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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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3
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Bojda M, Cimprichová A, Vavríková B, Filipková A, Gdovinová Z. Intravenous thrombolysis for stroke in pregnancy should be administered if the benefit outweighs the risk: A case report and recommended diagnostic workup. WOMENS HEALTH 2021; 17:1745506521999495. [PMID: 33710947 PMCID: PMC7958154 DOI: 10.1177/1745506521999495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction: There is an ongoing debate about the use of recombinant tissue plasminogen activator in
acute stroke during pregnancy. The aim of our case report is to present that even in a
small stroke centre intravenous thrombolysis can be used on a pregnant woman if the
benefit outweighs the risk and to summarize the diagnostic workup in a pregnant woman
with stroke. Case report: Our case describes a 31-year-old woman presenting in her third trimester with a sudden
onset of slurred speech, severe right hemiparesis, facial nerve central palsy, eyes
deviation to the left, right side hemianopia, hemisensory loss, psychomotor agitation
and pain in the right lower limb. She was successfully treated with recombinant tissue
plasminogen activator with almost complete recovery (NIHSS 1 after 10 days), and 23 days
after intravenous thrombolysis, she delivered in the 37th week a healthy male infant.
The first documented successful outcome from thrombolysis for this condition in Slovakia
supports the notion of giving intravenous recombinant tissue plasminogen activator to
pregnant patients with disabling ischaemic stroke who meet the criteria for
thrombolysis. Discussion: At the end of case study, a recommended diagnostic workup for acute treatment of stroke
in pregnant women is presented.
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Affiliation(s)
- Marek Bojda
- Department of Neurology, Faculty Hospital Trenčín, Trencin, Slovakia
| | | | - Bibiana Vavríková
- Department of Neurology, Faculty Hospital Trenčín, Trencin, Slovakia
| | - Alena Filipková
- Department of Neurology, Faculty Hospital Trenčín, Trencin, Slovakia
| | - Zuzana Gdovinová
- Department of Neurology, Faculty of Medicine, P.J. Šafarik University and University Hospital L. Pasteur, Košice, Slovakia
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4
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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
Acute stroke in pregnancy can be devastating. Although neurologists will at some point be involved in the management, most of these patients are likely to first be evaluated by an obstetric care provider. It is, therefore, important for obstetric care providers to have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical. Once suspected, a head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component. Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]). Blood pressure (BP) control is paramount when administering tPA. During pregnancy, we recommend maintaining a BP between 140-160/90-110 mm Hg during tPA treatment. Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients. The use of therapeutic anticoagulation during the acute management of ischemic stroke is not indicated owing to an increased risk of hemorrhagic transformation. Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels. Serum glucose levels should be kept between 140 and 180 mg/dL. Antiplatelet agents are indicated for secondary prevention. The management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should overall follow same guidelines as for nonpregnant individuals.
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6
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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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7
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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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8
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Wildman JK, Rimawi BH. Cerebral pontine infarctions during pregnancy - A case report and review of the literature. Case Rep Womens Health 2019; 21:e00097. [PMID: 30733924 PMCID: PMC6358547 DOI: 10.1016/j.crwh.2019.e00097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 01/13/2019] [Accepted: 01/22/2019] [Indexed: 11/29/2022] Open
Abstract
Cerebrovascular disease is not uncommon during pregnancy as a result of either venous or arterial occlusion, or a hemorrhagic event, resulting in ischemia. Pregnancy may alter the prognosis of these neurologic disorders, with increased risks of morbidity and mortality for the mother and the developing fetus. Etiologies of stroke during pregnancy and the postpartum period include preeclampsia, eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), amniotic fluid embolism, postpartum angiopathy, postpartum cardiomyopathy, thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), cerebral venous thrombosis, CNS infections, and maternal thrombophilia. Essentially any of the vessels in the brain can be involved in cerebral infarction; however, pontine infarctions are rare and are generally secondary to occlusive insults or after dissection of an aneurysm. Though not common, these conditions can result in devastating sequelae and significant disability. Scant literature is available regarding pontine infarctions during pregnancy. Here we present a rare case of a pregnant patient who presented with new-onset seizures and was found to have a cerebral pontine infarction on imaging. The purpose of this article is to summarize existing data regarding the incidence, risk factors, and potential etiologies, as well as treatment strategies for pontine infarctions during pregnancy. Pontine infarctions are rare during pregnancy and do not differ compared to non-pregnant women. A CT scan, MRI and lumbar puncture can safely be performed during pregnancy for diagnosis purposes. Treatment options available during pregnancy is similar to those used in non-pregnant women. Immediate delivery of a pregnant woman with a vascular cerebral injury is not always indicated. The risk of recurrence is likely to be low, and thus should not impact on mode of delivery.
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Affiliation(s)
- Jenna Kaye Wildman
- University of South Alabama, Children's and Women's Hospital, Department of Obstetrics and Gynecology, 251 Cox Street, Mobile, AL 36604, United States
| | - Bassam H Rimawi
- University of South Alabama, Children's and Women's Hospital, Department of Obstetrics and Gynecology, 251 Cox Street, Mobile, AL 36604, United States.,Division of Maternal Fetal Medicine, United States
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9
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Watanabe TT, Ichijo M, Kamata T. Uneventful Pregnancy and Delivery after Thrombolysis Plus Thrombectomy for Acute Ischemic Stroke: Case Study and Literature Review. J Stroke Cerebrovasc Dis 2018; 28:70-75. [PMID: 30268366 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/21/2018] [Accepted: 09/02/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis with recombinant tissue plasminogen activator and endovascular mechanical thrombectomy are known to be the most effective treatments in the acute phase of ischemic stroke. However, the safety of intravenous systemic thrombolysis with recombinant tissue plasminogen and endovascular mechanical thrombectomy during pregnancy is not well-confirmed. We describe a case of an uneventful pregnancy and delivery after thrombolysis plus endovascular mechanical thrombectomy for acute ischemic stroke. MATERIALS AND METHODS The patient's medical records were reviewed retrospectively. A comprehensive systemic literature search of the PubMed database was conducted. CASE PRESENTATION A 36-year-old woman at 21 weeks gestation presented with a sudden headache, dysarthria, and right hemiparesis. Magnetic resonance angiography revealed occlusion of the left internal carotid artery. Recombinant tissue plasminogen activator was administered intravenously 193 minutes after symptom onset, and endovascular mechanical thrombectomy was started immediately. Recanalization of her left internal carotid artery was achieved. The patient continued to experience mild hemiparesis after the initial treatment and started rehabilitation. The fetus remained in satisfactory condition during the pregnancy and was delivered at 38 weeks without obvious maternal or neonatal complications. No apparent abnormality has been observed in the newborn in the first year of life. CONCLUSIONS Intravenous recombinant tissue plasminogen and endovascular mechanical thrombectomy could be considered as treatment for acute ischemic stroke during pregnancy unless high risks of hemorrhage or preterm labor are expected.
