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Dong J, Ma Y, Chen Y, Guo J, Zhang T, Yang T, Zhang H, Yan F, Han L. Prevalence and influencing factors of patient delay in stroke patients: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:202. [PMID: 38700541 DOI: 10.1007/s10143-024-02436-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 03/03/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Determine the prevalence and influencing factors of patient delay in stroke patients and explore variation in prevalence by country and delayed time. METHODS PubMed, The Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Database (CBM), Weipu database, and Wanfang database were comprehensively searched for observational studies from inception to April, 2023. The pooled prevalence, odds ratio (OR), and 95% confidence intervals (CI) were calculated with Stata 16.0 software. RESULTS In total, 2721 articles were screened and data from 70 studies involving 85,468 subjects were used in meta-analysis. The pooled prevalence of patient delay in stroke patients was 59% (95% CI, 0.54-0.64). The estimates of pooled prevalence calculated for African, Asian, and European patient delay in stroke patients were 55% (0.29-0.81), 61% (0.56-0.66), and 49% (0.34-0.64).According to the patient delay time, the prevalence of 6 h, 5 h, 4.5 h, 3.5 h, 3 h and 2 h were 54% (0.47-0.61), 73% (0.61-0.86), 60% (0.49-0.71), 81% (0.68-0.93), 52% (0.42-0.62), 63% (0.19-1.07). Distance from the place of onset to the hospital > 10 km [OR=2.49, 95%CI (1.92, 3.24)], having medical insurance [OR = 0.45, 95%CI (0.26,0.80)], lack of stroke-related knowledge [OR = 1.56, 95%CI (1.08,2.26)], education level below junior high school [OR = 1.69, 95%CI (1.22,2.36)], non-emergency medical services (Non-EMS) [OR = 2.10, 95%CI (1.49,2.97)], living in rural areas [OR = 1.54, 95%CI (1.15,2.07)], disturbance of consciousness [OR = 0.60, 95%CI (0.39,0.93)], history of atrial fibrillation [OR = 0.53, 95%CI (0.47,0.59)], age ≥ 65 years [OR = 1.18, 95%CI (1.02,1.37)], National institutes of health stroke scale (NIHSS) ≤ 4 points [OR= 2.26, 95%CI (1.06,4.79)]were factors for patient delay in stroke patients. CONCLUSIONS The prevalence of patient delay in stroke patients is high, we should pay attention to the influencing factors of patient delay in stroke patients and provide a theoretical basis for shortening the treatment time of stroke patients.
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Affiliation(s)
- Jianhui Dong
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China
| | - Yuxia Ma
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China.
- School of First Clinical Medical, Lanzhou University, Lanzhou, Gansu, 730000, China.
| | - Yanru Chen
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China
| | - Jiali Guo
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China
| | - Tong Zhang
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China
| | - Tingting Yang
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China
| | - Hongyan Zhang
- Department of Nursing, Gansu Provincial Hospital, Lanzhou, Gansu, 730030, China
| | - Fanghong Yan
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China
| | - Lin Han
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, 730010, China.
- Department of Nursing, Gansu Provincial Hospital, Lanzhou, Gansu, 730030, China.
