department of Patophysiology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania
| | - Laura Barcutean
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Sebastian Andone
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Smaranda Maier
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
- Correspondence:
| | - Iulia-Adela Drăghici
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Rodica Balasa
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
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Yan KL, Ko NU, Hetts SW, Weinsheimer S, Abla AA, Lawton MT, Kim H. Maternal and Fetal Outcomes in Women with Brain Arteriovenous Malformation Rupture during Pregnancy. Cerebrovasc Dis 2021; 50:296-302. [PMID: 33640891 DOI: 10.1159/000513573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sporadic brain arteriovenous malformations (BAVM) are a major cause of hemorrhagic stroke in younger persons. Prior studies have reported contradictory results regarding the risk of hemorrhage during pregnancy, and there are no standard guidelines for the management of pregnant women who present with BAVM rupture. The purpose of this study is to describe maternal and fetal outcomes and treatment strategies in patients with BAVM hemorrhage during pregnancy. METHODS We performed a retrospective review of the University of California, San Francisco Brain AVM Project database for female patients who were pregnant at the time of BAVM hemorrhage between 2000 and 2017. Clinical and angiographic characteristics at presentation, BAVM treatment, and maternal outcomes using modified Rankin scale (mRS) score at presentation and 2-year follow-up were recorded. Fetal outcomes were abstracted from medical records and maternal reports. RESULTS Sixteen patients presented with BAVM hemorrhage during pregnancy, 81% (n = 13) of whom were in their second or third trimester. Three patients (19%) who were in their first trimester terminated or miscarried pregnancy prior to BAVM intervention. Of the remaining 13 patients, 77% (n = 10) received emergent BAVM treatment at time of hemorrhage prior to delivery, and 85% of patients achieved BAVM obliteration and good maternal outcomes (mRS 0-2) at 2-year follow-up. All patients had uncomplicated deliveries (69% cesarean and 23% vaginal) with no reports of postnatal cognitive or developmental delays in infants at 2-year follow-up. CONCLUSIONS Our study shows good long-term maternal and fetal outcomes in ruptured BAVM patients presenting during pregnancy, the majority who received BAVM interventional treatment prior to delivery.
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Affiliation(s)
- Kimberly L Yan
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nerissa U Ko
- Department of Neurology, University of California - San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Engineering, University of California - San Francisco, San Francisco, California, USA
| | - Shantel Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California, USA,
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Opaskar A, Massaquoi R, Sila C. Stroke in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:283-293. [PMID: 33632448 DOI: 10.1016/b978-0-12-819814-8.00032-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stroke in pregnancy is rare and has a wide range of etiologies and implications on stroke management that differ from nonpregnant individuals. The highest risk of stroke is during the third trimester and puerperium period, where hypertensive disorders of pregnancy occur; however, stroke can occur at any point during pregnancy. In this chapter, we will provide an overview of the epidemiology of stroke in pregnancy and then review the specific etiologies of ischemic and hemorrhagic stroke as they relate to pregnant women. Finally, we discuss the process of acute stroke evaluation in pregnancy and the management of women after stroke with regard to long-term risk factors, medications, and implications in future pregnancies. Throughout the chapter, we highlight relevant guidelines from the American Heart Association and American Stroke Association and key literature on stroke in pregnancy.
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Affiliation(s)
- Amanda Opaskar
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Reyanna Massaquoi
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Cathy Sila
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
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Austin K, Seeho S, Ibiebele I, Ford J, Morris J, Torvaldsen S. Pregnancy outcomes for women with a history of stroke: A population-based record linkage study. Aust N Z J Obstet Gynaecol 2020; 61:239-243. [PMID: 33179764 DOI: 10.1111/ajo.13267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/30/2020] [Accepted: 09/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about the pregnancy outcomes of women who have had a stroke prior to a first pregnancy. AIM To identify a cohort of primiparous women giving birth to a single baby and compare the pregnancy outcomes of those with a pre-pregnancy stroke hospitalisation record to those without a stroke hospitalisation record. MATERIALS AND METHODS Record linkage study of all primiparous women aged 15-44 years with singleton pregnancies birthing in New South Wales, Australia from 2003 to 2015. Stroke was identified from 2001 to 2015 hospital data using International Classification of Diseases tenth Edition - Australian Modification codes I60-64. Women whose first hospital record of stroke was during pregnancy or <42 days after birth were excluded. Outcomes included diabetes or hypertension during pregnancy, mode of delivery, haemorrhage, severe maternal morbidity (validated composite outcome indicator), gestational age at birth, Apgar score (1 min < 7), and small-for-gestational age. RESULTS Of 487 767 women with a first pregnancy, 124 (2.5/10 000) had a hospital record which included a pre-pregnancy stroke diagnosis. Women with a stroke history were more likely to have an early-term delivery (37-38 weeks; relative risk (RR) 1.49, 95% CI 1.17-1.90) and a pre-labour caesarean (RR 2.83, 95% CI 2.20-3.63). There were no significant differences in other maternal or neonatal outcomes. CONCLUSION This is the largest reported study of pregnancy and birth outcomes for women with a history of stroke. With the exception of pre-labour caesarean, there were no differences in pregnancy outcomes for women with a history of stroke compared with women with no history of stroke.