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Affiliation(s)
| | - Masahiko Ichijo
- Department of Neurology, Japanese Red Cross Musashino Hospital, Musashino, Tokyo, Japan
| | - Tomoyuki Kamata
- Department of Neurology, Japanese Red Cross Musashino Hospital, Musashino, Tokyo, Japan
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10
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Remote Intracerebral Hemorrhage Following Intravenous Thrombolysis in Pregnancy at 31 Weeks Gestation: A Case Report and Review of the Literature. Neurologist 2018; 23:19-22. [PMID: 29266040 DOI: 10.1097/nrl.0000000000000165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Intravenous recombinant tissue-type plasminogen activator thrombolysis in pregnancy for acute ischemic stroke is infrequent. As a rare complication of thrombolysis, remote intracerebral hemorrhage (rICH) whose mechanisms are unclear has not gained enough attention until now. CASE REPORT We present here a case of 26-year-old pregnant woman at 31 weeks gestation who suffered from sudden onset right-sided hemiparesis and slurred speech. She successfully received intravenous recombinant tissue-type plasminogen activator thrombolysis within 2.5 hours from stroke onset. Further workup demonstrated multiple and bilateral acute cerebral infarcts due to cardioembolism. At 6 hours after thrombolysis, multifocal intracerebral hemorrhages were developed in her left cerebellum and right temporal cortex, remote from the initial infarct areas. However, the patient achieved a final complete recovery of symptoms. Despite diffusion-weighted imaging could not confirm infarct in the areas of hemorrhages, multiple cerebral embolism was suggested to be involved in the etiology of rICH. CONCLUSIONS rICH is different from local intracerebral hemorrhage in its risk factors, neurological outcomes, and underlying mechanisms. Patients with rICH may have favorable outcomes and multiple cerebral embolism is still one of the important mechanisms for postthrombolytic rICH.
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11
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Ladhani NNN, Swartz RH, Foley N, Nerenberg K, Smith EE, Gubitz G, Dowlatshahi D, Potts J, Ray JG, Barrett J, Bushnell C, Bal S, Chan WS, Chari R, El Amrani M, Gandhi S, Hill MD, James A, Jeerakathil T, Jin A, Kirton A, Lanthier S, Lausman A, Leffert LR, Mandzia J, Menon B, Pikula A, Poppe A, Saposnik G, Sharma M, Bhogal S, Smitko E, Lindsay MP. Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy. Int J Stroke 2018; 13:743-758. [PMID: 30021491 DOI: 10.1177/1747493018786617] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.
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Affiliation(s)
- Noor Niyar N Ladhani
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Richard H Swartz
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada
| | - Norine Foley
- 4 Department of Foods and Nutrition, Western University, London, Ontario, Canada.,5 workHORSE Consulting Group, London, Ontario, Canada
| | - Kara Nerenberg
- 6 Department of Medicine, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Gord Gubitz
- 9 Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,10 Department of Medicine (Neurology), Dalhousie University, Halifax, Canada
| | | | - Jayson Potts
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Joel G Ray
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Jon Barrett
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Cheryl Bushnell
- 14 Wake Forest Baptist Stroke Center, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - Simerpreet Bal
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Wee-Shian Chan
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Radha Chari
- 15 Faculty of Medicine & Dentistry, Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Meryem El Amrani
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Shital Gandhi
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,17 Sinai Health System, Toronto, Canada
| | - Michael D Hill
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Andra James
- 18 Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - Thomas Jeerakathil
- 19 Department of Medicine & Dentistry (Neurosciences), University of Alberta, Edmonton, Canada
| | - Albert Jin
- 20 Department of Medicine, Queen's University, Kingston, Canada
| | - Adam Kirton
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Sylvain Lanthier
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Andrea Lausman
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Lisa Rae Leffert
- 21 Department of Obstetric Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Mandzia
- 22 Department of Clinical Neurological Sciences, Western University, London, Canada
| | - Bijoy Menon
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Aleksandra Pikula
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,23 Neurovascular Unit, University Health Network/Toronto Western Hospital, Toronto, Canada
| | - Alexandre Poppe
- 24 Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Gustavo Saposnik
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,25 Stroke Research Unit, St. Michael's Hospital, Toronto, Canada
| | - Mukul Sharma
- 26 Division of Neurology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Sanjit Bhogal
- 5 workHORSE Consulting Group, London, Ontario, Canada
| | | | - M Patrice Lindsay
- 27 Heart and Stroke Foundation of Canada, Toronto, Canada.,28 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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12
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Sousa Gomes M, Guimarães M, Montenegro N. Thrombolysis in pregnancy: a literature review. J Matern Fetal Neonatal Med 2018; 32:2418-2428. [DOI: 10.1080/14767058.2018.1434141] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Marina Sousa Gomes
- Department of Obstetrics and Gynecology, Alto Minho Local Healthcare Unit, Viana do Castelo, Portugal
| | - Mariana Guimarães
- Department of Obstetrics and Gynecology, São João Hospital Center, Porto, Portugal
| | - Nuno Montenegro
- Department of Obstetrics and Gynecology, São João Hospital Center, Porto, Portugal
- Medicine Faculty, University of Porto, Porto, Portugal
- Institute of Public Health of the University of Porto, Porto, Portugal
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13
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Landais A, Chaumont H, Dellis R. Thrombolytic Therapy of Acute Ischemic Stroke during Early Pregnancy. J Stroke Cerebrovasc Dis 2017; 27:e20-e23. [PMID: 29191741 DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 12/17/2016] [Indexed: 10/18/2022] Open
Abstract
Thrombolytic treatment (recombinant tissue plasminogen activator [rt-PA]) has established efficacy in acute ischemic stroke, but pregnancy has been an exclusion criterion for all clinical trials that validated alteplase in acute stroke, so our knowledge about its use in this condition is limited. Herein we report the successful use of intravenous rt-PA thrombolysis, uncomplicated by neither hemorrhage development nor other complication in a woman who was 13 weeks pregnant with acute ischemic stroke. The brain magnetic resonance imaging diffusion-weighted sequences showed increased signal in the territory of the left middle cerebral artery. Our case had a good maternal and fetal outcome, and advocates that the use of thrombolytics may be feasible in pregnant patients and help to avoid residual neurologic deficits. A summary of published cases in the early aspect of pregnancy and outcomes is presented. Risks and benefits to mother and fetus must be weighted up, but intravenous thrombolysis must not be considered as an absolute contraindication, even in early pregnancy.