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Deshmukh A, Alharbi NF, Alwadai MM, Katsanos AH, Ng K, van Adel B. Direct MT without tPA in the Second Trimester of Pregnancy with LVO. Neurol India 2023; 71:804-806. [PMID: 37635532 DOI: 10.4103/0028-3886.383835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Affiliation(s)
- Aviraj Deshmukh
- Stroke and Interventional Neurologist, Northern Ontario School of Medicine, Health Sciences North, Sudbury, ON, Canada
| | - Naif Faisal Alharbi
- King Fahad General Hospital, Ministry of Health Al Mustashfa Al Am, Al Andalus, Jeddah, Saudi Arabia
| | - Mohammed Mesfer Alwadai
- King Fahad General Hospital, Ministry of Health Al Mustashfa Al Am, Al Andalus, Jeddah, Saudi Arabia
| | - Aris H Katsanos
- Division of Neurology, Hamilton General Hospital, McMaster University, 237 Barton St E, Hamilton, ON L8L 2X2, Canada
| | - Kelvin Ng
- Division of Neurology, Hamilton General Hospital, McMaster University, 237 Barton St E, Hamilton, ON L8L 2X2, Canada
| | - Brian van Adel
- Department of Neurointervention, Hamilton General Hospital, McMaster University, 237 Barton St E, Hamilton, ON L8L 2X2, Canada
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3
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Pregnancy-Related Stroke: A Review. Obstet Gynecol Surv 2022; 77:367-378. [PMID: 35672877 DOI: 10.1097/ogx.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance The maternal risk of strokes in the United States is approximately 30/100,000 pregnancies, and strokes are the eighth leading cause of maternal death. Because of the relationship between stroke and significant neurological disability/maternal death, obstetrical health care providers must be able to identify, evaluate, diagnosis, and treat these women. Evidence Acquisition PubMed was searched using the search terms "stroke" OR "cerebrovascular accident" OR "intracranial hemorrhage" AND "pregnancy complications" OR "risk factors" OR "management" OR "outcome." The search was limited to the English language and was restricted to articles from 2000 to 2020. Results There were 319 abstracts identified, and 90 of the articles were ultimately used as the basis of this review. Presenting stroke signs and symptoms include headache, composite neurologic defects, seizures, and/or visual changes. Diagnosis is typically made with computed tomography scan using abdominal shielding or magnetic resonance imaging without contrast. Management options for an ischemic stroke include reperfusion therapy with intravenous recombinant tissue plasminogen activator catheter-based thrombolysis and/or mechanical thrombectomy. Hemorrhagic strokes are treated similarly to strokes outside of pregnancy, and that treatment is based on the severity and location of the hemorrhage. Conclusions and Relevance Early recognition and management are integral in decreasing the morbidity and mortality associated with a stroke in pregnancy. Relevance Statement This study was an evidence-based review of stroke in pregnancy and how to diagnose and mange a pregnancy complicated by a stroke.
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Kremer C, Gdovinova Z, Bejot Y, Heldner MR, Zuurbier S, Walter S, Lal A, Epple C, Lorenzano S, Mono ML, Karapanayiotides T, Krishnan K, Jovanovic D, Dawson J, Caso V. European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum. Eur Stroke J 2022; 7:I-XIX. [PMID: 35647308 PMCID: PMC9134774 DOI: 10.1177/23969873221078696] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/19/2022] [Indexed: 01/01/2023] Open
Abstract
Pregnancy, postpartum and menopause are regarded as periods women are more
vulnerable to ischaemic events. There are conflicting results regarding stroke
risk and hormone replacement therapy (HRT) during menopause. Stroke in pregnancy
is generally increasing with serious consequences for mother and child;
therefore, recommendations for acute treatment with intravenous thrombolysis
(IVT) and/or mechanical thrombectomy (MT) are needed. The aim of this guideline
is to support and guide clinicians in treatment decisions in stroke in women.
Following the “Grading of Recommendations and Assessment, Development and
Evaluation (GRADE)” approach, the guidelines were developed according to the
European Stroke Organisation (ESO) Standard Operating Procedure. Systematic
reviews and metanalyses were performed. Based on available evidence,
recommendations were provided. Where there was a lack of evidence, an expert
consensus statement was given. Low quality of evidence was found to suggest
against the use of HRT to reduce the risk of stroke (ischaemic and haemorrhagic)
in postmenopausal women. No data was available on the outcome of women with
stroke when treated with HRT. No sufficient evidence was found to provide
recommendations for treatment with IVT or MT during pregnancy, postpartum and
menstruation. The majority of members suggested that pregnant women can be
treated with IVT after assessing the benefit/risk profile on an individual
basis, all members suggested treatment with IVT during postpartum and
menstruation. All members suggested treatment with MT during pregnancy. The
guidelines highlight the need to identify evidence for stroke prevention and
acute treatment in women in more vulnerable periods of their lifetime to
generate reliable data for future guidelines.