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Affiliation(s)
- Kathryn Austin
- Women and Babies Research, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sean Seeho
- Women and Babies Research, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ibinabo Ibiebele
- Women and Babies Research, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Ford
- Women and Babies Research, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jonathan Morris
- Women and Babies Research, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Siranda Torvaldsen
- Women and Babies Research, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,School of Public Health and Community Medicine, UNSW Sydney, Sydney, New South Wales, Australia
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Cho MJ, Shin DI, Han MK, Yum KS. Acute amnesia during pregnancy due to bilateral fornix infarction: A case report. World J Clin Cases 2020; 8:4494-4498. [PMID: 33083409 PMCID: PMC7559690 DOI: 10.12998/wjcc.v8.i19.4494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/12/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Stroke is an important cause of maternal morbidity and mortality during pregnancy and puerperium. Isolated amnesia is a rare clinical symptom caused by ischemic stroke during pregnancy. We present the first documented case of acute amnesia during pregnancy due to bilateral fornix infarction.
CASE SUMMARY A 32-year-old nullipara presented at 35 wk of gestation with acute amnesia and headache. Brain magnetic resonance imaging and angiography revealed acute infarction in the bilateral anterior fornix. There was no evidence of causative abnormality after extensive work-up, including for vascular abnormality, cardiac disease, coagulopathy, and pregnancy-related conditions. The patient was diagnosed with cryptogenic stroke. Aspirin was administered immediately, and the patient recovered fully without recurrence.
CONCLUSION Acute isolated amnesia due to stroke is rare during pregnancy. Early diagnosis of stroke and immediate treatment prevent neurologic sequelae.
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Affiliation(s)
- Min Jai Cho
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju-si 28644, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si 28644, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si 463-707, South Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si 28644, South Korea
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Nussbaum ES, Goddard JK, Davis AR. A Systematic Review of Intracranial Aneurysms in the Pregnant Patient - A Clinical Conundrum. Eur J Obstet Gynecol Reprod Biol 2020; 254:79-86. [PMID: 32942080 DOI: 10.1016/j.ejogrb.2020.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/22/2020] [Accepted: 08/27/2020] [Indexed: 01/12/2023]
Abstract
Hemodynamic and hormonal changes during pregnancy can increase rates of formation, growth, and rupture of intracranial aneurysms (IA), and the increased incidence of subarachnoid hemorrhage (SA) in pregnant patients represents a risk to both mother and fetus. Despite this, management and treatment guidelines have not been defined for this patient population. In most instances, treatment decisions are made on a case-by-case basis with varying degrees of input from subspecialists. Important considerations, such as aneurysm location, morphology, size, growth pattern, and patient characteristics have not been presented in a management algorithm in the context of the pregnant patient. Given limited and controversial literature describing management of IAs in pregnant patients, we performed a systematic literature review. We then describe our multidisciplinary team approach and provide analysis of existing literature to provide guidelines for the management of the pregnant patient with an IA. A systematic review was undertaken to identify studies describing the management of IAs in the pregnant patient using the PubMed database. Overall maternal and fetal morbidity and mortality rates were determined. Data was analyzed for 1537 patients, including 1115 (73%) pregnant with ruptured intracranial aneurysms. In most cases, these aneurysms were managed conservatively (77%; 781/1013); however, when treatment was provided, surgical clipping was the most common modality (15%; 149/1013). Overall maternal outcomes were reported for 934 cases with morbidity and mortality rates of 5% (42/934) and 21% (194/934), respectively. Overall fetal outcomes were reported for 114 cases with morbidity and mortality rates of 10% (12/119) and 8% (9/119), respectively. Pregnancy-associated physiological changes likely elevate the risk of intracranial aneurysm formation, growth, and rupture. Treatment for aneurysms and SAs is safe and effective during pregnancy when risks are properly mitigated. Due to the complexity of care, such patients should be treated using a collaborative, interdisciplinary approach by a multidisciplinary team.