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Affiliation(s)
- Anne Landais
- Neurology Department, University Hospital of Pointe-à-Pitre, France.
| | - Hugo Chaumont
- Neurology Department, University Hospital of Pointe-à-Pitre, France
| | - Rachel Dellis
- Neurology Department, University Hospital of Pointe-à-Pitre, France
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14
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Bhogal P, Aguilar M, AlMatter M, Karck U, Bäzner H, Henkes H. Mechanical Thrombectomy in Pregnancy: Report of 2 Cases and Review of the Literature. INTERVENTIONAL NEUROLOGY 2017; 6:49-56. [PMID: 28611834 DOI: 10.1159/000453461] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mechanical thrombectomy has recently proved extremely effective in improving the outcome of patients with large vessel occlusion. Despite this, questions still remain over certain cohorts of patients that were excluded from the large randomised controlled trials. One such cohort includes pregnant patients. Although thromboembolic stroke is uncommon in pregnancy, the outcome from this pathology can be devastating. SUMMARY We present 2 cases of mechanical thrombectomy in pregnancy both of which underwent successful flow restoration without complications. We discuss the incidence of stroke in pregnancy, potential pitfalls of imaging, radiation protection issues, and the role of thrombolysis as well as the available literature on mechanical thrombectomy in this cohort. KEY MESSAGE Thrombectomy in pregnancy can be performed safely with no significant changes required to the procedure itself. Radiation exposure during the procedure should be minimised and shielding used to prevent scatter radiation to the fetus; however, given the potential risks of thrombolysis in this cohort of patients, mechanical thrombectomy should be considered in all stages of pregnancy.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiologische Klinik, University of Duisburg-Essen, Essen, Germany
| | - Marta Aguilar
- Neuroradiologische Klinik, University of Duisburg-Essen, Essen, Germany
| | - Muhammad AlMatter
- Neuroradiologische Klinik, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Karck
- Frauenklinik, Klinikum Stuttgart, Stuttgart, University of Duisburg-Essen, Essen, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, University of Duisburg-Essen, Essen, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, University of Duisburg-Essen, Essen, Germany.,Medizinische Fakultät, University of Duisburg-Essen, Essen, Germany
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Reining-Festa A, Földy D, Coulibaly-Wimmer M, Eischer L, Heger M, Fertl E. Intravenous thrombolysis of stroke in early pregnancy: a case report and review of the literature. J Neurol 2016; 264:397-400. [PMID: 28028624 DOI: 10.1007/s00415-016-8369-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 12/13/2016] [Accepted: 12/16/2016] [Indexed: 05/29/2023]
Affiliation(s)
- Alice Reining-Festa
- Department of Neurology, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Vienna, Austria.
| | - Daniela Földy
- Department of Neurology, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Vienna, Austria
| | | | - Lisbeth Eischer
- Department of Hematology and Hemostaseology, Allgemeines Krankenhaus, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Maria Heger
- Department of Cardiology, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Vienna, Austria
| | - Elisabeth Fertl
- Department of Neurology, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Vienna, Austria
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Tversky S, Libman RB, Reppucci ML, Tufano AM, Katz JM. Thrombolysis for Ischemic Stroke during Pregnancy: A Case Report and Review of the Literature. J Stroke Cerebrovasc Dis 2016; 25:e167-70. [PMID: 27523596 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/02/2016] [Accepted: 06/17/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Our knowledge of the safety of thrombolytic therapy in pregnancy stems from individual case reports and series. We report the successful use of intravenous alteplase (tissue plasminogen activator; tPA) thrombolysis in a pregnant woman with acute cardioembolic stroke presumed to be paradoxical embolism through a patent foramen ovale. METHODS A literature review found several case reports and case series of pregnant patients treated with either intravenous or intra-arterial tPA for acute ischemic stroke. RESULTS A literature review yielded 10 cases of intravenous tPA administration and 5 cases of intra-arterial tPA. In total, there were 3 cases of asymptomatic intracerebral hemorrhage and 1 case of maternal and fetal death. CONCLUSIONS Our patient improved clinically with no residual deficits. There was no evidence of placental or fetal injury following administration of tPA on follow-up obstetrical evaluations.
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O'Neal MA. Neurology of Pregnancy: A Case-Oriented Review. Neurol Clin 2016; 34:717-31. [PMID: 27445250 DOI: 10.1016/j.ncl.2016.04.009] [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: 10/21/2022]
Abstract
The anatomic and physiologic changes that occur during pregnancy are unique. A neurologist needs to be aware of normal pregnancy-induced physiologic changes in the cardiovascular, renal, hematologic, and autoimmune systems, and the local anatomic changes, which include alteration of body habitus and pelvic ligaments. These changes are clearly advantageous, but in certain circumstances may predispose to pathology. In addition, pregnancy effects treatment of chronic neurologic conditions as regards medication safety and metabolism. This case-oriented review discusses the important aspects of pregnancy physiology and an approach to treatment of common disorders encountered during pregnancy including stroke, multiple sclerosis, epilepsy, and compression neuropathies.
