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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Obstetric and perinatal outcomes in women with cerebrovascular accident vs. transient ischemic attack: an evaluation of a population database. Arch Gynecol Obstet 2024:10.1007/s00404-024-07627-7. [PMID: 39009865 DOI: 10.1007/s00404-024-07627-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Abstract
PURPOSE Cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs) are uncommon neurologic events in women of childbearing age. We aimed to compare pregnancy, delivery, and neonatal outcomes between women who suffered from a CVA and those who experienced a TIA. METHODS A retrospective population-based cohort study was performed using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. Included were all pregnant women who delivered or had a maternal death in the US between 2004 and 2014. We compared women with an ICD-9 diagnosis of a CVA before or during pregnancy to those diagnosed with a TIA before, during the pregnancy, or during the delivery admission. Pregnancy and perinatal outcomes were compared between the two groups, using multivariate logistic regression to control for confounders. RESULTS Among 9,096,788 women in the database, 898 met the inclusion criteria. Of them, 706 women (7.7/100,000) had a CVA diagnosis, and 192 (2.1/100,000) had a TIA diagnosis. Women with a CVA, compared to those with a TIA, had a higher rate of pregnancy-induced hypertension (aOR 3.82,95%CI 2.14-6.81, p < 0.001); preeclampsia (aOR 2.6,95%CI 1.3-5.2, p = 0.007), eclampsia (aOR 13.78,95% CI 1.84-103.41, p < 0.001); postpartum hemorrhage (aOR 4.52,95%CI 1.31-15.56, p = 0.017), blood transfusion (aOR 5.57,95%CI 1.65-18.72, p = 0.006), and maternal death (54 vs. 0 cases, 7.6% vs. 0%), with comparable neonatal outcomes. CONCLUSION Women diagnosed with a CVA before or during pregnancy had a higher incidence of myriad maternal complications, including hypertensive disorders of pregnancy, postpartum hemorrhage, and death, compared to women with a TIA diagnosis, with comparable neonatal outcomes, stressing the different prognoses of these two conditions, and the importance of these patients' diligent follow-up and care.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada.
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada
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Inozemtsev K, Yeh E, Nasr NF. Neurologic disease in the obstetric patient. Curr Opin Anaesthesiol 2024:00001503-990000000-00217. [PMID: 39011740 DOI: 10.1097/aco.0000000000001405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW Neurologic disorders and complications during pregnancy are common, but guidelines and data are sparse. This review aims to give an overview of recent developments in neuroanesthesia and management of neuropathology during pregnancy, with the hope that these may fill the gaps in current guidelines and recommendations, as well as their implications for an anesthetic approach. RECENT FINDINGS Neuraxial and general anesthesia are safe in multiple sclerosis and myasthenia gravis, though neuromuscular blockade response is unpredictable and risk for exacerbation exists. Cerebral vascular pathology is common and carries a significant morbidity and mortality burden, but thrombolytic and endovascular therapies are often appropriate and safe. Instrumental vaginal delivery can minimize intracranial pressure shifts and is a viable option. Tumors and cerebral malformations require a complex multidisciplinary and anesthetic approach. SUMMARY While clinical trials remain sparse, larger population-based studies offer insight into the optimal approach to the parturient with neurologic disease.
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Affiliation(s)
- Konstantin Inozemtsev
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, Illinois, USA
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3
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Richardt A, Aarnio K, Korhonen A, Rantanen K, Verho L, Curtze S, Laivuori H, Gissler M, Tikkanen M, Ijäs P. Acute recanalization therapy for ischemic stroke during pregnancy and puerperium. J Neurol 2024; 271:4046-4056. [PMID: 38568226 PMCID: PMC11233356 DOI: 10.1007/s00415-024-12313-4] [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: 01/21/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND The safety and efficacy of intravenous thrombolysis (IVT) and endovascular thrombectomy for an ischemic stroke (IS) during pregnancy and puerperium are poorly studied. We evaluated the complications and outcome of recanalization therapy in maternal ISs. METHODS A nationwide cohort of maternal ISs in Finland during 1987-2016 was collected by linking national healthcare registers: Medical Birth Register, Hospital Discharge Register, and Cause-Of-Death Register. The diagnoses were verified retrospectively from patient records. IVT-treated patients were compared to controls, who were young females with non-pregnancy-related IS from the Helsinki Stroke Thrombolysis Registry. RESULTS Totally, 12 of 97 (12.4%) maternal ISs were treated with recanalization therapy. Compared to controls, IVT-treated maternal IS patients had more frequently early (age-adjusted odds ratio (aOR) = 7.63, 95% CI 1.49-39.04) and major (aOR = 8.59, 95% CI 2.09-35.31) neurological improvements, measured using the National Institute of Health Stroke Scale. Good functional outcomes (modified Rankin Scale 0-2) at three months were equally common in maternal ISs and controls. No other complications were observed in IVT-treated maternal ISs than 1 (9.1%) symptomatic nonfatal intracranial hemorrhage. Among maternal IS patients treated with recanalization or conventional therapy, good functional outcome at the end of the follow-up was less common in recanalization-treated patients (66.7% vs 89.4%, aOR = 0.22, 95% CI 0.052-0.90), but otherwise outcomes were similar. CONCLUSIONS In this small nationwide cohort of maternal ISs, the complications of recanalization therapy were rare, and the outcomes were similar in IVT-treated maternal IS patients and controls. Maternal ISs should not be excluded from recanalization therapy in otherwise eligible situations.
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Affiliation(s)
- Anna Richardt
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Karoliina Aarnio
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aino Korhonen
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Verho
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital, The Wellbeing Services County of Pirkanmaa, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Minna Tikkanen
- Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland
| | - Petra Ijäs
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Transient ischemic attack and pregnancy, delivery and neonatal outcomes-An evaluation of a population database. Int J Gynaecol Obstet 2024; 166:412-418. [PMID: 38311958 DOI: 10.1002/ijgo.15387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Transient ischemic attack (TIA) is rare in women of reproductive age. We aimed to compare perinatal outcomes between women who suffered from a TIA to those who did not. METHODS A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of a TIA to those without. RESULTS Overall, 9 096 788 women met the inclusion criteria. Of these, 203 women (2.2/100000) had a TIA (either before or during pregnancy). Women with TIA, compared to those without, were more likely to be older than 35 years of age, white, in the highest income quartile, be insured by private insurance and suffer from obesity and chronic hypertension. Patients in the TIA group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 2.5, 95% CI: 1.55-4.05, P < 0.001), pre-eclampsia (aOR 3.77, 95% CI: 2.15-6.62, P < 0.001), eclampsia (aOR 28.05, 95% CI: 6.91-113.95, P < 0.001), preterm delivery (aOR 1.78, 95% CI: 1.03-3.07, P = 0.039), and maternal complications such as deep vein thrombosis (aOR 33.3, 95% CI: 8.07-137.42, P < 0.001). Regarding neonatal outcomes, patients with a TIA, compared to those without, had a higher rate of congenital anomalies (aOR 7.04, 95% CI: 2.86-17.32, P < 0.001). CONCLUSION Women with a TIA diagnosis before or during pregnancy had a higher rate of maternal complications, including hypertensive disorders of pregnancy and venous thromboembolism, as well as an increased risk of congenital anomalies.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
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Ibeh C, Kulick ER, Boehme AK, Friedman AM, Miller EC, Bello NA. Incident stroke in individuals with peripartum cardiomyopathy. Am Heart J 2024; 275:138-140. [PMID: 38908422 DOI: 10.1016/j.ahj.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 06/15/2024] [Accepted: 06/18/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM), a form of heart failure with reduced ejection fraction (HFrEF) that occurs during the final month of pregnancy through the first 5 months postpartum, is associated with heightened risk for maternal morbidity and mortality. Stroke is a common complication of HFrEF but there is limited data on the incidence of stroke in PPCM. METHODS Using statewide, nonfederal administrative data from 2000 to 2015, we analyzed age-adjusted risk of stroke within 3 years after PPCM-associated pregnancies. RESULTS PPCM was associated with a greater than 4-fold increased risk of pregnancy-related stroke (aHR 4.7, 95% CI: 3.0-7.5). This risk was highest at the time of PPCM diagnosis but remained elevated in the first postpartum year. CONCLUSION Our findings confirm the strong association between PPCM and stroke, with risk that persists throughout and after the peripartum period.