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Affiliation(s)
- Eric S Nussbaum
- National Brain Aneurysm & Tumor Center, Department of Neurosurgery, United Hospital, St. Paul, MN, United States.
| | | | - Amber R Davis
- Superior Medical Experts, St. Paul, MN, United States
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Desai M, Wali AR, Birk HS, Santiago-Dieppa DR, Khalessi AA. Role of pregnancy and female sex steroids on aneurysm formation, growth, and rupture: a systematic review of the literature. Neurosurg Focus 2020; 47:E8. [PMID: 31261131 DOI: 10.3171/2019.4.focus19228] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Women have been shown to have a higher risk of cerebral aneurysm formation, growth, and rupture than men. The authors present a review of the recently published neurosurgical literature that studies the role of pregnancy and female sex steroids, to provide a conceptual framework with which to understand the various risk factors associated with cerebral aneurysms in women at different stages in their lives. METHODS The PubMed database was searched for "("intracranial" OR "cerebral") AND "aneurysm" AND ("pregnancy" OR "estrogen" OR "progesterone")" between January 1980 and February 2019. A total of 392 articles were initially identified, and after applying inclusion and exclusion criteria, 20 papers were selected for review and analysis. These papers were then divided into two categories: 1) epidemiological studies about the formation, growth, rupture, and management of cerebral aneurysms in pregnancy; and 2) investigations on female sex steroids and cerebral aneurysms (animal studies and epidemiological studies). RESULTS The 20 articles presented in this study include 7 epidemiological articles on pregnancy and cerebral aneurysms, 3 articles reporting case series of cerebral aneurysms treated by endovascular therapies in pregnancy, 3 epidemiological articles reporting the relationship between female sex steroids and cerebral aneurysms through retrospective case-control studies, and 7 experimental studies using animal and/or cell models to understand the relationship between female sex steroids and cerebral aneurysms. The studies in this review report similar risk of aneurysm rupture in pregnant women compared to the general population. Most ruptured aneurysms in pregnancy occur during the 3rd trimester, and most pregnant women who present with cerebral aneurysm have caesarean section deliveries. Endovascular treatment of cerebral aneurysms in pregnancy is shown to provide a new and safe form of therapy for these cases. Epidemiological studies of postmenopausal women show that estrogen hormone therapy and later age at menopause are associated with a lower risk of cerebral aneurysm than in matched controls. Experimental studies in animal models corroborate this epidemiological finding; estrogen deficiency causes endothelial dysfunction and inflammation, which may predispose to the formation and rupture of cerebral aneurysms, while exogenous estrogen treatment in this population may lower this risk. CONCLUSIONS The aim of this work is to equip the neurosurgical and obstetrical/gynecological readership with the tools to better understand, critique, and apply findings from research on sex differences in cerebral aneurysms.
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Affiliation(s)
| | - Arvin R Wali
- 2Department of Neurological Surgery, University of California, San Diego, California
| | - Harjus S Birk
- 2Department of Neurological Surgery, University of California, San Diego, California
| | | | - Alexander A Khalessi
- 2Department of Neurological Surgery, University of California, San Diego, California
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O'Neal MA. Obstetric and Gynecologic Disorders and the Nervous System. Continuum (Minneap Minn) 2020; 26:611-631. [PMID: 32487899 DOI: 10.1212/con.0000000000000860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article highlights the multiple intersections between obstetric/gynecologic issues and neurologic disorders. RECENT FINDINGS Neurologic issues can arise related to contraceptive medications, infertility treatments, pregnancy, and menopause. This article explores these areas in chronologic order, beginning with women's neurologic conditions that overlap their reproductive years and those that may occur during pregnancy and continuing through menopause. For each disorder, the epidemiology, pathophysiology, complications, and best sex-based treatment are described. Recent findings and treatments are highlighted. SUMMARY Obstetric and gynecologic disorders may present with neurologic symptoms, so it is important for neurologists to understand these intersections to deliver the best care for our female patients.