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Affiliation(s)
- Christine Kremer
- Neurology Department, Clinical Sciences Lund University, Skåne University Hospital, Malmö, Sweden
| | - Zuzana Gdovinova
- Neurology Department, Faculty of Medicine, Pavol Jozef Safarik University Košice, Košice, Slovakia
| | - Yannick Bejot
- Dijon Stroke Registry, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University of Burgundy, University Hospital of Dijon, Dijon, France
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Susanna Zuurbier
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Silke Walter
- Department of Neurology, Saarland University, Homburg, Germany
| | - Avtar Lal
- European Stroke Organisation (ESO), Basel, Switzerland
| | - Corina Epple
- Department of Neurology, Klinikum Hanau, Hanau, Germany
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marie-Luise Mono
- Department of Neurology, Municipal Hospital Waid und Triemli, Zürich, University Hospital and University of Bern, Bern Switzerland
| | - Theodore Karapanayiotides
- 2nd Department of Neurology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dejana Jovanovic
- Department of Emergency Neurology, Neurology Clinic, Medical Faculty, University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia Perugia, Italy
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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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Dicpinigaitis AJ, Sursal T, Morse CA, Briskin C, Dakay K, Kurian C, Kaur G, Sahni R, Bowers C, Gandhi CD, Mayer SA, Al-Mufti F. Endovascular Thrombectomy for Treatment of Acute Ischemic Stroke During Pregnancy and the Early Postpartum Period. Stroke 2021; 52:3796-3804. [PMID: 34538088 DOI: 10.1161/strokeaha.121.034303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke (AIS) is a rare occurrence during pregnancy and the postpartum period. Existing literature evaluating endovascular mechanical thrombectomy (MT) for this patient population is limited. METHODS The National Inpatient Sample was queried from 2012 to 2018 to identify and characterize pregnant and postpartum patients (up to 6 weeks following childbirth) with AIS treated with MT. Complications and outcomes were compared with nonpregnant female patients treated with MT and to other pregnant and postpartum patients managed medically. Complex samples regression models and propensity score matching were implemented to assess adjusted associations and to address confounding by indication, respectively. RESULTS Among 4590 pregnant and postpartum patients with AIS, 180 (3.9%) were treated with MT, and rates of utilization increased following the MT clinical trial era (2015-2018; 1.9% versus 5.3%, P=0.011). Compared with nonpregnant patients with AIS treated with MT, they experienced lower rates of intracranial hemorrhage (11% versus 24%, P=0.069) and poor functional outcome (50% versus 72%, P=0.003) at discharge. Pregnant/postpartum status was independently associated with a lower likelihood of development of intracranial hemorrhage (adjusted odds ratio, 0.26 [95% CI, 0.09-0.70]; P=0.008) following multivariable analysis adjusting for age, illness severity, and stroke severity. Following propensity score matching, pregnant and postpartum patients treated with MT and those medically managed differed in frequency of venous thromboembolism (17% versus 0%, P=0.001) and complications related to pregnancy (44% versus 64%, P=0.034), but not in functional outcome at discharge or hospital length of stay. Pregnant and postpartum women treated with MT did not experience mortality or miscarriage during hospitalization. CONCLUSIONS This large-scale analysis utilizing national claims data suggests that MT is a safe and efficacious therapy for AIS during pregnancy and the postpartum period. In the absence of prospective clinical trials, population-based cross-sectional analyses such as the present study provide valuable clinical insight.
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Affiliation(s)
| | - Tolga Sursal
- Department of Neurosurgery (T.S., C.D.G.), Westchester Medical Center, Valhalla, NY
| | - Catherine A Morse
- School of Medicine, New York Medical College, Valhalla, (A.L.D., C.A.M., C.B.)
| | - Camille Briskin
- School of Medicine, New York Medical College, Valhalla, (A.L.D., C.A.M., C.B.)
| | - Katarina Dakay
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Christeena Kurian
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Gurmeen Kaur
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Ramandeep Sahni
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.)