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Affiliation(s)
- Chinwe Ibeh
- Division of Stroke, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Erin R Kulick
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, PA
| | - Amelia K Boehme
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Eliza C Miller
- Division of Stroke, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Natalie A Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
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Ali M, van Etten ES, Akoudad S, Schaafsma JD, Visser MC, Ali M, Cordonnier C, Sandset EC, Klijn CJM, Ruigrok YM, Wermer MJH. Haemorrhagic stroke and brain vascular malformations in women: risk factors and clinical features. Lancet Neurol 2024; 23:625-635. [PMID: 38760100 DOI: 10.1016/s1474-4422(24)00122-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/18/2024] [Accepted: 03/14/2024] [Indexed: 05/19/2024]
Abstract
Haemorrhagic stroke is a severe condition with poor prognosis. Biological sex influences the risk factors, presentations, treatment, and patient outcomes of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and vascular malformations. Women are usually older at onset of intracerebral haemorrhage compared with men but have an increased risk of aneurysmal subarachnoid haemorrhage as they age. Female-specific factors such as pregnancy, eclampsia or pre-eclampsia, postmenopausal status, and hormone therapy influence a woman's long-term risk of haemorrhagic stroke. The presence of intracranial aneurysms, arteriovenous malformations, or cavernous malformations poses unique clinical dilemmas during pregnancy and delivery. In the absence of evidence-based guidelines for managing the low yet uncertain risk of haemorrhagic stroke during pregnancy and delivery in women with vascular malformations, multidisciplinary teams should carefully assess the risks and benefits of delivery methods for these patients. Health-care providers should recognise and address the challenges that women might have to confront when recovering from haemorrhagic stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Saloua Akoudad
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Joanna D Schaafsma
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marieke C Visser
- Department of Neurology, Amsterdam University Medical Centre, Location AMC, Amsterdam, Netherlands
| | - Mahsoem Ali
- Department of Surgery, Amsterdam University Medical Centre, Location VUmc, Amsterdam, Netherlands
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, UMR-S1172, Lille Neuroscience and Cognition, Lille, France
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marieke J H Wermer
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
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Osteraas ND. Sex-based difference in selected stroke etiologies: cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, dissection, migraine, pregnancy/puerperium/OC use. J Stroke Cerebrovasc Dis 2024; 33:107753. [PMID: 38703878 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024] Open
Abstract
Females are at higher risk than males for a multitude of cerebrovascular conditions, both common and rare; partially resulting from a complex interplay between differing process involving genetics, hormonal influences, common cerebrovascular risk factors among others. Specific topics including cervical artery dissection, cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, migraine, along with these disorders in the setting of pregnancy, puerperium and oral contraceptive utilization. Epidemiology, pathophysiology, presentation, basics of management and outcomes are presented, with sex differences throughout.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neuroscience at Saint Lukes Hospital, Advocate Aurora Health. 2900 W Oklahoma Ave, Milwaukee, WI 53215, United States.
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8
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Dawood MH, Mahmood K, Roshan M, Sherani LR, Perveen H. Evaluation of stroke in pregnant and non-pregnant women of reproductive years: A multicenter ambispective cohort study in a low- to middle-income country. SAGE Open Med 2024; 12:20503121241242610. [PMID: 38601136 PMCID: PMC11005509 DOI: 10.1177/20503121241242610] [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: 08/03/2023] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Objective Early recognition of stroke symptoms and risk factors is important for timely intervention to improve outcomes. This study aimed to investigate differences in stroke frequency, risk factors, and presentation in pregnant and non-pregnant women of reproductive years. Methods This multicenter ambispective cohort study, conducted from 4th August 2021 to 4th March 2023, examined strokes in women of reproductive years at the neurology outpatient/emergency department of five busiest/referred neuro-medical facilities in Karachi, Pakistan, where patients from across the nation are assessed. In all, 1210 patients were enrolled via consecutive or convenient sampling retrospectively from January 2017 to August 2021 and prospectively from August 2021 to March 2023. Pregnancy-related and non-pregnancy-related stroke occurrence and characteristics were compared using the chi-square/Fischer's exact test. Results 56% were non-pregnancy-related strokes and 44% were pregnancy-related strokes with non-pregnancy-related strokes approximately equal throughout the reproductive years (15-24 years = 34%, 25-34 years = 25%, 35-45 years = 41%) and pregnancy-related stroke between 15 and 35 years (82%). In the non-pregnancy-related stroke, arterial stroke dominated (96.4%); while in pregnancy-related stroke, arterial stroke accounted for 61.4% and venous stroke for 38.6% of cases. Middle cerebral artery was a typical stroke site (66%). Infarction was the most significant CT/MRI finding (PRS = 89%, NPRS = 66%), with pregnancy-related stroke hemorrhagic stroke occurring in only 11% of cases and non-pregnancy-related stroke comprising one-third (34%). The most prevalent etiologies were eclampsia in pregnancy-related stroke (32%), hypertension in non-pregnancy-related stroke (40%), and cardiac problems among both groups (25%:33%). Weakness and headache were the common clinical manifestations among both groups. In the pregnancy-related and non-pregnancy-related stroke groups, the initial presentation of stroke resulted in severe disability for 91% and 75%, respectively. With timely treatment, the outcome improved significantly. The mortality rate was 7% for the pregnancy-related stroke group and 4% for the non-pregnancy-related stroke group. Conclusions Our findings show that stroke is prevalent among reproductive-year women, posing a significant mortality risk if not adequately recognized and treated. Awareness, research, and screening of stroke risk factors and their often-overlooked early presentation (i.e., headache and weakness) in reproductive years are essential to reducing stroke occurrence among reproductive-year women.
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Affiliation(s)
- Muhammad Hamza Dawood
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Kauser Mahmood
- Department of Neurology, Fazaia Ruth Fau Medical College PAF base Faisal (Air University, Islamabad), Karachi, Pakistan
| | - Mavra Roshan
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Lailamah Rehman Sherani
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Haseefa Perveen
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
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Sariyeva M, Haghighi N, Mitchell A, Booker WA, Petersen NH, Shields AD, Ghoshal S, Agarwal S, Park S, Claassen J, Connolly ES, Roh DJ, Miller EC. Primary and Secondary Intracerebral Hemorrhage in Pregnant and Nonpregnant Young Adults by SMASH-UP Criteria. J Am Heart Assoc 2024; 13:e034032. [PMID: 38533990 PMCID: PMC11179753 DOI: 10.1161/jaha.123.034032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity, but its pathophysiology is poorly characterized. We investigated characteristics of pregnancy-associated ICH (P-ICH), compared with ICH in similar aged nonpregnant adults of both sexes. METHODS AND RESULTS We performed a retrospective analysis of 134 adults aged 18 to 44 years admitted to our center with nontraumatic ICH from January 1, 2012, to December 31, 2021. We compared ICH characteristics among 3 groups: those with P-ICH (pregnant or within 12 months of end of pregnancy); nonpregnant women; and men. We categorized ICH pathogenesis according to a modified scheme, SMASH-UP (structural, medications, amyloid angiopathy, systemic, hypertension, undetermined, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome), and calculated odds ratios and 95% CIs for primary (spontaneous small-vessel) ICH versus secondary ICH (structural lesions or coagulopathy related), using nonpregnant women as the reference. We also compared specific ICH pathogenesis by SMASH-UP criteria and functional outcomes between groups. Of 134 young adults with nontraumatic ICH, 25 (19%) had P-ICH, of which 60% occurred postpartum. Those with P-ICH had higher odds of primary ICH compared with nonpregnant women (adjusted odds ratio, 4.5 [95% CI, 1.4-14.7]). The odds of primary ICH did not differ between men and nonpregnant women. SMASH-UP pathogenesis for ICH differed significantly between groups (P<0.001). While the in-hospital mortality rate was lowest in the P-ICH group (4%) compared with nonpregnant women (13%) and men (24%), 1 in 4 patients with P-ICH were bedbound and dependent at the time of discharge. CONCLUSIONS In our cohort of young adults with ICH, 1 in 5 was pregnancy related. P-ICH differed in pathogenesis compared with non-pregnancy-related ICH in young adults, suggesting unique pathophysiology.
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Affiliation(s)
- Mehriban Sariyeva
- Department of Neurology, Stroke DivisionColumbia UniversityNew YorkNY
| | - Noora Haghighi
- Department of Neurology, Stroke DivisionColumbia UniversityNew YorkNY
| | - Amanda Mitchell
- Department of Neurology, Neurocritical Care DivisionColumbia UniversityNew YorkNY
| | - Whitney A. Booker
- Department of Obstetrics and Gynecology, Maternal‐Fetal Medicine DivisionColumbia UniversityNew YorkNY
| | - Nils H. Petersen
- Department of Neurology, Neurocritical Care DivisionYale UniversityNew HavenCT
| | - Andrea D. Shields
- Department of Obstetrics and Gynecology, Maternal‐Fetal Medicine DivisionUniversity of Connecticut HealthHartfordCT
| | - Shivani Ghoshal
- Department of Neurology, Neurocritical Care DivisionColumbia UniversityNew YorkNY
| | - Sachin Agarwal
- Department of Neurology, Neurocritical Care DivisionColumbia UniversityNew YorkNY
| | - Soojin Park
- Department of Neurology, Neurocritical Care DivisionColumbia UniversityNew YorkNY
- Department of Biomedical InformaticsColumbia UniversityNew YorkNY
| | - Jan Claassen
- Department of Neurology, Neurocritical Care DivisionColumbia UniversityNew YorkNY
| | | | - David J. Roh
- Department of Neurology, Neurocritical Care DivisionColumbia UniversityNew YorkNY
| | - Eliza C. Miller
- Department of Neurology, Stroke DivisionColumbia UniversityNew YorkNY
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Poggetti F, Schwarz G, Piano M, Gatti A, Aquilano MC, Di Como M, Protti A, Bonoldi E, Agostoni EC, Cascio Rizzo A. Intraluminal carotid thrombus leading to postpartum stroke: a case study. Neurol Sci 2024; 45:1735-1739. [PMID: 38244118 DOI: 10.1007/s10072-024-07335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Intraluminal non-occlusive thrombus (ILT) is a rare cause of ischemic stroke. Although in most cases ILT is associated with arterial wall disorders, it has also been documented in patients with thrombophilic conditions. CASE REPORT We present a case of carotid ILT in a 38-year-old puerperal woman with pregnancy-induced hypercoagulability. Following in vitro fertilization pregnancy, she experienced acute left-sided weakness 9 days after delivery. CT angiography revealed an intraluminal filling defect in the right carotid bulb, suggestive of a thrombus, along with ipsilateral MCA sub-occlusion. Mechanical thrombectomy was performed, achieving complete vessel recanalization without any endovascular intervention on the carotid ILT. Comprehensive evaluation excluded any underlying carotid vessel wall disease (such as atherosclerosis, inflammatory diseases, arterial dissection, focal dysplasia), inherited or acquired thrombophilia, and the sole prothrombotic risk factor identified was the puerperium. Histological thrombus analysis showed fibrin/platelet-rich material with significant macrophage infiltration (consistent with an intermediate/organized thrombus, suggesting potential embolization from a pre-existing carotid ILT). Anti-thrombotic treatment (acetylsalicylic acid 100 mg and enoxaparin 6000 UI) resulted in complete thrombus resolution at follow-up. CONCLUSION ILT should be considered a potential case of embolic stroke in pregnancy or puerperium. Vessel imaging is essential for diagnosis. Histological thrombus analysis can provide insights into the pathophysiological mechanisms of stroke.