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Affiliation(s)
- Mary Angela O'Neal
- Department of Neurology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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18
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Leffert LR, Clancy CR, Bateman BT, Cox M, Schulte PJ, Smith EE, Fonarow GC, Kuklina EV, George MG, Schwamm LH. Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period. Am J Obstet Gynecol 2016; 214:723.e1-723.e11. [PMID: 26709084 DOI: 10.1016/j.ajog.2015.12.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/02/2015] [Accepted: 12/13/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Stroke, which is a rare but devastating event during pregnancy, occurs in 34 of every 100,000 deliveries; obstetricians are often the first providers to be contacted by symptomatic patients. At least one-half of pregnancy-related strokes are likely to be of the ischemic stroke subtype. Most pregnant or newly postpartum women with ischemic stroke do not receive acute stroke reperfusion therapy, although this is the recommended treatment for adults. Little is known about these therapies in pregnant or postpartum women because pregnancy has been an exclusion criterion for all reperfusion trials. Until recently, pregnancy and obstetric delivery were specifically identified as warnings to intravenous alteplase tissue plasminogen activator in Federal Drug Administration labeling. OBJECTIVE The primary study objective was to compare the characteristics and outcomes of pregnant or postpartum vs nonpregnant women with ischemic stroke who received acute reperfusion therapy. STUDY DESIGN Pregnant or postpartum (<6 weeks; n = 338) and nonpregnant (n = 24,303) women 18-44 years old with ischemic stroke from 1991 hospitals that participated in the American Heart Association's Get With the Guidelines-Stroke Registry from 2008-2013 were identified by medical history or International Classification of Diseases, Ninth Revision, codes. Acute stroke reperfusion therapy was defined as intravenous tissue plasminogen activator, catheter-based thrombolysis, or thrombectomy or any combination thereof. A sensitivity analysis was done on patients who received intravenous tissue plasminogen activator monotherapy only. Chi-square tests were used for categoric variables, and Wilcoxon Rank-Sum was used for continuous variables. Conditional logistic regression was used to assess the association of pregnancy with short-term outcomes. RESULTS Baseline characteristics of the pregnant or postpartum vs nonpregnant women with ischemic stroke revealed a younger group who, despite greater stroke severity, were less likely to have a history of hypertension or to arrive via emergency medical services. There were similar rates of acute stroke reperfusion therapy in the pregnant or postpartum vs nonpregnant women (11.8% vs 10.5%; P = .42). Pregnant or postpartum women were less likely to receive intravenous tissue plasminogen activator monotherapy (4.4% vs 7.9%; P = .03), primarily because of pregnancy and recent surgery. There was a trend toward increased symptomatic intracranial hemorrhage in the pregnant or postpartum patients who were treated with tissue plasminogen activator, yet no cases of major systemic bleeding or in-hospital death occurred, and there were similar rates of discharge to home. Data on the timing of pregnancy, which were available in 145 of 338 cases, showed that 44.8% of pregnancy-related strokes were antepartum, that 2.8% occurred during delivery, and that 52.4% were during the postpartum period. CONCLUSIONS Using data from the Get With the Guidelines-Stroke Registry to assemble the largest cohort of pregnant or postpartum ischemic stroke patients who had been treated with reperfusion therapy, we observed that pregnant or postpartum women had similarly favorable short-term outcomes and equal rates of total reperfusion therapy to nonpregnant women, despite lower rates of intravenous tissue plasminogen activator use. Future studies should identify the characteristics of pregnant and postpartum ischemic stroke patients who are most likely to safely benefit from reperfusion therapy.
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19
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Steinberg A, Moreira TP. Neuroendocrinal, Neurodevelopmental, and Embryotoxic Effects of Recombinant Tissue Plasminogen Activator Treatment for Pregnant Women with Acute Ischemic Stroke. Front Neurosci 2016; 10:51. [PMID: 26941596 PMCID: PMC4766278 DOI: 10.3389/fnins.2016.00051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/04/2016] [Indexed: 11/23/2022] Open
Abstract
Thrombolysis with recombinant tissue plasminogen activator (rTPA) was the first evidence-based treatment approved for acute stroke. Ischemic stroke is relatively uncommon in fertile women but treatment is often delayed or not given. In randomized trials, pregnancy has been an exclusion criterion for thrombolysis. Physiologic TPA has been shown to have neuroendocrine effects namely in vasopressin secretion. Important TPA effects in brain function and development include neurite outgrowth, migration of cerebellar granular neurons and promotion of long-term potentiation, among others. Until now, no neuroendocrine side-effects have been reported in pregnant women treated with rTPA. The effects of rTPA exposure in the fetus following intravenous thrombolysis in pregnant women are still poorly understood. This depends on low case frequency, short-duration of exposure and the fact that rTPA molecule is too large to pass the placenta. rTPA has a short half-life of 4–5 min, with only 10% of its concentration remaining in circulation after 20 min, which may explain its safety at therapeutically doses. Ischemic stroke during pregnancy occurs most often in the third trimester. Complication rates of rTPA in pregnant women treated for thromboembolic conditions and ischemic stroke were found to be similar when compared to non-pregnant women (7–9% mortality). In embryos of animal models so far, no indications of a teratogenic or mutagenic potential were found. Pregnancy is still considered a relative contraindication when treating acute ischemic stroke with rTPA, however, treatment risk must be balanced against the potential of maternal disability and/or death.
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Affiliation(s)
- Anna Steinberg
- Department of Neurology, Karolinska University HospitalStockholm, Sweden; Stroke Research Unit, Department of Clinical Neuroscience, Karolinska InstitutetStockholm, Sweden
| | - Tiago P Moreira
- Department of Neurology, Karolinska University HospitalStockholm, Sweden; Stroke Research Unit, Department of Clinical Neuroscience, Karolinska InstitutetStockholm, Sweden
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21
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Ritchie J, Lokman M, Panikkar J. Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery. BMJ Case Rep 2015; 2015:bcr-2015-209563. [PMID: 26264941 DOI: 10.1136/bcr-2015-209563] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Stroke during pregnancy is fortunately a rare event, however, it can have severe consequences, with 9.5% of all maternal deaths being related to stroke. The most common presentation is an ischaemic stroke. There has been much debate as to the correct treatment for such cases' and whether thrombolysis can be used safely in pregnancy. Our case describes a 28-year-old woman with a previous normal vaginal delivery presenting in her third trimester with a sudden onset of dense left hemiparesis. She was successfully treated with alteplase, an intravenous recombinant tissue-type plasminogen activator, and made a full recovery after normal delivery of a healthy infant. This case report highlights one of the first documented successful outcomes from thrombolysis for this condition in the UK and may help inform future management of these women.