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Abstract
Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Zhou X, Tang G. Factors Associated With Acute Stroke During Pregnancy and Puerperium. J Am Coll Cardiol 2020; 75:2279-2280. [DOI: 10.1016/j.jacc.2020.02.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 11/15/2022]
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Deems NP, Leuner B. Pregnancy, postpartum and parity: Resilience and vulnerability in brain health and disease. Front Neuroendocrinol 2020; 57:100820. [PMID: 31987814 PMCID: PMC7225072 DOI: 10.1016/j.yfrne.2020.100820] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/25/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
Risk and resilience in brain health and disease can be influenced by a variety of factors. While there is a growing appreciation to consider sex as one of these factors, far less attention has been paid to sex-specific variables that may differentially impact females such as pregnancy and reproductive history. In this review, we focus on nervous system disorders which show a female bias and for which there is data from basic research and clinical studies pointing to modification in disease risk and progression during pregnancy, postpartum and/or as a result of parity: multiple sclerosis (MS), depression, stroke, and Alzheimer's disease (AD). In doing so, we join others (Shors, 2016; Galea et al., 2018a) in aiming to illustrate the importance of looking beyond sex in neuroscience research.
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Affiliation(s)
- Nicholas P Deems
- The Ohio State University, Department of Psychology, Columbus, OH, USA
| | - Benedetta Leuner
- The Ohio State University, Department of Psychology, Columbus, OH, USA.
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Meeks JR, Bambhroliya AB, Alex KM, Sheth SA, Savitz SI, Miller EC, McCullough LD, Vahidy FS. Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period. JAMA Netw Open 2020; 3:e202769. [PMID: 32286658 PMCID: PMC7156993 DOI: 10.1001/jamanetworkopen.2020.2769] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancy-related ICH risk, including risk during the extended postpartum period. OBJECTIVE To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum. DESIGN, SETTING, AND PARTICIPANTS This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7- to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020. EXPOSURES Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed. MAIN OUTCOMES AND MEASURES Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes. RESULTS A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23). Advanced maternal age (adjusted odds ratio [OR], 1.08; 95% CI, 1.05-1.10), nonwhite race (adjusted ORs, 2.44 [95% CI, 1.73-3.44] for black patients, 2.12 [95% CI, 1.34-3.35] for Asian patients, and 1.59 [95% CI, 1.12-2.26] for Hispanic patients), hypertension (adjusted OR, 2.02; 95% CI, 1.19-3.42), coagulopathy (adjusted OR, 14.17; 95% CI, 9.17-21.89), preeclampsia or eclampsia (adjusted OR, 9.23; 95% CI, 6.99-12.19), and tobacco use (adjusted OR, 2.83; 95% CI, 1.53-5.23) were independently associated with ICH during pregnancy and the postpartum period. Pregnancy-related ICH was associated with a higher risk of maternal (relative risk difference, 792.6; absolute risk difference, 0.18) and fetal (relative risk difference, 5.3; absolute risk difference, 0.03) death, compared with pregnancies without ICH. CONCLUSIONS AND RELEVANCE These findings suggest that the risk of ICH is significantly higher during the third trimester of pregnancy and the first 12 weeks post partum. There are age and race disparities in ICH risk that are associated with devastating maternal and fetal outcomes. These data illustrate the critical need for continuous monitoring and aggressive management of ICH-associated risk factors. These findings suggest that extended postpartum monitoring of high-risk women may be warranted.
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Affiliation(s)
- Jennifer R. Meeks
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | | | - Katie M. Alex
- Department of Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Sunil A. Sheth
- Department of Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Sean I. Savitz
- Department of Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Eliza C. Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | | | - Farhaan S. Vahidy
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
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Zandi S, Atcheson CLH, Yousefi SR, Zahedi F, Mirkarimi S, Nasseri K. Postpartum Headache due to Cerebellar Infarct Initially Misdiagnosed as Postdural Puncture Headache: A Case Report. A A Pract 2020; 14:e01190. [PMID: 32224699 DOI: 10.1213/xaa.0000000000001190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present the case of a 39-year-old woman with postpartum cerebellar infarction (CI) following spinal anesthesia for cesarean delivery. The patient experienced mild headache after postoperative day 1 and returned on postoperative day 6 with a severe headache. For the subsequent 3 days, she underwent conservative treatment for presumed postdural puncture headache (PDPH) before neurologic decline and diagnosis of CI on postoperative day 9. She subsequently underwent craniotomy and debridement of necrotic tissues. Prolonged or position-independent postpartum headache should prompt broadening of the differential diagnosis beyond PDPH to include other more rare but serious causes of postpartum headache.