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Affiliation(s)
- Francesca Poggetti
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ghil Schwarz
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mariangela Piano
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonella Gatti
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Costanza Aquilano
- Department of Hematology, Oncology and Molecular Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Di Como
- Department of Hematology, Oncology and Molecular Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandra Protti
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuela Bonoldi
- Department of Hematology, Oncology and Molecular Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elio Clemente Agostoni
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Cascio Rizzo
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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Hanna M, Wabnitz A, Grewal P. Sex and stroke risk factors: A review of differences and impact. J Stroke Cerebrovasc Dis 2024; 33:107624. [PMID: 38316283 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors. METHODS We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review. RESULTS Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels. CONCLUSIONS By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.
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Affiliation(s)
- Mckay Hanna
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ashley Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Parneet Grewal
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States.
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12
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Lepercq J, Rossignol M, Jonard M. [Maternal mortality by stroke in France 2016-2018]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:259-262. [PMID: 38373489 DOI: 10.1016/j.gofs.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.
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Affiliation(s)
- Jacques Lepercq
- Maternité Port-Royal, hôpital Cochin, GHU Paris centre, AP-HP, 75014 Paris, France; Université de Paris Cité, 75006 Paris, France.
| | - Mathias Rossignol
- Département d'anesthésie-réanimation et SMUR, hôpital Lariboisière, AP-HP, 75465 Paris, France
| | - Marie Jonard
- Service de réanimation polyvalente, pôle de soins critiques, hôpital de Lens, 62307 Lens, France
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13
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Vest T, Rantanen K, Verho L, Aarnio K, Korhonen A, Richardt A, Strbian D, Gissler M, Laivuori H, Tikkanen M, Ijäs P. Etiology of intracerebral hemorrhage during pregnancy or puerperium: A nationwide study. Eur J Neurol 2024; 31:e16012. [PMID: 37532682 DOI: 10.1111/ene.16012] [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: 05/22/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage during pregnancy or puerperium (pICH) is one of the leading causes of maternal death worldwide. However, limited epidemiological data exist on the etiology and outcomes of pICH, which is required to guide prevention and treatment. METHODS A retrospective nationwide cohort study and a nested case-control study was performed in Finland 1987-2016. We identified women with incident pICH by linking the Medical Birth Register (MBR) and the Hospital Discharge Register (HDR). The clinical details were collected from patient records. Three matched controls with a pregnancy without ICH were selected for each case from the MBR. RESULTS In total, 49 pICH cases were identified. Half of these cases occurred during pregnancy, and the other half during peripartum and puerperium. Based on the SMASH-U (structural vascular lesion, medication, amyloid angiopathy, systemic disease, hypertension, undetermined) classification, 35.4% of the patients had a systemic disease, most commonly preeclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome; 31.3% had a structural vascular lesion; 31.3% had an undetermined etiology; and one patient (2.1%) had hypertension. The most important risk factor was hypertensive disorders of pregnancy (HDP; odds ratio = 3.83, 95% confidence interval = 1.60-9.15), occurring in 31% of the cases. Maternal mortality was 12.5%, and 20.9% of the surviving women had significant disability (modified Rankin Scale = 3-5) 3 months after the pICH. Women with systemic disease had the worst outcomes. CONCLUSIONS Even in a country with a comprehensive pregnancy surveillance system, the maternal mortality rate for pICH is high, and the sequelae are severe. Early recognition and treatment of the key risk factor, HDP, is crucial to help prevent this serious pregnancy complication.
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Affiliation(s)
- Teresa Vest
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Verho
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aino Korhonen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anna Richardt
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere, Tampere, Finland
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Thomas EH, Woodward S, Ahmad S. Managing pregnancy-related stroke risk with known bilateral internal carotid artery webs. Obstet Med 2024; 17:63-65. [PMID: 38660326 PMCID: PMC11037199 DOI: 10.1177/1753495x211037910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/20/2021] [Indexed: 04/26/2024] Open
Abstract
Carotid webs are intraluminal shelf-like projections caused by thickening of the arterial tunica intima. Due to their projections forming a nidus for thrombus formation and subsequent embolus, they are considered to be a rare cause of ischaemic strokes. We report a case of a woman with a background of recurrent ischaemic strokes due to bilateral carotid webs who presented with a twin pregnancy. We use this case to discuss how her pregnancy-related stroke risk was subsequently medically managed.
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Affiliation(s)
- Elin H Thomas
- Department of Stroke Medicine, University Hospital of Wales, UK
| | | | - Shakeel Ahmad
- Department of Stroke Medicine, University Hospital of Wales, UK
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15
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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Pregnancy, delivery and neonatal outcomes in women with a cerebrovascular-accident history prior to delivery - Evaluation of a population database. Heliyon 2024; 10:e25631. [PMID: 38375247 PMCID: PMC10875378 DOI: 10.1016/j.heliyon.2024.e25631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Objective Cerebrovascular accidents (CVA) in childbearing-age women are rare. We aimed to evaluate the association between CVA events prior to delivery and obstetrical and neonatal outcomes. Methods A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) database. All pregnant women who delivered or had a maternal death in the US from 2004 to 2014 were included in the study. We performed a comparison between women with an ICD-9 diagnosis of CVA before the delivery admission and those without. Obstetrical and neonatal outcomes were compared between the two groups. Results In total, 9,096,788 women fulfilled the inclusion criteria. Among them, 695 women (7.6 per 100,000) were diagnosed with a CVA before delivery. Women with a history of CVA, compared to those without, were more likely to be Black, older than 35 years of age, and suffer from obesity, chronic hypertension, pregestational diabetes, and thyroid disease. Patients with a prior CVA, compared to those without, had higher rates of pregnancy-induced hypertension (aOR 6.41, 95% CI 5.03-8.39, p < 0.001), preeclampsia (aOR 7.65, 95% CI 6.03-9.71, p < 0.001), and eclampsia (aOR 171.56, 95% CI 124.63-236.15, p < 0.001). Additionally, they had higher rates of preterm delivery (aOR 1.72, 95% CI 1.33-2.22,p = 0.003), cesarean section (aOR 2.69, 95% CI 2.15-3.37, p < 0.001), and maternal complications such as a peripartum hysterectomy (aOR 11.62, 95% CI 5.77-23.41, p < 0.001), postpartum hemorrhage (aOR 3.39, 95 % CI 2.52-4.54, p < 0.001), disseminated intravascular coagulation (aOR 16.32, 95% CI 11.33-23.52, p < 0.001), venous thromboembolism (aOR 45.08, 95% CI 27.17-74.8, p < 0.001), and maternal death (aOR 486.11, 95% CI 307.26-769.07, p < 0.001). Regarding neonatal outcomes, patients with a prior CVA, compared to those without, had a higher rate of intrauterine fetal demise and congenital anomalies. Conclusion Women with a CVA event before delivery have a significantly higher incidence of maternal complications, including hypertensive disorders of pregnancy, and neonatal complications, such as intrauterine fetal demise and congenital anomalies. Rates of maternal death were dramatically increased, and this association requires further evaluation.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Michael H. Dahan
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
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16
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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17
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Sur NB, Kozberg M, Desvigne-Nickens P, Silversides C, Bushnell C. Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps. Stroke 2024; 55:248-258. [PMID: 38134258 DOI: 10.1161/strokeaha.122.040449] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Stroke is a leading cause of death and disability in the United States and worldwide, necessitating comprehensive efforts to optimize stroke risk factor management. Health disparities in stroke incidence, prevalence, and risk factor management persist among various race/ethnic, geographic, and socioeconomic populations and negatively impact stroke outcomes. This review highlights existing literature and guidelines for stroke risk factor management, emphasizing health disparities among certain populations. Moreover, stroke risk factors for special groups, including the young, the very elderly, and pregnant/peripartum women are outlined. Strategies for stroke risk factor improvement at every level of the health care system are discussed, from the individual patient to providers, health care systems, and policymakers. Improving stroke risk factor management in the context of the social determinants of health, and with the goal of eliminating inequities and disparities in stroke prevention strategies, are critical steps to reducing the burden of stroke and equitably improving public health.
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Affiliation(s)
- Nicole B Sur
- Department of Neurology, University of Miami Miller School of Medicine, FL (N.B.S.)
| | - Mariel Kozberg
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (M.K.)
| | | | | | - Cheryl Bushnell
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC (C.B.)