| | - Chirag D Gandhi
- Department of Neurosurgery (T.S., C.D.G.), Westchester Medical Center, Valhalla, NY
| | - Stephan A Mayer
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Fawaz Al-Mufti
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
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Juma FO, Ngunga LM, Waweru-Siika W, Sokhi DS. Safe Thrombolysis During Pregnancy for Recurrent Acute Ischaemic Stroke Due to Concomitant Isolated Left Ventricular Non-Compaction and Bilateral Foetal Posterior Communicating Arteries. Int Med Case Rep J 2021; 14:591-595. [PMID: 34512040 PMCID: PMC8420642 DOI: 10.2147/imcrj.s324717] [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: 06/22/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
Isolated left ventricular non-compaction (ILVNC) is a rare congenital cardiomyopathy and is associated with arrhythmias, heart failure and thromboembolism including ischaemic stroke. Pregnancy is a relative contraindication to thrombolysis for acute ischaemic stroke, although case reports suggest the treatment can be given in selected cases. We report a case of recurrent cryptogenic strokes in a 36-year-old female who was thrombolysed with good outcome at 37 weeks’ gestation and was eventually found to have ILVNC as the cause. She had a predilection to recurrent posterior circulatory strokes due to foetal posterior communicating arteries. To our knowledge this is the first case report of safe thrombolysis for acute ischaemic stroke in pregnancy caused by ILVNC.
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Affiliation(s)
- Fatimah Osman Juma
- Department of Medicine, Faculty of Health Sciences, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Leonard Mzee Ngunga
- Department of Medicine, Faculty of Health Sciences, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Wangari Waweru-Siika
- Department of Medicine, Faculty of Health Sciences, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Dilraj Singh Sokhi
- Department of Medicine, Faculty of Health Sciences, Aga Khan University Medical College of East Africa, Nairobi, Kenya
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Yoshida S, Miyakoshi A, Arai D, Kawanabe Y, Sato T. A Case of an Early Pregnant Woman with Congenital Protein S Deficiency Who Underwent Mechanical Thrombectomy. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:204-210. [PMID: 37502450 PMCID: PMC10370991 DOI: 10.5797/jnet.cr.2020-0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 07/04/2021] [Indexed: 07/29/2023]
Abstract
Objective Large vessel occlusion (LVO) stroke during pregnancy is rare but a life-threatening issue for the mother and fetus. We report a rare case of a pregnant woman with congenital protein S deficiency who underwent mechanical thrombectomy. Case Presentation A 35-year-old woman presented with right hemiplegia and aphasia. The National Institutes of Health Stroke Scale was 23 and MRI revealed acute infarction on the left hemisphere. MRA showed disruption of the left middle cerebral artery. Mechanical thrombectomy was performed following intravenous thrombolysis, and then complete recanalization was achieved. The reduction in protein S activity due to pregnancy was suspected to have affected LVO. Subsequently, the patient was diagnosed with congenital protein S deficiency and recovered to modified Rankin scale 2 at 3 months after the onset. Conclusion Aggravation of congenital protein S deficiency due to pregnancy led to the onset of LVO. The patient showed a good outcome after mechanical thrombectomy.
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Affiliation(s)
- Shota Yoshida
- Department of Neurosurgery, Shizuoka General Hospital, Shizuoka, Shizuoka, Japan
| | - Akinori Miyakoshi
- Department of Neurosurgery, Shizuoka General Hospital, Shizuoka, Shizuoka, Japan
| | - Daisuke Arai
- Department of Neurosurgery, Shizuoka General Hospital, Shizuoka, Shizuoka, Japan
| | - Yoshifumi Kawanabe
- Department of Neurosurgery, Shizuoka General Hospital, Shizuoka, Shizuoka, Japan
| | - Tsukasa Sato
- Department of Neurosurgery, Shizuoka General Hospital, Shizuoka, Shizuoka, Japan
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9
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Neuro-anesthesiology in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021. [PMID: 32736750 DOI: 10.1016/b978-0-444-64239-4.00010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Management of the pregnant patient requiring neurosurgery poses multiple challenges, juxtaposing pregnancy-specific considerations with that accompanying the safe provision of intracranial or spine surgery. There are no specific evidence-based recommendations, and case-by-case interdisciplinary discussions will guide informed decision-making about the timing of delivery vis-à-vis neurosurgery, the performance of cesarean delivery immediately before neurosurgery, consequences of neurosurgery on subsequent delivery, or even the optimal anesthetic modality for neurosurgery and/or cesarean delivery. In general, identifying whether increased intracranial pressure poses a risk for herniation is crucial before allowing neuraxial procedures. Modified rapid sequence induction with advanced airway approaches (videolaryngoscopic or fiberoptic) allows improved airway manipulation with reduced risks associated with endotracheal intubation of the obstetric airway. Currently, very few anesthetic drugs are avoided in the neurosurgical pregnant patient; however, ensuring access to critical care units for prolonged monitoring and assistance of the respiratory-compromised patient is necessary to ensure safe outcomes.