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22
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Boyko M, Iancu D, Lesiuk H, Dowlatshahi D, Shamy MCF. Decision Making and the Limits of Evidence: A Case Study of Acute Stroke in Pregnancy. Neurohospitalist 2015; 6:70-5. [PMID: 27053984 DOI: 10.1177/1941874415594120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
We report the case of a pregnant woman treated for acute ischemic stroke and review the literature on acute stroke treatment in pregnancy. To our knowledge, this is the first case reporting the successful use of intravenous tissue plasminogen activator and a stent retriever for acute stroke in pregnancy. We then use this case to consider the way medical knowledge is used in therapeutic decision making and argue that decision making necessarily extends beyond the limits of clinical trial evidence.
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Affiliation(s)
- Matthew Boyko
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniela Iancu
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Howard Lesiuk
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa, Ottawa, Ontario, Canada
| | - Michel C F Shamy
- Department of Medicine (Neurology), University of Ottawa, Ottawa, Ontario, Canada
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23
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Marchidann A, Balucani C, Levine SR. Expansion of Intravenous Tissue Plasminogen Activator Eligibility Beyond National Institute of Neurological Disorders and Stroke and European Cooperative Acute Stroke Study III Criteria. Neurol Clin 2015; 33:381-400. [DOI: 10.1016/j.ncl.2015.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Razmara A, Bakhadirov K, Batra A, Feske SK. Cerebrovascular complications of pregnancy and the postpartum period. Curr Cardiol Rep 2015; 16:532. [PMID: 25239155 DOI: 10.1007/s11886-014-0532-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Cerebrovascular complications of pregnancy, though uncommon, threaten women with severe morbidity or death, and they are the main causes of major long-term disability associated with pregnancy. In this review, we discuss the epidemiology, pathophysiology, presentation and diagnosis, and management and outcomes of ischemic and hemorrhagic stroke and cerebral venous thrombosis. We also discuss the posterior reversible encephalopathy syndrome, the reversible cerebral vasoconstriction syndrome including postpartum cerebral angiopathy, and their relationship as overlapping manifestations of pre-eclampsia-eclampsia.
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Affiliation(s)
- Ali Razmara
- Fellow in Vascular Neurology, Massachusetts General and Brigham and Women's Hospitals, Boston, MA, USA,
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25
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Abstract
Stroke is the leading cause of acquired disability and the third leading cause of death in women worldwide. Sex differences in risk factors, treatment response and quality of life after stroke complicate stroke management in women. Women have an increased lifetime incidence of stroke compared to men, largely due to a sharp increase in stroke risk in older postmenopausal women. Women also have an increased lifetime prevalence of stroke risk factors, including hypertension and atrial fibrillation in postmenopausal women, as well as abdominal obesity and metabolic syndrome in middle-aged women. Controversy continues over the risks of oral contraceptives, hormone therapy and surgical intervention for carotid stenosis in women. Pregnancy and the postpartum period represent a time of increased risk, presenting challenges to stroke management. Recognition of these issues is critical to improving acute care and functional recovery after stroke in women.
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Affiliation(s)
- Matthew D Howe
- Department of Neuroscience, The University of Connecticut Health Center, Farmington, CT 06030, USA
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26
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Pongrácz E, Farkas S, Dajka M, Csiba L. Intra-arterial Thrombolysis in Second Trimester of Pregnancy. A Case Report. ACTA ACUST UNITED AC 2015; 1:24-27. [PMID: 29967812 DOI: 10.1515/jccm-2015-0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 01/15/2015] [Indexed: 11/15/2022]
Abstract
Here we present a successful intra-arterial thrombolysis performed in the second trimester of pregnancy (21 weeks). The intervention resulted in complete recanalization of the occluded right middle cerebral artery and favourable clinical and gestational outcome. Together with cases described in respective medical literature our report affirms that in pregnancy acute ischemic stroke could be treated effectively applying intra-arterial thrombolysis (using rt-PA). This therapy could provide opportunity to help in such desperate situations.
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Affiliation(s)
- Endre Pongrácz
- Department of Neurology, Hetényi Géza Hospital, H-5001 Szolnok, Tószegi street 21, Debrecen, Hungary
| | - Szabolcs Farkas
- Department of Neurology, University of Debrecen, H-4012, Debrecen, Móricz Zsigmond street, no.22, Hungary
| | - Miklós Dajka
- Department of Radiology, Avas Medical Centre LLC, H-5001 Szolnok, Tószegi street 21, Debrecen, Hungary
| | - László Csiba
- Department of Neurology, University of Debrecen, H-4012, Debrecen, Móricz Zsigmond street, no.22, Hungary
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Moatti Z, Gupta M, Yadava R, Thamban S. A review of stroke and pregnancy: incidence, management and prevention. Eur J Obstet Gynecol Reprod Biol 2014; 181:20-7. [PMID: 25124706 DOI: 10.1016/j.ejogrb.2014.07.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 07/20/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Zoe Moatti
- Specialist Registrar Obstetrics and Gynaecology, Whipps Cross University Hospital, Whipps Cross Road, London E11 1NR, United Kingdom.