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18
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Field TS, Dizonno V, Almekhlafi MA, Bala F, Alhabli I, Wong H, Norena M, Villaluna MK, King-Azote P, Ratnaweera N, Mancini S, Van Gaal SC, Wilson LK, Graham BR, Sposato LA, Blacquiere D, Dewar BM, Boulos MI, Buck BH, Odier C, Perera KS, Pikula A, Tkach A, Medvedev G, Canfield C, Mortenson WB, Nadeau JO, Alshimemeri S, Benavente OR, Demchuk AM, Dowlatshahi D, Lanthier S, Lee AYY, Mandzia J, Suryanarayan D, Weitz JI, Hill MD. Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis. Stroke 2023; 54:2724-2736. [PMID: 37675613 PMCID: PMC10615774 DOI: 10.1161/strokeaha.123.044113] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Emerging data suggest that direct oral anticoagulants may be a suitable choice for anticoagulation for cerebral venous thrombosis (CVT). However, conducting high-quality trials in CVT is challenging as it is a rare disease with low rates of adverse outcomes such as major bleeding and functional dependence. To facilitate the design of future CVT trials, SECRET (Study of Rivaroxaban for Cerebral Venous Thrombosis) assessed (1) the feasibility of recruitment, (2) the safety of rivaroxaban compared with standard-of-care anticoagulation, and (3) patient-centered functional outcomes. METHODS This was a phase II, prospective, open-label blinded-end point 1:1 randomized trial conducted at 12 Canadian centers. Participants were aged ≥18 years, within 14 days of a new diagnosis of symptomatic CVT, and suitable for oral anticoagulation; they were randomized to receive rivaroxaban 20 mg daily, or standard-of-care anticoagulation (warfarin, target international normalized ratio, 2.0-3.0, or low-molecular-weight heparin) for 180 days, with optional extension up to 365 days. Primary outcomes were annual rate of recruitment (feasibility); and a composite of symptomatic intracranial hemorrhage, major extracranial hemorrhage, or mortality at 180 days (safety). Secondary outcomes included recurrent venous thromboembolism, recanalization, clinically relevant nonmajor bleeding, and functional and patient-reported outcomes (modified Rankin Scale, quality of life, headache, mood, fatigue, and cognition) at days 180 and 365. RESULTS Fifty-five participants were randomized. The rate of recruitment was 21.3 participants/year; 57% of eligible candidates consented. Median age was 48.0 years (interquartile range, 38.5-73.2); 66% were female. There was 1 primary event (symptomatic intracranial hemorrhage), 2 clinically relevant nonmajor bleeding events, and 1 recurrent CVT by day 180, all in the rivaroxaban group. All participants in both arms had at least partial recanalization by day 180. At enrollment, both groups on average reported reduced quality of life, low mood, fatigue, and headache with impaired cognitive performance. All metrics improved markedly by day 180. CONCLUSIONS Recruitment targets were reached, but many eligible participants declined randomization. There were numerically more bleeding events in patients taking rivaroxaban compared with control, but rates of bleeding and recurrent venous thromboembolism were low overall and in keeping with previous studies. Participants had symptoms affecting their well-being at enrollment but improved over time. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03178864.
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Affiliation(s)
- Thalia S Field
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Fouzi Bala
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
- Department of Radiology, Tours University Hospital, France (F.B.)
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Hubert Wong
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Monica Norena
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Maria Karina Villaluna
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Princess King-Azote
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Namali Ratnaweera
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Steven Mancini
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Stephen C Van Gaal
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Laura K Wilson
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, Canada (B.R.G.)
| | - Luciano A Sposato
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Dylan Blacquiere
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Brian M Dewar
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Mark I Boulos
- Sunnybrook Research Institute, Division of Neurology (M.I.B.), University Health Network, University of Toronto, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Canada (B.H.B.)
| | - Celine Odier
- Département de Neurosciences, Centre Hospitalier d'Université de Montréal, Université de Montréal, Canada (C.O.)
| | - Kanjana S Perera
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Canada (K.S.P.)
| | - Aleksandra Pikula
- Krembil Brain Institute (A.P.), University Health Network, University of Toronto, Canada
| | - Aleksander Tkach
- Kelowna General Hospital, Interior Health Authority, Canada (A.T.)
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health Authority, New Westminster, Canada (G.M.)
| | - Carolyn Canfield
- Department of Family Practice, Innovation Support Unit (C.C.), University of British Columbia, Vancouver, Canada
| | - W Ben Mortenson
- Department of Occupational Science and Occupational Therapy (W.B.M.), University of British Columbia, Vancouver, Canada
| | | | | | - Oscar R Benavente
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Dar Dowlatshahi
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Sylvain Lanthier
- Hôpital de Sacre-Coeur de Montréal, Département de Neurosciences, Université de Montréal, Canada (S.L.)
| | - Agnes Y Y Lee
- Division of Hematology (A.Y.Y.L.), University of British Columbia, Vancouver, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Deepa Suryanarayan
- Division of Hematology, Cumming School of Medicine (D.S.), University of British Columbia, Vancouver, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada (J.I.W.)
| | - Michael D Hill
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
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19
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Verho L, Tikkanen M, Äyräs O, Aarnio K, Rantanen K, Korhonen A, Richardt A, Laivuori H, Gissler M, Ijäs P. Pregnancy-associated stroke and the recurrence of stroke and other complications in subsequent pregnancies: Population-based retrospective cohort study. BJOG 2023; 130:1421-1429. [PMID: 37088716 DOI: 10.1111/1471-0528.17503] [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: 09/22/2022] [Revised: 03/05/2023] [Accepted: 03/08/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To examine the outcomes of the subsequent pregnancies from women with a previous pregnancy-associated stroke (PAS) in comparison to matched controls. DESIGN Population-based retrospective cohort study. SETTING AND POPULATION All women with a PAS in Finland 1987-2016 (n = 235) and controls (n = 694). METHODS We identified all subsequent deliveries and induced and spontaneous abortions for women with a previous PAS and their matched controls from the Medical Birth Register and the Hospital Discharge Register until 2016. The number, course and outcomes of the subsequent pregnancies were compared. Patient records were studied for PAS recurrence. MAIN OUTCOME MEASURES PAS recurrence and pregnancy complications. RESULTS Women with a previous PAS had fewer subsequent deliveries: 73 (31.1%) women had 122 deliveries in all, whereas 303 (47.3%) of the controls had 442 deliveries (age-adjusted odds ratio [OR] 0.54, 95% CI 0.38-0.76). Hypertensive disorders of pregnancy (HDP) (17.2% versus 5.7%, age-adjusted OR 4.0, 95% CI 1.7-9.3), especially chronic hypertension (age-adjusted OR 5.9, 95% CI 1.5-24.7), and any diabetes during pregnancy (24.6% versus 14.5%, age-adjusted OR 2.0, 95% CI 1.1-3.8) were more common in cases. Regarding HDP, the difference between groups was explained by underlying factors such as index pregnancy HDP (multivariable OR 2.4, 95% CI 0.8-6.7). PAS recurred in four cases (5.5%). CONCLUSIONS Subsequent pregnancies of women with a history of PAS are more often complicated with hypertensive disorders of pregnancy and any diabetes during pregnancy. PAS recurrence risk is considerable.
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Affiliation(s)
- Liisa Verho
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Obstetrics and Gynaecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Minna Tikkanen
- Obstetrics and Gynaecology, University of Helsinki, Helsinki, Finland
| | - Outi Äyräs
- Obstetrics and Gynaecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aino Korhonen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anna Richardt
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynaecology, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Centre for Child, Adolescent, and Maternal Health Research, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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20
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Greige T, Bilello LA, Singleton JM, Edlow JA. Acute headache in pregnant and post-partum patients: A clinical review. Am J Emerg Med 2023; 72:16-19. [PMID: 37451065 DOI: 10.1016/j.ajem.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Headaches during pregnancy and the post-partum period may be due to either an exacerbation of a pre-existing neurological presentation, a new pregnancy-related process, or a non-pregnancy related condition. Key physiologic changes during pregnancy and the post-partum period contribute to the vulnerability of this patient population and the increased risk of complications. OBJECTIVE OF THE REVIEW Review causes of headaches in pregnant and post-partum patients as well as neuroimaging techniques performed. DISCUSSION Headaches are a common complaint for pregnant and post-partum patients. For pregnant patients, a range of serious causes must be considered including cerebral venous thrombosis, posterior reversible encephalopathy syndrome and stroke. Primary headaches are responsible for most post-partum headaches, however other causes also include pre-clampsia, cerebral venous thrombosis and post-dural headache. Determining the optimal imaging technique in this vulnerable population remains a challenge given the scarce guidelines. CONCLUSION The greatest difficulty while evaluating pregnant and post-partum patients presenting with an acute headache in an emergency setting is to determine whether the headache is due to a primary disorder such as migraines or is secondary to an underlying, sometimes serious pathology. The following review explores evidenced-based diagnosis of headache in this particular setting.
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Affiliation(s)
- Tatiana Greige
- Boston Medical Center, Department of Neurology, One Boston Medical Center Pl, Boston, MA 02118, United States of America.
| | - Leslie A Bilello
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2(nd) Floor, Boston, MA 02115, United States of America.
| | - Jennifer M Singleton
- University of Colorado Health Highlands Ranch Hospital, Department of Emergency Medicine, 1500 Park Central Drive, Highlands Ranch, CO 80129, United States of America.
| | - Jonathan A Edlow
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2(nd) Floor, Boston, MA 02115, United States of America.
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21
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Lackovic M, Nikolic D, Jankovic M, Rovcanin M, Mihajlovic S. Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1707. [PMID: 37893425 PMCID: PMC10608338 DOI: 10.3390/medicina59101707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.