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10
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Abstract
New onset or exacerbation of preexisting neurologic symptoms during pregnancy often necessitates brain or spinal cord imaging. Magnetic resonance techniques are preferred imaging modalities during pregnancy and the postpartum period. Ionizing radiation with computed tomography and intravenous contrast material with magnetic resonance or computed tomography should be avoided during pregnancy. New onset of headaches in the last trimester or in the postpartum period may indicate cerebrovascular disease or a mass lesion, for which brain imaging is necessary. The continuum of cerebrovascular complications of pregnancy and enlarging lesions may produce neurologic symptoms later in pregnancy and after delivery, necessitating imaging.
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Affiliation(s)
- Dara G Jamieson
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA.
| | - Jennifer W McVige
- Dent Neurologic Institute, 3980 Sheridan Drive, Amherst, NY 14226, USA
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11
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Malaiyandi D, James E, Peglar L, Karim N, Henkel N, Guilliams K. Neurocritical Care of the Pregnant Patient. Curr Treat Options Neurol 2021; 23:22. [PMID: 34177249 PMCID: PMC8214980 DOI: 10.1007/s11940-021-00676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
Purpose of review To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. Recent findings Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria. Summary With the exception of direct abdominal computed tomography (CT), most imaging studies are reasonably safe in pregnancy. When emergent imaging is needed to prevent maternal morbidity or mortality, any CT sequence with or without contrast is appropriate to pursue. Though new safety data on antiplatelets, antihypertensives, thrombolytics, and antiepileptic drugs have increased options for disease management in pregnancy, unfractionated and low-molecular weight heparin remain the safest options for anticoagulation. Early studies on hypothermia, ketamine, and immunomodulating therapies in pregnancy are promising. In myasthenia gravis, new data on adjunct devices may allow more patients to undergo safe vaginal delivery, avoiding cesarean section and the associated risk of crisis. When difficult decisions regarding preterm delivery arise, recent outcome studies can help inform discussion. Lastly, when the feared complication of maternal death by neurologic criteria occurs, fetal somatic support may help to save at least one life.
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Affiliation(s)
- Deepa Malaiyandi
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,University of Toledo/ProMedica Neurosciences Center, 2130 W Central Ave, Ste. 201, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Elysia James
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Lindsay Peglar
- Department of Neurology, Washington University, St. Louis, MO USA
| | - Nurose Karim
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Nicholas Henkel
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Kristin Guilliams
- Department of Neurology, Washington University, St. Louis, MO USA.,Department of Pediatrics, Washington University, St. Louis, MO USA
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Abstract
In the last decades, there has been great progress in the field of stroke. With the introduction of acute therapies (intravenous thrombolysis and intra-arterial treatment), the outcome after stroke has improved significantly. Better prevention, improved acute therapy, and acute rehabilitation improved the morbidity and mortality rate after stroke. Gender differences in risk factors and epidemiology have been known for a long time, but lately attention to gender differences in stroke has increased. The aim of this mini-review is to demonstrate gender disparities in stroke with a focus on epidemiology, specific risk factors (gender-specific and unspecific), and outcomes. The influence of some risk factors for stroke is stronger in women (atrial fibrillation and hypertension) and there are risk factors exclusive to women such as pregnancy, pregnancy-associated hypertensive disorders, oral contraceptives, and hormonal replacement treatment. Data on the impact of other risk factors are inconsistent. The worse outcome after a stroke is mainly caused by demographic characteristics in women. Specific gender research is needed to better understand gender disparities in stroke to improve prevention strategies and treatment for women.