| | - Manish Gupta
- Consultant Obstetrician and Gynaecologist and Subspecialist in Maternal and Fetal Medicine, Barts and The Royal London NHS Trust, Whipps Cross University Hospital, Whipps' Cross Road, London E11 1NR, United Kingdom
| | - Rajendra Yadava
- Consultant Physician, Stroke Specialist, Barts and The Royal London NHS Trust, Whipps Cross University Hospital, Whipps' Cross Road, London E11 1NR, United Kingdom
| | - Sujatha Thamban
- Consultant Obstetrician and Gynaecologist at The Royal London Hospital, Barts and The Royal London NHS Trust, Whipps Cross University Hospital, Whipps' Cross Road, London E11 1NR, United Kingdom
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Frontera JA, Ahmed W. Neurocritical care complications of pregnancy and puerperum. J Crit Care 2014; 29:1069-81. [PMID: 25123793 DOI: 10.1016/j.jcrc.2014.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 06/02/2014] [Accepted: 07/08/2014] [Indexed: 12/27/2022]
Abstract
Neurocritical care complications of pregnancy and puerperum such as preeclampsia/eclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, seizures, ischemic and hemorrhagic stroke, postpartum angiopathy, cerebral sinus thrombosis, amniotic fluid emboli, choriocarcinoma, and acute fatty liver of pregnancy are rare but can be devastating. These conditions can present a challenge to physicians because pregnancy is a unique physiologic state, most therapeutic options available in the intensive care unit were not studied in pregnant patients, and in many situations, physicians need to deliver care to both the mother and the fetus, simultaneously. Timely recognition and management of critical neurologic complications of pregnancy/puerperum can be life saving for both the mother and fetus.
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Affiliation(s)
- Jennifer A Frontera
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Wamda Ahmed
- Neuroscience Intensive Care Unit, Departments of Neurology, Emory, Atlanta, Georgia
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Abstract
Ischemic stroke is uncommon during pregnancy, but decision making for acute revascularization therapy including intravenous recombinant tissue plasminogen activator (rt-PA) is difficult. The use of rt-PA remains controversial, but a systematic review of 16 patients (mean age 31.7 years) showed good results for both maternal (77.8%) and fetal (56.3%) outcomes. Pregnancy alone is not a solid contraindication for acute revascularization therapy including rt-PA. An endovascular approach might be beneficial for reducing the hemorrhagic complication; however, the treatment strategy should be considered based on the available treatment facility. Close cooperation with obstetrics is essential for the successful management of saving the lives of both the mother and the fetus.
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Affiliation(s)
- Teruyuki Hirano
- Department of Neurology, Oita University Faculty of Medicine, Yufu, Oita, Japan.
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30
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Abstract
PURPOSE OF REVIEW This article discusses the physiologic changes of pregnancy and how they affect risk of ischemic and hemorrhagic stroke and then reviews epidemiology, diagnosis, and treatment of ischemic and hemorrhagic stroke in pregnancy and the puerperium. RECENT FINDINGS This article updates our understanding of the relationship of preeclampsia/eclampsia to the posterior reversible encephalopathy syndrome and the reversible cerebral vasoconstriction syndrome, emphasizing their shared pathogenesis. It reviews the most recent data and offers recommendations concerning the use of thrombolytic and other revascularization therapies for pregnancy-related strokes. SUMMARY Although cerebrovascular complications are uncommon occurrences during pregnancy and the puerperium, stroke is still the most common seriously disabling complication of pregnancy. Therefore, stroke and other vascular issues raise questions about the best evaluation and management that is safe for mother and child.
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32
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Tang SC, Jeng JS. Management of stroke in pregnancy and the puerperium. Expert Rev Neurother 2014; 10:205-15. [DOI: 10.1586/ern.09.126] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Balami JS, Hadley G, Sutherland BA, Karbalai H, Buchan AM. The exact science of stroke thrombolysis and the quiet art of patient selection. ACTA ACUST UNITED AC 2013; 136:3528-53. [PMID: 24038074 DOI: 10.1093/brain/awt201] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The science of metric-based patient stratification for intravenous thrombolysis, revolutionized by the landmark National Institute of Neurological Disorders and Stroke trial, has transformed acute ischaemic stroke therapy. Recanalization of an occluded artery produces tissue reperfusion that unequivocally improves outcome and function in patients with acute ischaemic stroke. Recanalization can be achieved mainly through intravenous thrombolysis, but other methods such as intra-arterial thrombolysis or mechanical thrombectomy can also be employed. Strict guidelines preclude many patients from being treated by intravenous thrombolysis due to the associated risks. The quiet art of informed patient selection by careful assessment of patient baseline factors and brain imaging could increase the number of eligible patients receiving intravenous thrombolysis. Outside of the existing eligibility criteria, patients may fall into therapeutic 'grey areas' and should be evaluated on a case by case basis. Important factors to consider include time of onset, age, and baseline blood glucose, blood pressure, stroke severity (as measured by National Institutes of Health Stroke Scale) and computer tomography changes (as measured by Alberta Stroke Programme Early Computed Tomography Score). Patients with traditional contraindications such as wake-up stroke, malignancy or dementia may have the potential to receive benefit from intravenous thrombolysis if they have favourable predictors of outcome from both clinical and imaging criteria. A proportion of patients experience complications or do not respond to intravenous thrombolysis. In these patients, other endovascular therapies or a combination of both may be used to provide benefit. Although an evidence-based approach to intravenous thrombolysis for acute ischaemic stroke is pivotal, it is imperative to examine those who might benefit outside of protocol-driven practice.
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Affiliation(s)
- Joyce S Balami
- 1 Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
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34
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Abstract
The relative hypercoagulable state of pregnancy leads to an increased risk of thrombotic complications, of which some may be life-threatening or medically devastating. In the non-pregnant patient, the current guidelines suggest thrombolysis as the primary treatment in acute ischemic stroke, myocardial infarction when percutaneous intervention is unavailable, certain cases of mechanical valve thrombosis, and pulmonary embolism with hemodynamic compromise or shock. Given that clinical trial data regarding thrombolytic use in pregnant women are absent due to exclusion, the goal of this review is to summarize the available published data regarding the use of thrombolytic agents and subsequent outcomes and complications in pregnant women. Overall, the use of thrombolytic agents in pregnancy is associated with a relatively low reported complication rate, especially given the severe medical conditions for which they are indicated. The data would suggest that thrombolysis should be considered for appropriate indications similar to that of non-pregnant patients. However, caution should be exercised when drawing conclusions regarding maternal and fetal safety, given the lack of controlled clinical trials including pregnant women and the nature of the weak evidence level of the cumulative data presented in this review.