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Affiliation(s)
- Milan Lackovic
- University Hospital “Dragisa Misovic”, Heroja Milana Tepica 1, 11000 Belgrade, Serbia; (M.L.); (S.M.)
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Milena Jankovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Rovcanin
- Clinic for Gynecology and Obstetrics “Narodni Front”, 11000 Belgrade, Serbia;
| | - Sladjana Mihajlovic
- University Hospital “Dragisa Misovic”, Heroja Milana Tepica 1, 11000 Belgrade, Serbia; (M.L.); (S.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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22
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Mahendram S, Eichenbaum K. Acute Stroke at Term Pregnancy: What Should Happen Before the Epidural? Cureus 2023; 15:e45613. [PMID: 37868405 PMCID: PMC10588729 DOI: 10.7759/cureus.45613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Acute stroke is a time-sensitive medical diagnosis, and current standardized management algorithms do not specifically streamline care for pregnant patients with these symptoms. Here, we discuss the management of a 29-year-old parturient with a history of systemic lupus erythematosus (SLE) who presented with stroke-like symptoms. We discuss strategies to improve care by incorporating formal neurological and ophthalmologic evaluations prior to referral for neuraxial intervention, particularly in light of the developing concerns among ophthalmologists that retinal transient ischemic attacks (TIAs) and visual symptoms should be treated with the same acuity as cerebral TIAs and strokes. We propose an integrated stroke algorithm in the pregnant population with consideration for specific ophthalmologic evaluation. In the present case, labor induction and epidural placement were successfully performed once a more optimized workup was completed.
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Affiliation(s)
| | - Kenneth Eichenbaum
- Anesthesiology, Oakland University William Beaumont School of Medicine, Rochester, USA
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23
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Miller EC, Katsidoniotaki MI, Haghighi N, Dos Santos KRM, Booker WA, Petersen N, Wapner R, Bello NA, Kougioumtzoglou IA, Marshall RS. Dynamic cerebral autoregulation in postpartum individuals with and without preeclampsia. Pregnancy Hypertens 2023; 33:39-45. [PMID: 37524001 PMCID: PMC10528950 DOI: 10.1016/j.preghy.2023.07.176] [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: 01/31/2023] [Revised: 06/30/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Changes in dynamic cerebral autoregulation (DCA) may contribute to postpartum maternal cerebrovascular complications after preeclampsia. We hypothesized that DCA is impaired in the first week postpartum after diagnosis of preeclampsia with severe features (PSF), compared with normotensive postpartum individuals and healthy non-pregnant female volunteers. METHODS We measured DCA within seven days after delivery in individuals with and without PSF, using transcranial Doppler and continuous arterial blood pressure monitoring with finger plethysmography. Historical data from 28 healthy female non-pregnant volunteers, collected using the same methods, were used for comparison. We used generalized harmonic wavelets to estimate autoregulation parameters (phase shift and gain) in very low frequency and low frequency bands, with lower phase shift and higher gain indicating impaired DCA function. We compared DCA parameters between the three groups using the Kruskal Wallis test. RESULTS A total of 69 postpartum participants contributed data, of whom 49 had preeclampsia with severe features. Median phase shifts in both postpartum groups were higher compared with historical controls across all frequency ranges (p = 0.001), indicating faster autoregulatory response. Gain was higher in both postpartum groups than in historical controls across all frequency ranges (p = 0.04), indicating impaired dampening effect. CONCLUSION We found that postpartum individuals, regardless of preeclampsia diagnosis, had higher phase shifts and higher gain than healthy non-pregnant/postpartum female volunteers. Our results suggest hyperdynamic DCA with impaired dampening effect in the first week postpartum, regardless of preeclampsia diagnosis.
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Affiliation(s)
- Eliza C Miller
- Department of Neurology, Columbia University, New York, NY, United States.
| | - Maria I Katsidoniotaki
- Department of Civil Engineering and Engineering Mechanics, Columbia University, New York, NY, United States
| | - Noora Haghighi
- Department of Neurology, Columbia University, New York, NY, United States
| | - Ketson R M Dos Santos
- Earthquake Engineering and Structural Dynamics Laboratory, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, United States
| | - Nils Petersen
- Department of Neurology, Division of Stroke and Neurocritical Care, Yale University School of Medicine, New Haven, CT, United States
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, United States
| | - Natalie A Bello
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Ioannis A Kougioumtzoglou
- Department of Civil Engineering and Engineering Mechanics, Columbia University, New York, NY, United States
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24
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Wawak M, Tekieli Ł, Badacz R, Pieniążek P, Maciejewski D, Trystuła M, Przewłocki T, Kabłak-Ziembicka A. Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature. Biomedicines 2023; 11:2207. [PMID: 37626704 PMCID: PMC10452526 DOI: 10.3390/biomedicines11082207] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders. METHODS In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. RESULTS The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. CONCLUSIONS This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.
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Affiliation(s)
- Magdalena Wawak
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Łukasz Tekieli
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Rafał Badacz
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Piotr Pieniążek
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Damian Maciejewski
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Mariusz Trystuła
- Department of Vascular and Endovascular Surgery, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland;
| | - Tadeusz Przewłocki
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
- Noninvasive Cardiovascular Laboratory, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
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25
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Bukhari S, Yaghi S, Bashir Z. Stroke in Young Adults. J Clin Med 2023; 12:4999. [PMID: 37568401 PMCID: PMC10420127 DOI: 10.3390/jcm12154999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Stroke in young adults is associated with significant morbidity, and its prevalence is rising in the United States. This is partly attributed to a rise in the prevalence of traditional risk factors including hypertension, hypercholesterolemia, obesity, diabetes mellitus, smoking and heart disease. In addition, there are non-modifiable risk factors comprising migraine, pregnancy and postpartum state, illicit drug use, oral contraceptives and hypercoagulable state. The mechanisms causing stroke in young adults are unique and include cervical dissection, cardioembolic phenomenon, vasculitis and vasculopathy, connective tissue disease, patent foramen ovale and cerebral venous thrombosis. The diagnosis of stroke in the young population can be challenging given its myriad clinical presentations. In this document, we provide an overview of the epidemiology of stroke in young adults, explore mechanisms that may explain increasing rates of stroke in this population, and provide a critical updated overview of the existing literature on the management and prevention of stroke in young adults.
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Affiliation(s)
- Syed Bukhari
- Temple University Hospital, Philadelphia, PA 19140, USA
| | - Shadi Yaghi
- Department of Medicine, Brown University, Providence, RI 02912, USA; (S.Y.); (Z.B.)
| | - Zubair Bashir
- Department of Medicine, Brown University, Providence, RI 02912, USA; (S.Y.); (Z.B.)
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26
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Bitar G, Sibai BM, Chen HY, Neff N, Blackwell S, Chauhan SP, Bartal MF. Pregnancy-Associated Stroke and Outcomes Related to Timing and Hypertensive Disorders. Obstet Gynecol 2023:00006250-990000000-00811. [PMID: 37411017 DOI: 10.1097/aog.0000000000005249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To estimate temporal trends of stroke in the peripartum period and to assess the relationship between stroke and maternal adverse outcomes vis-à-vis timing and hypertension. METHODS We conducted a retrospective, cross-sectional study using the National Inpatient Sample to identify hospitalizations with pregnancy-associated stroke in the United States (2016-2019). Temporal trends in pregnancy-associated stroke were examined according to timing of stroke (antepartum vs postpartum) and both prepregnancy and pregnancy hypertensive disorders (yes vs no). Multivariable Poisson regression models with robust error variance were used to examine the association among maternal adverse outcomes, timing of stroke, and hypertensive disorders. RESULTS Among 15,977,644 pregnancy hospitalizations, 6,100 hospitalizations (38.2/100,000 hospitalizations) were with pregnancy-associated stroke. Of these, 3,635 (59.6%) had antepartum pregnancy-associated stroke and 2,465 (40.4%) had postpartum pregnancy-associated stroke; alternatively, 2,640 (43.3%) had hypertensive disorders, and 3,460 (56.7%) were without hypertensive disorders. From 2016 to 2019, the overall rate of pregnancy-associated stroke (37.5 to 40.8/100,000 pregnancy hospitalizations, P=.028), rate of postpartum pregnancy-associated stroke (14.6 to 17.6/100,000 pregnancy hospitalizations, P=.005), and rate of pregnancy-associated stroke with hypertensive disorders (14.9 to 17.2/100,000 pregnancy hospitalizations, P=.013) increased. Antepartum pregnancy-associated stroke and pregnancy-associated stroke without hypertensive disorders, however, remained stable. Despite higher risk of maternal morbidity in postpartum stroke hospitalizations, including mechanical ventilation and pneumonia, there was no significant difference in in-hospital mortality between antepartum and postpartum stroke. Similarly, between pregnancy-associated stroke with hypertensive disorders and stroke without hypertensive disorders, an increased risk of mechanical ventilation, seizure, and prolonged hospital stay was seen for stroke with hypertensive disorders without an increase in mortality. CONCLUSION A nationally representative sample of hospitalizations in the United States indicates an increasing trend in the rate of postpartum stroke. Almost half of hospitalizations with pregnancy-associated stroke have concomitant hypertensive disorders. Risk of adverse outcomes, but not mortality, is elevated in patients with stroke occurring in the postpartum period and stroke associated with hypertensive disorders.