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Affiliation(s)
- Sydney Corbière
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Barbara Tettenborn
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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13
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Hanson R, Brown P, Temple-Cooper M, Hoyt M. Puerperium Stroke and Subsequent Tissue-Type Plasminogen Activator-Induced Hemorrhage: A Case Report. A A Pract 2021; 15:e01459. [PMID: 33955867 DOI: 10.1213/xaa.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of ischemic stroke in an apparently healthy 35-year-old gravida 2 para 1 who was treated with tissue-type plasminogen activator (tPA) 9 hours after vaginal delivery that resulted in severe hemorrhage. Limited data suggest use of thrombolytics in pregnancy is safe, but there is a paucity of evidence assessing their use immediately postpartum. We describe successful combination of tPA with endovascular mechanical thrombectomy (EMT) for treatment of postpartum stroke, which was followed by extensive uterine bleeding.
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Affiliation(s)
| | - Peter Brown
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mary Temple-Cooper
- Department of Pharmacy, Hillcrest Hospital, Cleveland Clinic Health System, Mayfield Heights, Ohio
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Tsivgoulis G, Kargiotis O, De Marchis G, Kohrmann M, Sandset EC, Karapanayiotides T, de Sousa DA, Sarraj A, Safouris A, Psychogios K, Vadikolias K, Leys D, Schellinger PD, Alexandrov AV. Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence. Ther Adv Neurol Disord 2021; 14:1756286421997368. [PMID: 33737956 PMCID: PMC7934037 DOI: 10.1177/1756286421997368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens 15344, Greece
| | | | - Gianmarco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Martin Kohrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | - Theodore Karapanayiotides
- Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Amrou Sarraj
- Department of Neurology, The University of Texas at Houston, Houston, TX, USA
| | - Apostolos Safouris
- Second Department of Neurology, National & Kapodistiran University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Didier Leys
- Department of Neurology (Stroke Unit), Lille Neuroscience and Cognition, Degenerative and Vascular Cognitive Disorders, University of Lille, INSERM (U-1172), Lille, France
| | - Peter D Schellinger
- Department of Neurology, Johannes Wesling Medical Center Minden, UK RUB Minden, Germany
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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15
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Dinehart E, Leon Guerrero C, Pham A, Chandra S, Petersen SM, Bathgate S, Ahmadzia H. Extending the window for thrombolysis for treatment of acute ischaemic stroke during pregnancy: a review. BJOG 2020; 128:516-520. [PMID: 32920999 DOI: 10.1111/1471-0528.16495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 11/29/2022]
Abstract
Historically, safety of intravenous recombinant tissue plasminogen activator (IV rt-PA) for the treatment of acute ischaemic stroke (AIS) is limited to use within 4.5 hours from symptom onset. Recent studies suggest the treatment window may be extended when patients have salvageable brain tissue on advanced neuroimaging. This paper describes a novel use of IV rt-PA for treatment of AIS in a pregnant patient within an extended-time window (>4.5 hours, and <9 hours) based on advanced neuroimaging with a favourable outcome. TWEETABLE ABSTRACT: Novel use of IV rt-PA for treatment of AIS in pregnancy within an extended-time window based on advanced imaging with a favourable outcome.
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Affiliation(s)
- E Dinehart
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - C Leon Guerrero
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - A Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - S Chandra
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - S M Petersen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - S Bathgate
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H Ahmadzia
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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16
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Moriyama T, Sugiura Y, Hayashi Y, Kinoshita F, Yamamura R, Moriya M, Tatsumi C, Yokoe M, Nagatsuka K, Ishihara M, Goto T, Nishio M, Watanabe Y. Thrombolysis and Mechanical Thrombectomy for Acute Ischemic Stroke in Pregnancy: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:124-128. [PMID: 37502798 PMCID: PMC10370802 DOI: 10.5797/jnet.cr.2020-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/15/2020] [Indexed: 07/29/2023]
Abstract
Objective Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT) are effective treatments for acute ischemic stroke (AIS). However, the treatment for AIS in pregnancy is not established because no clinical trials have included pregnant patients. We present a case of middle cerebral artery (MCA) M2 segment occlusion in pregnancy treated with IV thrombolysis and endovascular therapy. Case Presentation A 36-year-old woman being 6 weeks pregnant presented with right-sided hemiparesis and aphasia. MRI showed a high-intensity area on diffusion-weighted imaging of the left parietal lobe, and MRA showed left MCA M2 segment occlusion. She underwent IV rt-PA and MT and achieved thrombolysis in cerebral infarction 2b revascularization without complications. The protein S concentration was lower than that in the physiological changes during pregnancy. She was diagnosed with embolic stroke related to coagulopathy in pregnancy, and she underwent anticoagulation. At the 3-month follow-up, the modified Rankin Scale was 0. She miscarried at 4 months, and the fetal death was presumed to be obstetric cause. Conclusion IV rt-PA and MT may be effective and safe treatments for pregnant patients. Estimated fetal radiation exposure during MT is low and is presumed not to affect fetal development. We should mitigate the radiation dose and reduce the dose of iodinated contrast agents, particularly in pregnant patients.