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Affiliation(s)
- Eric J Gartman
- Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, Pawtucket, RI, USA
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35
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Grear KE, Bushnell CD. Stroke and pregnancy: clinical presentation, evaluation, treatment, and epidemiology. Clin Obstet Gynecol 2013; 56:350-9. [PMID: 23632643 PMCID: PMC3671374 DOI: 10.1097/grf.0b013e31828f25fa] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Stroke is a neurological emergency that carries a risk of morbidity and mortality. Recent studies have shown that the incidence of stroke, although rare, is increasing in pregnant females. In this review, stroke and other vasculopathies in the pregnant and postpartum female are examined. A discussion of the symptoms and clinical presentation of stroke is provided and the current guideline for treatment of stroke in pregnancy. Finally, the data illustrating the recent increases in stroke incidence are outlined.
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Affiliation(s)
- Karrie E Grear
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
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Affiliation(s)
- Akira ISHII
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine
| | - Susumu MIYAMOTO
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine
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Thrombolytic therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: a case report and literature review. Neurologist 2012; 18:44-8. [PMID: 22217616 DOI: 10.1097/nrl.0b013e31823d7af0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Thrombolysis for acute ischemic stroke has been rarely administrated during pregnancy. Paradoxical embolism through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation (AVM) is an identified risk factor for ischemic stroke. CASE REPORT We report a 24-year-old woman at 11 weeks gestation who developed a sudden onset of dysarthria, hemiparesis, and hemisensory loss. She was diagnosed as having an ischemic stroke in the left middle cerebral artery (MCA) territory. She was treated with intra-arterial recombinant tissue plasminogen activator with subsequent resolution of her neurological deficits. Further workup revealed the presence of a PFO with a large right-to-left shunt. After being put on antithrombotic therapy, she presented again at 13 gestational weeks with a new ischemic infarction in the vertebrobasilar territory. Her PFO was closed percutaneously under ultrasonic guidance but the right-to-left shunt persisted. After a normal delivery, she was found to have a large pulmonary AVM which was successfully resected without complication. CONCLUSIONS This report describes the successful usage of intra-arterial tissue plasminogen activator for acute ischemic stroke during early pregnancy. In patients with presumed paradoxical embolism, careful attention should be paid to rule out a coexistence of PFO and pulmonary AVM.
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Acheampong P, Ford GA. Pharmacokinetics of alteplase in the treatment of ischaemic stroke. Expert Opin Drug Metab Toxicol 2012; 8:271-81. [DOI: 10.1517/17425255.2012.652615] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Stroke, the sudden onset of brain dysfunction from a vascular cause, is one of the most common causes of long-term disability. Although rare during childbearing years, stroke is even more devastating when it occurs in a young woman trying to start a family. Pregnancy and the postpartum period are associated with an increased risk of ischemic stroke and intracerebral hemorrhage, although the incidence estimates have varied. There are several causes of stroke that are in fact unique to pregnancy and the postpartum period, such as preeclampsia and eclampsia, amniotic fluid embolus, postpartum angiopathy and postpartum cardiomyopathy. Data regarding these individual entities are scant. Most concerning is the lack of data regarding both prevention and acute management of pregnancy-related stroke. The purpose of this article is to summarize existing data regarding incidence, risk factors and potential etiologies, as well as treatment strategies for stroke in pregnancy.
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Affiliation(s)
- Jessica Tate
- Wake Forest University Baptist Medical Center Stroke Center, Women's Health Center of Excellence, Wake Forest University Health Sciences, Winston Salem, NC 27157, USA
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Abstract
Acute neurological diseases requiring hospitalization are relatively rare in women of childbearing age. However, during pregnancy and the postpartum period, several diseases increase in prevalence. Some are unique to the pregnant/postpartum state including preeclampsia and delivery-associated neuropathies. Others, although indirectly related to pregnancy, such as cerebral venous thrombosis, ischemic stroke, and intracerebral hemorrhage, increase in frequency and carry considerable risk of morbidity and mortality. In addition, treatment options are often limited. This review discusses the diseases more commonly seen during pregnancy and the postpartum period, with a focus on emergent neurological diseases and their management. Interventional therapies will also be discussed.
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Affiliation(s)
| | - Louise D. McCullough
- Hartford Hospital Stroke Center, Hartford CT, USA
- The University of Connecticut Health Center, Farmington, CT, USA
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Orchard EA, Wilson N, Ormerod OJM. The management of cryptogenic stroke in pregnancy. Obstet Med 2011; 4:2-6. [PMID: 27579087 DOI: 10.1258/om.2010.100027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2010] [Indexed: 01/21/2023] Open
Abstract
Cerebrovascular accidents (CVAs) during pregnancy are uncommon but can have devastating consequences. The causes of CVA in both the pregnant and the non-pregnant state are diverse and require thorough investigation. Recent studies have indicated that embolic stroke in young adults may be caused by paradoxical emboli through a patent foramen ovale (PFO), suggesting that the presence of a PFO should be specifically sought in pregnant or postpartum women presenting with CVA. This review will outline the causes of CVAs in pregnancy and the role of paradoxical emboli, with a focus on PFO.
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Affiliation(s)
- E A Orchard
- Department of Cardiology, John Radcliffe Hospital , Oxford OX3 9DU , UK
| | - N Wilson
- Department of Cardiology, John Radcliffe Hospital , Oxford OX3 9DU , UK
| | - O J M Ormerod
- Department of Cardiology, John Radcliffe Hospital , Oxford OX3 9DU , UK
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Del Zotto E, Giossi A, Volonghi I, Costa P, Padovani A, Pezzini A. Ischemic Stroke during Pregnancy and Puerperium. Stroke Res Treat 2011; 2011:606780. [PMID: 21331336 PMCID: PMC3038679 DOI: 10.4061/2011/606780] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 12/04/2010] [Indexed: 11/30/2022] Open
Abstract
Ischemic stroke during pregnancy and puerperium represents a rare occurrence but it could be a serious and stressful event for mothers, infants, and also families. Whenever it does occur, many concerns arise about the safety of the mother and the fetus in relation to common diagnostic tests and therapies leading to a more conservative approach. The physiological adaptations in the cardiovascular system and in the coagulability that accompany the pregnant state, which are more significant around delivery and in the postpartum period, likely contribute to increasing the risk of an ischemic stroke.