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Affiliation(s)
- Ghamar Bitar
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; and the Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
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27
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Renedo D, Acosta JN, Koo AB, Rivier C, Sujijantarat N, de Havenon A, Sharma R, Gill TM, Sheth KN, Falcone GJ, Matouk CC. Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses. Stroke 2023; 54:1538-1547. [PMID: 37216451 PMCID: PMC10212531 DOI: 10.1161/strokeaha.122.041891] [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: 11/07/2022] [Accepted: 04/14/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists. DESIGN Observational study using data from All of Us research program and Mendelian Randomization analyses. METHODS Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk. RESULTS Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5-6.8]; P<0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3-15.7]; P<0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2-58.6]; P<0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately (P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15-1.84]; P=0.002). CONCLUSIONS Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.
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Affiliation(s)
- Daniela Renedo
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Julián N. Acosta
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Andrew B. Koo
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Cyprien Rivier
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Thomas M. Gill
- Department of Internal Medicine, Division of Geriatric Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Guido J. Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Charles C. Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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Richardt A, Aarnio K, Korhonen A, Rantanen K, Verho L, Laivuori H, Gissler M, Tikkanen M, Ijäs P. Etiology and risk factors of ischemic stroke during pregnancy and puerperium: A population-based study. Eur Stroke J 2023; 8:475-482. [PMID: 37231685 DOI: 10.1177/23969873231170096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Ischemic stroke (IS) is an uncommon, but potentially life-changing, complication of pregnancy. The aim of this study was to analyze the etiology and risk factors of pregnancy-associated IS. PATIENTS AND METHODS We collected a population-based retrospective cohort of patients diagnosed with IS during pregnancy or puerperium in Finland from 1987 to 2016. These women were identified by linking the Medical Birth Register (MBR) with the Hospital Discharge Register. Three matched controls were selected from MBR for each case. The diagnosis and temporal relationship of IS to pregnancy, and clinical details were verified from patient records. RESULTS A total of 97 women (median age 30.7 years) were identified as having pregnancy-associated IS. The most common etiologies based on TOAST classification were cardioembolism in 13 (13.4%), other determined in 27 (27.8%) and undetermined in 55 (56.7%) patients. Fifteen patients (15.5%) had embolic strokes of undetermined sources. The most important risk factors were pre-eclampsia, eclampsia, gestational hypertension, and migraine. IS patients had more frequently traditional and pregnancy-related stroke risk factors than the controls (OR 2.38, 95% CI 1.48-3.84) and the risk of IS multiplied with the number of risk factors (4-5 risk factors: OR 14.21, 95% CI 1.12-180.48). DISCUSSION AND CONCLUSION Rare causes and cardioembolism were frequent etiologies for pregnancy-associated IS, but in half of the women, the etiology remained undetermined. The risk of IS increased with the number of risk factors. Surveillance and counseling of pregnant women, especially with multiple risk factors, is crucial for the prevention of pregnancy-associated IS.
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Affiliation(s)
- Anna Richardt
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aino Korhonen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Verho
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannele Laivuori
- Department of Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Marulanda E, Tornes L. Obstetric and Gynecologic Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:763-796. [PMID: 37341330 DOI: 10.1212/con.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article discusses obstetric and gynecologic associations with common neurologic disorders. LATEST DEVELOPMENTS Neurologic complications of obstetric and gynecologic disorders can arise throughout the lifespan. Caution should be exercised when prescribing fingolimod and natalizumab to patients with multiple sclerosis who are of childbearing potential because of the risk of disease rebound when they are discontinued. OnabotulinumtoxinA is considered safe in pregnancy and lactation based on long-term observational data. Hypertensive disorders of pregnancy are associated with higher subsequent cerebrovascular risk, likely via multiple mechanisms. ESSENTIAL POINTS Neurologic disorders may present in a variety of obstetric and gynecologic contexts, with meaningful implications for recognition and treatment. These interactions must be considered when treating women with neurologic conditions.
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Lucia M, Viviana M, Alba C, Giulia D, Carlo DR, Grazia PM, Luca T, Federica VM, Immacolata VA, Grazia PM. Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis. J Clin Med 2023; 12:jcm12082994. [PMID: 37109329 PMCID: PMC10141482 DOI: 10.3390/jcm12082994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.
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Affiliation(s)
- Merlino Lucia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Matys Viviana
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Crognale Alba
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - D'Ovidio Giulia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Della Rocca Carlo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, 04100 Latina, Italy
| | - Porpora Maria Grazia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Titi Luca
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Viscardi Maria Federica
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Volpicelli Agnese Immacolata
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Piccioni Maria Grazia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
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Garg A, Roeder H, Leira EC. In-hospital outcomes and recurrence of stroke during pregnancy and puerperium. Int J Stroke 2023; 18:445-452. [PMID: 35838335 DOI: 10.1177/17474930221116209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are limited data regarding the best management and outcomes of acute stroke during pregnancy and the puerperium. METHODS Pregnancy-related hospitalizations with age > 18 years were identified from the Nationwide Readmissions Database 2016-2018. The study cohort consisted of all patients with acute stroke and a 5% random sample of the remaining non-stroke hospitalizations. Logistic regression and survival analyses were used to compare the in-hospital outcomes and readmissions in patients with and without acute stroke. RESULTS There were 11,829,044 pregnancy-related hospitalizations, of which 4057 had acute stroke. The mean ± SD age of the study cohort was 29.0 ± 5.7 years. Among patients with acute ischemic stroke, 60 (3.7%) patients received intravenous thrombolysis and 112 (6.8%) patients underwent endovascular thrombectomy. Among patients with intracranial hemorrhage, 205 (10.5%) patients underwent ventriculostomy and 18 (0.9%) patients underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 10.7 vs 2.7 days), higher in-hospital mortality (4.6% vs 0.0001%) and were less likely to discharge home (73.0% vs 98.6%). Non-elective readmission within 90 days of discharge occurred in 14.8% of patients with stroke versus in 3.9% of patients without stroke. Readmissions due to cerebrovascular events occurred in 2.3% of patients with stroke versus in 0.007% of patients without stroke within 1 year of discharge, with mean ± SD time to readmission 66.2 ± 78.0 days. CONCLUSION Stroke is a serious complication of pregnancy, associated with high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients, and the risk is highest during the initial 3 months.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hannah Roeder
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Enrique C Leira
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Fang M, Wang J, Wang Z, Chen Y, Xu W, Tao C, Ma L, You C, Hu X, Xia F. Impact of hypertensive disorders of pregnancy on short- and long-term outcomes of pregnancy-associated hemorrhagic stroke. Front Neurol 2023; 14:1097183. [PMID: 37006493 PMCID: PMC10060960 DOI: 10.3389/fneur.2023.1097183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/17/2023] [Indexed: 03/18/2023] Open
Abstract
Background and purposeThough hypertension disorders of pregnancy (HDP) are recognized as independent pregnancy-associated stroke risk factors, few studies have considered their impact on stroke prognosis. Therefore, we intended to evaluate the impact of HDP on short- and long-term outcomes of pregnancy-associated hemorrhagic stroke (HS).MethodsWe conducted a retrospective analysis of patients admitted to our hospital from May 2009 to December 2021 with a diagnosis of pregnancy-associated HS. After dividing patients into two groups by the presence of a diagnosis of HDP or not, the short- (at the time of discharge) and long-term (after discharge follow-up) outcomes were compared by mRS (modified Rankin Scale) scores, and poor functional outcome defined as mRS > 2. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported.ResultsTwenty-two HDP and 72 non-HDP pregnancy-associated HS patients were enrolled and follow-up after 4.7 ± 3.6 years. There was no significant difference between the two groups regarding short-term outcomes, but patients with HDP were more likely to reach poor functional outcomes at long-term follow-up (aOR = 4.47, 95% CI = 1.28–15.67, p = 0.019).ConclusionsIn this retrospective study, women with hypertension disorders of pregnancy did not show worse short-term outcomes of pregnancy-associated hemorrhagic stroke compared to those without but had poorer long-term functional outcomes. This underlines the importance of prevention, recognition, and treatment of hypertension disorders in these women.
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Affiliation(s)
- Mei Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jiayan Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Zexu Wang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yuqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Wei Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- *Correspondence: Xin Hu
| | - Fan Xia
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Fan Xia
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Wiącek M, Oboz-Adaś A, Kuźniar K, Karaś A, Jasielski P, Bartosik-Psujek H. Acute Ischemic Stroke in Pregnancy : A Practical Focus on Neuroimaging and Reperfusion Therapy. Clin Neuroradiol 2023; 33:31-39. [PMID: 36112175 PMCID: PMC10014666 DOI: 10.1007/s00062-022-01215-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pregnancy increases the risk of acute ischemic stroke (AIS) among young women and is responsible for about 5% of maternal deaths and significant disability. Concerns of potential adverse events of imaging and reperfusion therapies in this group of patients can lead to a substantial delay or omission of treatment that can significantly worsen outcomes. OBJECTIVE The objective of this study is to discuss main concerns of diagnosis and therapy of pregnant patients with AIS regarding neuroimaging and reperfusion treatment. RESULTS The cumulative radiation dose of computed tomography (CT)-based entire diagnostic procedure (noncontrast CT, CT-angiography and CT-perfusion) is estimated to be below threshold for serious fetal radiation exposure adverse events. Similarly, magnetic resonance imaging(MRI)-based imaging is thought to be safe as long as gadolinium contrast media are avoided. The added risk of intravenous thrombolysis (IVT) and mechanical thrombectomy during pregnancy is thought to be very low. Nevertheless, some additional safety measures should be utilized to reduce the risk of radiation, contrast media and hypotension exposure during diagnostic procedures or reperfusion treatment. CONCLUSION Fetal safety concerns should not preclude routine diagnostic work-up (except for gadolinium contrast media administration) in childbearing AIS women, including procedures applied in unknown onset and late onset individuals. Due to rather low added risk of serious treatment complications, pregnancy should not be a sole contraindication for neither IVT, nor endovascular treatment.