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Affiliation(s)
- Takuya Moriyama
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yuri Sugiura
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yuto Hayashi
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Fukuaki Kinoshita
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Ryohei Yamamura
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masayuki Moriya
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Chikao Tatsumi
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masaru Yokoe
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masahiro Ishihara
- Department of Neurosurgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Tetsu Goto
- Department of Neurosurgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masami Nishio
- Department of Neurosurgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yuko Watanabe
- Department of Obstetrics and Gynecology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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17
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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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18
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Kular S, Ram R, Balian V, Tse G, Coley S, Jivraj S, Nagaraja S. Mechanical thrombectomy for acute stroke in pregnancy. Neuroradiol J 2020; 33:134-139. [PMID: 31984865 PMCID: PMC7140301 DOI: 10.1177/1971400919900635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Several recent randomised control trials have shown adjunctive endovascular mechanical thrombectomy to be an effective and safe treatment for acute stroke superior to medical therapy alone. Despite this, questions remain over certain groups of patients that have been excluded from these studies, such as pregnant women. We believe this is a topic of increasing clinical significance with minimal data in the literature. In this article we discuss stroke in pregnancy and highlight the important technical considerations of endovascular mechanical thrombectomy, including minimising radiation exposure to the mother and fetus.
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Affiliation(s)
- Saminderjit Kular
- Department of Clinical Radiology,
Sheffield Teaching Hospitals, Sheffield, UK
| | - Ramya Ram
- Department of Obstetrics and
Gynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Vartan Balian
- Department of Clinical Radiology,
Sheffield Teaching Hospitals, Sheffield, UK
| | - George Tse
- Department of Clinical Radiology,
Sheffield Teaching Hospitals, Sheffield, UK
| | - Stuart Coley
- Department of Clinical Radiology,
Sheffield Teaching Hospitals, Sheffield, UK
| | - Shenaaz Jivraj
- Department of Obstetrics and
Gynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Sanjoy Nagaraja
- Department of Clinical Radiology,
Sheffield Teaching Hospitals, Sheffield, UK
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19
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20
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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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21
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Wiącek M, Kaczorowski R, Oboz-Adaś A, Kuźniar K, Bartosik-Psujek H. Acute ischemic stroke in a third trimester of pregnancy - cesarean section followed by mechanical thrombectomy. Int J Neurosci 2019; 130:739-742. [PMID: 31842636 DOI: 10.1080/00207454.2019.1702539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Acute ischemic stroke (AIS) in pregnancy, despite being a rare event, poses a serious risk for mother's and child's health. There are no strict treatment guidelines in this group of patients, with safety and efficacy of intravenous recombinant tissue-plasminogen-activator (rtPA) and mechanical thrombectomy (MT) being uncertain.Case Presentation: We present a case of gravid 27-year-old patient with left middle cerebral artery (MCA) proximal occlusion causing AIS that was successfully treated with MT. Being in 35th gestational week, it was decided to perform caesarean section before endovascular treatment. The outcome of treatment was good, with no mother's neurological deficit and proper child development in the 5-year observation.Conclusions: MT is probably safe and efficient treatment method in selected pregnant women. No harmful effects on further pregnancy course and parturition have been observed to date.