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Affiliation(s)
- Shokrollah Zandi
- From the Department of Neurosurgery, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Seyedeh Reyhaneh Yousefi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Farhad Zahedi
- Department of Anesthesiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sadafsadat Mirkarimi
- Department of Anesthesiology, Jacobi Medical Center, Albert Einstein College of Medicine, PGY1 Preliminary Resident, New York, New York
| | - Karim Nasseri
- Department of Anesthesiology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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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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Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:3-31. [PMID: 32768092 PMCID: PMC7528571 DOI: 10.1016/b978-0-444-64240-0.00001-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Jean Rodriguez Lopez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5174] [Impact Index Per Article: 1034.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Limaye K, Van de Walle Jones A, Shaban A, Desai S, Al Kasab S, Almallouhi E, Holmstedt CA, Ortega-Gutierrez S, Haussen DC, Nogueira R, Mont'Alverne F, Ragiotto C, Rebello LC, Jovin TG, Hasan D, Jadhav A. Endovascular management of acute large vessel occlusion stroke in pregnancy is safe and feasible. J Neurointerv Surg 2019; 12:552-556. [PMID: 31801850 DOI: 10.1136/neurintsurg-2019-015578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/13/2019] [Accepted: 11/20/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Stroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy. METHODS Patients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed. RESULTS A total of seven subjects were identified. The average age was 33.2 years (range 25-38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9-28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0-5). CONCLUSION EVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population.
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Affiliation(s)
- Kaustubh Limaye
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa, Iowa City, Iowa, USA
| | - Ann Van de Walle Jones
- Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Amir Shaban
- Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Shashvat Desai
- Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa, Iowa City, Iowa, USA
| | - Diogo C Haussen
- Neurology, Neurosurgery and Radiology, Emory University School of Medicine/Marcus Stroke and Neuroscience Center - Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Raul Nogueira
- Neurology, Neurosurgery and Radiology, Emory University School of Medicine/Marcus Stroke and Neuroscience Center - Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Carlos Ragiotto
- Neurology, Hospitas das Clinicas Samuel Libania, Pouso Alegre, Brazil
| | - Leticia C Rebello
- Neurology, Emory University School of Medicine/Marcus Stroke and Neuroscience Center - Grady Memorial Hospital, Atlanta, Georgia, USA.,Neurology, Hospital Brasilia, Brasilia, Brazil
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - David Hasan
- Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Ashutosh Jadhav
- Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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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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Sohail R, Bashir Q, Kanwal S, Ali MI. Cerebral arteriovenous malformations during pregnancy: a management dilemma. BMJ Case Rep 2019; 12:12/11/e228759. [PMID: 31712225 DOI: 10.1136/bcr-2018-228759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The rupture of a brain cranial arteriovenous malformation (bAVM) has been associated with pregnancy; however, due to scarcity of data about this rare condition, management still remains a dilemma both for obstetricians and neurophysicians. The management plan is decided after weighing the benefits of bAVM treatment against the risk of bleeding in pregnancy. There is consensus on deciding the treatment of ruptured brain AVM during pregnancy based on neurological and not obstetrical indications. The management is decided using a multidisciplinary approach.We report the case of a primigravida who presented at 15 weeks of gestation with intracranial haemorrhage secondary to ruptured bAVM, which was managed by glue embolisation. However, she presented again after 9 days in a moribund condition with fever, vomiting and malaise. The family was very concerned about the patient. The multidisciplinary team after evaluation of patient decided for hysterotomy based on the deteriorating maternal condition.
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Affiliation(s)
- Rubina Sohail
- Obstetrics & Gynaecology, Services Institute of Medical Sciences, Lahore, Pakistan .,Obstetrics & Gynaecology, Hameed Latif Hospital, Lahore, Pakistan
| | - Qasim Bashir
- Neurology, Hameed Latif Hospital, Lahore, Punjab, Pakistan
| | - Shahlla Kanwal
- Obstetrics & Gynaecology, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Maryam Iqbal Ali
- Obstetrics & Gynaecology, Hameed Latif Hospital, Lahore, Pakistan
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