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Affiliation(s)
- Marcin Wiącek
- Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszow, Poland
| | - Antonina Oboz-Adaś
- Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland.
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszow, Poland.
| | - Katarzyna Kuźniar
- Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszow, Poland
| | - Anna Karaś
- Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszow, Poland
| | - Patryk Jasielski
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszow, Poland
| | - Halina Bartosik-Psujek
- Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
- Department of Neurology, Clinical Regional Hospital No. 2, Rzeszow, Poland
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Ranjan R, Ken-Dror G, Martinelli I, Grandone E, Hiltunen S, Lindgren E, Margaglione M, Le Cam Duchez V, Bagan Triquenot A, Zedde M, Mancuso M, Ruigrok YM, Worrall B, Majersik JJ, Putaala J, Haapaniemi E, Zuurbier SM, Brouwer MC, Passamonti SM, Abbattista M, Bucciarelli P, Lemmens R, Pappalardo E, Costa P, Colombi M, Aguiar de Sousa D, Rodrigues S, Canhao P, Tkach A, Santacroce R, Favuzzi G, Arauz A, Colaizzo D, Spengos K, Hodge A, Ditta R, Han TS, Pezzini A, Coutinho JM, Thijs V, Jood K, Tatlisumak T, Ferro JM, Sharma P. Age of onset of cerebral venous thrombosis: the BEAST study. Eur Stroke J 2023; 8:344-350. [PMID: 37021156 PMCID: PMC10069208 DOI: 10.1177/23969873221148267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/12/2022] [Indexed: 01/09/2023] Open
Abstract
Background Cerebral venous thrombosis (CVT) is an uncommon cause of stroke in young adults. We aimed to determine the impact of age, gender and risk factors (including sex-specific) on CVT onset. Methods We used data from the BEAST (Biorepository to Establish the Aetiology of Sinovenous Thrombosis), a multicentre multinational prospective observational study on CVT. Composite factors analysis (CFA) was performed to determine the impact on the age of CVT onset in males and females. Results A total of 1309 CVT patients (75.3% females) aged ⩾18 years were recruited. The overall median (IQR-interquartile range) age for males and females was 46 (35-58) years and 37 (28-47) years (p < 0.001), respectively. However, the presence of antibiotic-requiring sepsis (p = 0.03, 95% CI 27-47 years) among males and gender-specific risk factors like pregnancy (p < 0.001, 95% CI 29-34 years), puerperium (p < 0.001, 95% CI 26-34 years) and oral contraceptive use (p < 0.001, 95% CI 33-36 years) were significantly associated with earlier onset of CVT among females. CFA demonstrated a significantly earlier onset of CVT in females, ~12 years younger, in those with multiple (⩾1) compared to '0' risk factors (p < 0.001, 95% CI 32-35 years). Conclusions Women suffer CVT 9 years earlier in comparison to men. Female patients with multiple (⩾1) risk factors suffer CVT ~12 years earlier compared to those with no identifiable risk factors.
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Affiliation(s)
- Redoy Ranjan
- Institute of Cardiovascular Research Royal Holloway, University of London (ICR2UL), London, UK
| | - Gie Ken-Dror
- Institute of Cardiovascular Research Royal Holloway, University of London (ICR2UL), London, UK
| | - Ida Martinelli
- Fondazione IRCCS Ca’Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Elvira Grandone
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. Home for the Relief of Suffering, S. Giovanni Rotondo, Foggia, Italy
- Medical and Surgical Department, University of Foggia, Foggia, Italy
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Lindgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Veronique Le Cam Duchez
- Normandy University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit and INSERM CIC-CRB 1404, Rouen, France
| | | | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Local Health Unit – Authority IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Ynte M Ruigrok
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Brad Worrall
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Elena Haapaniemi
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Susanna M Zuurbier
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Serena M Passamonti
- Fondazione IRCCS Ca’Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Maria Abbattista
- Fondazione IRCCS Ca’Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca’Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Leuven, Belgium
- VIB Center for Brain & Disease Research, Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Emanuela Pappalardo
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Paolo Costa
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Marina Colombi
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal
- CEEM and Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Sofia Rodrigues
- Department of Neurosciences, Hospital of Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Patrícia Canhao
- Department of Neurosciences, Hospital of Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Aleksander Tkach
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Giovanni Favuzzi
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. Home for the Relief of Suffering, S. Giovanni Rotondo, Foggia, Italy
| | - Antonio Arauz
- Stroke Clinic, National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Mexico City, Mexico
| | - Donatella Colaizzo
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. Home for the Relief of Suffering, S. Giovanni Rotondo, Foggia, Italy
| | - Kostas Spengos
- Department of Neurology, University of Athens School of Medicine, Eginition Hospital, Athens, Greece
| | - Amanda Hodge
- McMaster University, Pathology and Molecular Medicine, Population Health Research Institute and Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Reina Ditta
- McMaster University, Pathology and Molecular Medicine, Population Health Research Institute and Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Thang S Han
- Institute of Cardiovascular Research Royal Holloway, University of London (ICR2UL), London, UK
- Department of Diabetes and Endocrinology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, UK
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
| | - Pankaj Sharma
- Institute of Cardiovascular Research Royal Holloway, University of London (ICR2UL), London, UK
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London, UK
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Hemorrhagic Stroke in Pregnancy. Clin Obstet Gynecol 2023; 66:223-230. [PMID: 36044629 DOI: 10.1097/grf.0000000000000739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Hemorrhagic stroke carries a high risk of disability and mortality. The obstetrical population is at increased risk. Prompt diagnosis and maternal stabilization with a multidisciplinary approach are the mainstays in management. Computed tomography head is the diagnostic imaging of choice and is considered safe in pregnancy. Fetal status optimization before neurosurgery and delivery should be considered if the fetus is viable or if worsening maternal condition. Obstetric indications guide the mode of delivery. Cesarean delivery may be indicated to reduce increasing intracranial pressure. Neuraxial anesthesia should be considered to minimize catecholamine surges, reduce sedation, and control blood pressures.
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Stroke in Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023. [DOI: 10.1007/s13669-023-00351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1190] [Impact Index Per Article: 1190.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Béjot Y, Olié V, Lailler G, Grave C, Regnault N, Blacher J, Duloquin G, Gabet A. Acute revascularization therapy for ischemic stroke during pregnancy and post-partum in France. Eur Stroke J 2023; 8:467-474. [DOI: 10.1177/23969873231156208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Introduction: Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in women with ischemic stroke (IS) during pregnancy/post-partum is challenging, and recent guidelines claimed for additional information to better argue its effectiveness and safety. This observational national study aimed to describe characteristics, rates and outcomes of pregnant/post-partum women receiving acute revascularization therapy for IS compared to their non-pregnant counterparts, and pregnant women with IS not receiving such therapy. Patients and methods: In this cross-sectional study, all women aged 15–49 years hospitalized in France for IS between 2012 and 2018 were retrieved from the French hospital discharge databases. Pregnant or post-partum (⩽6 weeks after delivery) women were identified. Data about patients’ characteristics, risk factors, revascularization therapy, delivery, post-stroke survival, and recurrent vascular events during follow-up were recorded. Results: Over the study period, 382 women with pregnancy-related IS were registered. Among them, 7.3% ( n = 28) received a revascularization therapy, including nine cases during pregnancy, one the same day as delivery, and 18 during the post-partum period, compared with 8.5% ( n = 1285) in women with non-pregnancy-related IS ( n = 15,084). Treated pregnant/post-partum women had more severe IS than not-treated pregnant/post-partum. Compared with treated not-pregnant women, they were younger, but did not differ regarding other characteristics including stroke severity. There were no differences in systemic or intracranial hemorrhages or in the length of hospital stay between pregnant/post-partum women compared with treated not-pregnant women. All women receiving revascularization during pregnancy had a live baby. After a mean follow-up of 4.3 years, all pregnant/post-partum women were alive, one had recurrent IS and none had other vascular events. Discussion and conclusion: Only a few women with pregnancy-related IS were treated with acute revascularization therapy, but this was proportionately similar to their non-pregnant counterparts, from whom they did not differed regarding characteristics, survival, and risk of recurrent events. These findings suggest that stroke physicians applied treatment strategies of IS in a similar way regardless of pregnancy in France, and this attitude was an anticipation but consistent with the recently published guidelines on the topic.