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Affiliation(s)
- Marcin Wiącek
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszów, Poland.,Faculty of Medicine, University of Rzeszów, Rzeszów, Poland
| | - Rafał Kaczorowski
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszów, Poland
| | | | | | - Halina Bartosik-Psujek
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszów, Poland.,Faculty of Medicine, University of Rzeszów, Rzeszów, Poland
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22
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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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23
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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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24
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Kuwano A, Kubota Y, Nonaka T, Miyao S, Nakamoto H, Kawamata T. Mechanical Thrombectomy for Middle Cerebral Artery Occlusion Suspected of Ovarian Hyperstimulation Syndrome: Case Report and Review of the Literature. World Neurosurg 2019; 132:300-302. [PMID: 31525479 DOI: 10.1016/j.wneu.2019.09.023] [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] [Received: 07/28/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic disorder associated with infertility treatment. The main pathology of OHSS is intravascular dehydration and hyperestrogenemia. In mild cases, abdominal symptoms are the main symptoms, but in severe cases, thrombosis such as cerebral infarction may occur. CASE DESCRIPTION A 36-year-old woman was undergoing infertility treatment in obstetrics and gynecology for infertility. She received HMG-HCG therapy and artificial insemination 1 week before onset, and on the day of onset she had mild abdominal distension and was suspected of having OHSS. She was prescribed aspirin for prevention of thrombosis. She presented with right upper hemiparesis and aphasia. Magnetic resonance imaging showed left middle cerebral artery occlusion. We performed mechanical thrombectomy and finally achieved Thrombolysis in Cerebral Infarction 3 recanalization. We suspected embolism as the etiology of cerebral infarction and started anticoagulation therapy. Various examinations were conducted to investigate the embolism source, but no anatomic abnormality or thrombophilia factors were observed. Because the patient had OHSS since admission, we concluded that OHSS was suspected as the cause of the stroke. CONCLUSIONS We experienced the first case of mechanical thrombectomy for middle cerebral artery occlusion suspected to be caused by OHSS. It is necessary to suspect OHSS involvement if young women, especially those on infertility treatment, show neurologic deficits.
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Affiliation(s)
- Atsushi Kuwano
- Department of Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuichi Kubota
- Department of Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Taku Nonaka
- Department of Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoru Miyao
- Department of Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hidetoshi Nakamoto
- Department of Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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25
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Ryman KM, Pace WD, Smith S, Fontaine GV. Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature. Pharmacotherapy 2019; 39:767-774. [PMID: 31077601 DOI: 10.1002/phar.2278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute ischemic stroke (AIS) during pregnancy is a rare but serious complication. Intravenous alteplase is the only medication approved for hyperacute treatment of AIS; however, it has not been evaluated prospectively in pregnancy. Pregnancy was an exclusion criterion in prospective AIS studies and was only recently removed as a relative contraindication in the 2018 American Heart Association/American Stroke Association Stroke guidelines. Due to the exclusion of pregnant women from randomized controlled trials, the safety of fibrinolytic therapy in pregnant patients is not well established. In this review, we report the use of intravenous alteplase for AIS in two pregnant patients, with temporally associated clinical improvement and without complications to either the mother or fetus. Additionally, we summarize a systematic review of the literature for both intravenous and intra-arterial alteplase use for AIS in pregnant patients. A total of 31 cases met inclusion criteria for this review of assessment of safety and efficacy of alteplase use in pregnancy. Existing case reports and guidelines support the use of alteplase for AIS in pregnant patients without contraindications.
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Affiliation(s)
- Klayton M Ryman
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
- Department of Pharmacy, Baylor University Medical Center, Dallas, Texas
| | - Wilson D Pace
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
| | - Shawn Smith
- Department of Neurology, Intermountain Medical Center, Murray, Utah
- Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Gabriel V Fontaine
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah
- Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah
- Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
- Roseman University College of Pharmacy, South Jordan, Utah
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26
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Abstract
PURPOSE OF THE REVIEW Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence. RECENT FINDINGS The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.
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Affiliation(s)
- Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
- Neurological Institute of New York, 710 West 168th Street, 6th floor, New York, NY, 10032, USA.
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