Stroke during pregnancy: therapeutic options and role of percutaneous device closure

Every Patent Foramen Ovale Should Be Closed

At present, the patent foramen ovale (PFO) does not receive the deserved medical attention. The PFO poses a serious threat to health and even the life of mankind. The first respective case report in the medical literature dates back to the 19th century. It led to death. The fact that a PFO is present in roughly 25% of people underscores its overall potential to cause harm. Yet at the same time, the sheer number discourages the medical community from screening for it and from treating it. About 5% of the population have particularly dangerous forms of PFOs. Such PFOs portray a high enough risk for clinical events, the likes of death, stroke, myocardial infarction, or ocular, visceral, and peripheral embolism, to justify screening for them. Highly significant health incidents being at stake, it appears obvious that PFO closure should be used for primary prevention. This is supported by the fact that closing a PFO is the simplest intervention in cardiology, with presumably the highest clinical yield. Being mainly a preventive measure, PFO closure represents a mechanical vaccination. When closing PFOs for one of the rarer therapeutic indications (migraine, platypnea orthodeoxia, etc.), patients automatically profit from the collateral benefit of getting, at the same time, mechanically vaccinated for life against paradoxical embolism. Vice versa, closing a PFO for the prevention of paradoxical embolism betters or cures migraine or exercise dyspnea not infrequently, thereby improving quality of life as a collateral benefit.

Pregnancy-Associated Stroke

Cerebrovascular accident, or stroke, is the fourth leading cause of death for all women and the eighth leading cause of pregnancy-associated death. The physiologic changes of pregnancy increase the risk of cerebrovascular accident for women. With current incidence rates, a facility with 3300 births per year can anticipate caring for one woman with a pregnancy-related stroke at least every 2 years. All maternity care providers must be able to assess women experiencing stroke-like symptoms and initiate timely care to mitigate brain tissue damage, decrease long-term morbidity, and prevent mortality. The 2 main types of stroke, ischemic and hemorrhagic, have similar presenting symptoms but very different pathophysiology and treatment. This article reviews assessment and initial treatment of pregnant and postpartum women experiencing stroke and provides guidance for subsequent maternity and primary care to assist front-line perinatal care providers who may be the first to treat affected women or may resume primary care after diagnosis.

Patent foramen ovale (PFO), stroke and pregnancy

Patent foramen ovale (PFO)-related stroke is increasingly recognized as an important etiology of ischemic embolic stroke-accounting for up to 50% of strokes previously considered 'cryptogenic' or with an unknown mechanism. As a 'back door to the brain,' PFO can allow venous clots to enter arterial circulation via interatrial right-to-left shunting, potentially resulting in ischemic stroke. We observe that clinically, PFO-related stroke affects women of childbearing age, and that pregnancy-owing to major changes in hemocoagulative, hormonal, and cardiovascular parameters-can enhance stroke risks. However, no systematic study has been performed and little is known regarding complications, pregnancy outcomes and treatment for PFO-related stroke during pregnancy. To identify and characterize the complications and clinical outcomes related to PFOs during pregnancy, we performed a literature review and analysis from all reported cases of pregnancy with PFO-related complications in the medical literature from 1970 to 2015. We find that during pregnancy and post-partum, PFO is associated with complications affecting multiple organs, including the brain, heart and lung. The three principal complications reported are stroke, pulmonary emboli and myocardial infarction. In contrast to other pregnancy-related stroke etiologies, which peak during later pregnancy and postpartum, PFO-related stroke peaks during early pregnancy (first and second trimester-60%), and most patients had good neurological outcome (77%). In patients with PFO with recurrent stroke during pregnancy, additional key factors include high-risk PFO morphology (atrial septal aneurysm), larger right-to-left shunt, multiple gestation and concurrent hypercoagulability. Compared to strokes of other etiologies during pregnancy, most PFO stroke patients experienced uneventful delivery (93%) of healthy babies with a good clinical outcome. We conclude with recommended clinical treatment strategies for pregnant patients with PFO suggested by the data from these cases, and the clinical experience of our Cardio-Neurology Clinic.

A review of stroke and pregnancy: incidence, management and prevention

Stroke, defined as a focal or global disturbance of cerebral function lasting over 24h resulting from disruption of its blood supply, is a devastating event for a pregnant woman. This can result in long-term disability or death, and impact on her family and unborn child. In addition to pre-existing patient risk factors, the hypercoagulable state and pre-eclampsia need to be taken into account. The patterns and types of stroke affect pregnant women differ from the non-pregnant female population of child-bearing age. Like other thrombo-embolic diseases in pregnancy, stroke is essentially a disease of the puerperium. Population studies have estimated the risk of stroke at between 21.2 and 46.2 per 100,000. The US Nationwide Inpatient Sample, identified 2850 pregnancies complicated by stroke in the United States in 2000-2001, for a rate of 34.2 per 100,000 deliveries. There were 117 deaths, a mortality rate of 1.4 per 100,000. Both the mortality and disability rates were higher than previously reported, with 10-13% of women dying. With the increasing prevalence of obesity, hypertension and cardiac disease amongst women of child-bearing age, so is the incidence of stroke during pregnancy and the puerperium. In the United States, an alarming trend toward higher numbers of stroke hospitalizations during the last decade was demonstrated in studies from 1995 to 1996 and 2006 to 2007. The rate of all types of stroke increased by 47% among antenatal hospitalizations, and by 83% among post-partum hospitalizations. Hypertensive disorders, obesity and heart disease complicated 32% of antenatal admissions and 53% of post-partum admissions. In addition to pre-existing patient risk factors, the hypercoagulable state and pre-eclampsia need to be taken into account. The patterns and types of stroke affect pregnant women differ from the non-pregnant female population of child-bearing age. Like other thrombo-embolic diseases in pregnancy, stroke is essentially a disease of the puerperium.