Most of the causes of an ischemic stroke in the young may also occur in pregnant patients. Despite this, there are specific conditions related to pregnancy which may be considered when assessing this particular group of patients such as pre-eclampsia-eclampsia, choriocarcinoma, peripartum cardiomiopathy, amniotic fluid embolization, and postpartum cerebral angiopathy. This article will consider several questions related to pregnancy-associated ischemic stroke, dwelling on epidemiological and specific etiological aspects, diagnostic issue concerning the use of neuroimaging, and the related potential risks to the embryo and fetus. Therapeutic issues surrounding the use of anticoagulant and antiplatelets agents will be discussed along with the few available reports regarding the use of thrombolytic therapy during pregnancy.
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Affiliation(s)
- Elisabetta Del Zotto
- Dipartimento di Scienze Biomediche e Biotecnologie, Università degli Studi di Brescia, 25128 Brescia, Italy
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Cheng SJ, Chen PH, Chen LA, Chen CP. Stroke During Pregnancy and Puerperium: Clinical Perspectives. Taiwan J Obstet Gynecol 2010; 49:395-400. [DOI: 10.1016/s1028-4559(10)60088-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2010] [Indexed: 10/18/2022] Open
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Yamaguchi Y, Kondo T, Ihara M, Kawamata J, Fukuyama H, Takahashi R. [Intravenous recombinant tissue plasminogen activator in an 18-week pregnant woman with embolic stroke]. Rinsho Shinkeigaku 2010; 50:315-9. [PMID: 20535980 DOI: 10.5692/clinicalneurol.50.315] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We are reporting a 36 year-old woman, gravid 3, para 1, aborta 2, who was 18 weeks pregnant and developed a sudden onset of motor aphasia and hemiparesis on the right side. On the initial visit to our hospital, the NIH stroke scale was 6, and the brain MRI revealed high intensity areas in the left insular cortex and the periventricular white matter with occlusion of the left middle cerebral artery (MCA) branches. We diagnosed her as having cerebral embolism, and treated with intravenous recombinant tissue plasminogen activator (rt-PA) with subsequent recanalization of the occuluded left MCA branches. Her motor aphasia and hemiparesis disappeared within a few hours of initiating the therapy. She received aspirin for four months and then heparin until delivery to prevent recurrence. She delivered a healthy term infant without any apparent complications. An 18-week pregnancy itself is not considered a risk factor of stroke, and we ruled out the possibilities of dysfibrinogenemia, homocysteinemia, hereditary or acquired deficiencies of protein C, protein S, and antithrombin III deficiencies, and antiphospholipid antibody syndrome. However, her plasma factor VIII level was significantly elevated to more than 200% (reference for 18-week pregnant woman: 151 +/- 44%), which may have led to her acquired activated protein C resistance or hypercoagulability. As safety of thrombolytic therapy with rt-PA during pregnancy has not been established, this therapy could be carefully used upon due consideration of risks and benefits for both mother and fetus.
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Cronin CA, Weisman CJ, Llinas RH. Stroke treatment: beyond the three-hour window and in the pregnant patient. Ann N Y Acad Sci 2008; 1142:159-78. [PMID: 18990126 DOI: 10.1196/annals.1444.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
For acute stroke patients who arrive at the hospital within 3 h of symptom onset, the focus of care involves screening for eligibility to receive intravenous tissue plasminogen activator. The publication of the National Institute of Neurological Disorders and Stroke recombinant tissue-type plasminogen activator (tPA, or alteplase) study in 1995 (Marler, J.R. 1995, New England Journal of Medicine333: 1581-1587) spurred protocol changes, which continue to evolve, throughout the health care system in an effort to streamline the patient through the Emergency Medical System. The need to expedite patient evaluation involving emergency department, laboratory, radiology, and clinical neurology testing is clear and has been a focus of many stroke centers. For some patients, intravenous thrombolysis within 3 h has a dramatic effect on outcome. However, that is not the only course of action for acute stroke patients. This article will review some of the effective treatments for stroke patients beyond the first 3 h of their care.
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Affiliation(s)
- C A Cronin
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland 21224, USA
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De Keyser J, Gdovinová Z, Uyttenboogaart M, Vroomen PC, Luijckx GJ. Intravenous alteplase for stroke: beyond the guidelines and in particular clinical situations. Stroke 2007; 38:2612-8. [PMID: 17656661 DOI: 10.1161/strokeaha.106.480566] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Because of the risk of hemorrhage, especially in the brain, thrombolytic therapy with intravenous alteplase is restricted by guidelines, and only a small number of selected patients are being treated. Findings from metaanalyses, post hoc analyses of the randomized trials, and postlicensing experience suggest that more subjects, who otherwise have a poor predicted outcome without treatment, might benefit from intravenous alteplase. Summary of Review- There is a strong indication that treatment may still be beneficial beyond 3 hours up until 4.5 hours. The risk of symptomatic intracerebral hemorrhage is not increased in patients aged 80 years or older. Excluding patients with severe stroke or with early ischemic changes in more than one third of the middle cerebral artery territory on baseline CT scan is probably not necessary when treatment is started <3 hours of symptom onset. Patients with minor or improving symptoms can also benefit. Intravenous thrombolysis appears appropriate as first line therapy for posterior circulation stroke. Alteplase can be given to patients with cervical artery dissection, seizure at onset and evidence of acute ischemia on brain imaging, and after carefully weighing risk and benefit in pregnancy and during menstruation. There are anecdotal reports on its use in children, patients with recent myocardial infarction, cardiac embolus, intracranial aneurysm or arteriovenous malformation, prior stroke and recent surgery. There appears to be a substantially increased risk of symptomatic cerebral hemorrhage in hyperglycemic stroke patients. The combined intravenous and intraarterial approach to recanalization appears safe and is currently under investigation in a randomized trial. CONCLUSIONS This document does not intend to change the guidelines but reviews the literature on the use of intravenous alteplase for stroke beyond guidelines and in particular conditions.
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Affiliation(s)
- Jacques De Keyser
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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