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Affiliation(s)
- Yannick Béjot
- Dijon Stroke Registry, Department of Neurology, University Hospital of Dijon, EA7460, Pathophysiology and Epidemiology of Cardio-Cerebrovascular Disease (PEC2), University of Burgundy, Dijon, France
| | - Valérie Olié
- French Public Health Agency, Saint-Maurice, France
| | | | | | | | - Jacques Blacher
- Diagnosis and Therapeutic Center, Hotel Dieu, AP-HP, University Paris Descartes, Paris, France
| | - Gauthier Duloquin
- Dijon Stroke Registry, Department of Neurology, University Hospital of Dijon, EA7460, Pathophysiology and Epidemiology of Cardio-Cerebrovascular Disease (PEC2), University of Burgundy, Dijon, France
| | - Amélie Gabet
- French Public Health Agency, Saint-Maurice, France
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Yu AYX, Nerenberg KA, Diong C, Fang J, Chu A, Kapral MK, Edwards JD, Dancey SR, Austin PC, Auger N. Maternal Health Outcomes After Pregnancy-Associated Stroke: A Population-Based Study With 19 Years of Follow-Up. Stroke 2023; 54:337-344. [PMID: 36689587 DOI: 10.1161/strokeaha.122.041471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/07/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pregnancy-associated stroke carries high short-term morbidity and mortality, but data on subsequent maternal outcomes are limited. We evaluated long-term maternal health outcomes after pregnancy-associated stroke. METHODS In this retrospective cohort study, we used administrative data to identify pregnant adults aged ≤49 years with stroke between 2002-2020 in Ontario, Canada and 2 comparison groups: (1) non-pregnant female patients with stroke and (2) pregnant patients without stroke. Patients who survived the index admission were followed until 2021. After propensity score matching, we used Cox regression with a robust variance estimator to compare pregnant patients with stroke and the 2 comparison groups for the composite outcome of death and all-cause non-pregnancy readmission. Where proportional hazard assumption was not met, we reported time-varying hazard ratios (HR) with 95% CIs by modeling the log-hazard ratio as a function of time using restricted cubic splines. RESULTS We identified 217 pregnant patients with stroke, 7604 non-pregnant patients with stroke, and 1 496 256 pregnant patients without stroke. Of the 202 pregnant patients with stroke who survived the index stroke admission, 41.6% (6.8 per 100 person-years) subsequently died or were readmitted during follow-up. Median follow-up times were 5 years (pregnancy-associated stroke), 3 years (non-pregnant stroke), and 8 years (pregnant without stroke). Pregnant patients with stroke had a lower hazard of death and all-cause readmission compared with non-pregnant patients with stroke at 1-year follow-up (HR, 0.64 [95% CI, 0.44-0.94]), but this association did not persist during longer-term follow-up. Conversely, pregnant patients with stroke had higher hazard of death and readmission compared with pregnant patients without stroke at 1-year follow-up (HR, 5.70 [95% CI, 3.04-10.66]), and this association persisted for a decade. CONCLUSIONS Stroke during pregnancy is associated with long-term health consequences. It is essential to transition care postpartum to primary or specialty care to optimize vascular health.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada (A.Y.X.Y.)
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Kara A Nerenberg
- Departments of Medicine and Obstetrics and Gynecology, University of Calgary, Alberta, Canada (K.A.N.)
| | - Christina Diong
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Jiming Fang
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Anna Chu
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Moira K Kapral
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
- Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, Ontario, Canada (M.K.K.)
| | - Jodi D Edwards
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
- University of Ottawa Heart Institute, Ontario, Canada (J.D.E., S.R.D.)
| | - Sonia R Dancey
- University of Ottawa Heart Institute, Ontario, Canada (J.D.E., S.R.D.)
- School of Epidemiology and Public Heath, University of Ottawa, Ontario, Canada (J.D.E.)
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada (A.Y.X.Y., C.D., J.F., A.C., M.K.K., J.D.E., P.C.A.)
| | - Nathalie Auger
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Quebec, Canada (N.A.)
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40
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Cherian L. Women and Ischemic Stroke. Neurol Clin 2023; 41:265-281. [PMID: 37030957 DOI: 10.1016/j.ncl.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.
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Cipolla MJ, Tremble SM, DeLance N, Johnson AC. Worsened Stroke Outcome in a Model of Preeclampsia is Associated With Poor Collateral Flow and Oxidative Stress. Stroke 2023; 54:354-363. [PMID: 36689585 PMCID: PMC9888018 DOI: 10.1161/strokeaha.122.041637] [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: 10/24/2022] [Accepted: 12/15/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Preeclampsia increases the incidence of maternal stroke, a devastating condition that is on the rise. We investigated stroke outcome in a model of experimental preeclampsia with and without treatment with clinically relevant doses of magnesium sulfate (experimental preeclampsia+MgSO4) compared to normal late-pregnant and nonpregnant rats. METHODS Transient middle cerebral artery occlusion was used to induce focal stroke for either 1.5 or 3 hours. Infarct volume and hemorrhagic transformation were determined as measures of stroke outcome. Changes in core middle cerebral artery and collateral flow were measured by dual laser Doppler. The relationship between middle cerebral artery perfusion deficit and infarction was used as a measure of ischemic tolerance. Oxidative stress and endothelial dysfunction were measured by 3-nitrotyrosine and 8-isoprostane, in brain and serum, respectively. RESULTS Late-pregnant animals had robust collateral flow and greater ischemic tolerance of brain tissue, whereas experimental preeclampsia had greater infarction that was related to poor collateral flow, endothelial dysfunction, and oxidative stress. Importantly, pregnancy appeared preventative of hemorrhagic transformation as it occurred only in nonpregnant animals. MgSO4 did not provide benefit to experimental preeclampsia animals for infarction. CONCLUSIONS Stroke outcome was worse in a model of preeclampsia. As preeclampsia increases the risk of future stroke and cardiovascular disease, it is worth understanding the influence of preeclampsia on the material brain and factors that might potentiate injury both during the index pregnancy and years postpartum.
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Affiliation(s)
- Marilyn J. Cipolla
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Department Obstetrics, Gynecology & Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Department Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Department of Electrical and Biological Engineering, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT USA
| | - Sarah M. Tremble
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Nicole DeLance
- Department Pathology, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Abbie C. Johnson
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
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42
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Mittal S, Alsbrook D, Okwechime RT, Iqbal F, Nobleza COS. The landscape of disparities in obstetric neurocritical care and a path forward. Front Neurol 2023; 13:1008544. [PMID: 36686512 PMCID: PMC9853894 DOI: 10.3389/fneur.2022.1008544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 12/05/2022] [Indexed: 01/07/2023] Open
Abstract
Health disparities in the obstetric population affect maternal morbidity and mortality. In the past years, there has been no significant improvement in disparities in care in the obstetric population. Patients who are pregnant are known to have a higher risk of pregnancy-associated neurologic conditions such as stroke and intracerebral hemorrhage. They can also experience concomitant neurocritical care disease states such as status epilepticus and traumatic brain injury. Studies exploring the disparities of care among pregnant patients who are neurotically ill are lacking. We aim to provide the landscape of disparities of care among the obstetric neurocritically-ill population and provide potential actionable opportunities to address these disparities in care.
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Affiliation(s)
- Shilipi Mittal
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Diana Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Remi T. Okwechime
- NeuroMedicine ICU, Critical Care Program University of Rochester Medical Center, Rochester, NY, United States
| | - Farhana Iqbal
- Maimonides Medical Center, Brooklyn, NY, United States
| | - Christa O'Hana S. Nobleza
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States,Baptist Memorial Hospital/Baptist Medical Group, Memphis, TN, United States,*Correspondence: Christa O'Hana S. Nobleza ✉
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43
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LaHue SC, Paolini S, Waters JFR, O'Neal MA. Opinion and Special Article: The Need for Specialized Training in Women's Neurology. Neurology 2023; 100:38-42. [PMID: 36180236 PMCID: PMC9827127 DOI: 10.1212/wnl.0000000000201451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 09/08/2022] [Indexed: 01/11/2023] Open
Abstract
Women's Neurology is an emerging subspecialty that focuses on neurologic disorders across a woman's lifetime. This new domain recognizes that both health and disease are directly affected by hormonal and reproductive changes throughout the life span. This field includes neurologic diseases with a higher prevalence in women and diseases that require specialized management during pregnancy, postpartum period, lactation, and menopause. A survey was sent to US neurology residency program directors to understand the state of training in the area. Their responses highlighted an urgent need for additional education in this field for neurology residents. In this study, we discuss the educational gaps in this area, the clinical benefits of a women's neurology discipline, and the instructional gaps in this area and provide practical recommendations for training programs in women's neurology using 2 innovative fellowship programs.
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Affiliation(s)
- Sara C LaHue
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA.
| | - Stephanie Paolini
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA
| | - Janet F R Waters
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA
| | - Mary A O'Neal
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA
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44
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Yoon CW, Bushnell CD. Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes. J Stroke 2023; 25:2-15. [PMID: 36746378 PMCID: PMC9911842 DOI: 10.5853/jos.2022.03468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Stroke is a particularly important issue for women. Women account for over half of all persons who experienced a stroke. The lifetime risk of stroke is higher in women than in men. In addition, women have worse stroke outcomes than men. Several risk factors have a higher association with stroke in women than in men, and women-specific risk factors that men do not have should be considered. This focused review highlights recent findings in stroke epidemiology, risk factors, and outcomes in women.
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Affiliation(s)
- Cindy W. Yoon
- Department of Neurology, Inha University School of Medicine, Incheon, Korea
| | - Cheryl D. Bushnell
- Department of Neurology, Wake Forest University School of Medicine, Winston Salem, NC, USA,Correspondence: Cheryl D. Bushnell Department of Neurology, Wake Forest University School of Medicine, Medical Center Blvd, Winston Salem, NC 27157, USA Tel: +1-336-716-2983
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45
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Muacevic A, Adler JR, Jones J. Headache in Pregnancy: Preeclampsia and Intracerebral Hemorrhage. Cureus 2023; 15:e34086. [PMID: 36843722 PMCID: PMC9945921 DOI: 10.7759/cureus.34086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
Preeclampsia is a type of hypertensive disorder of pregnancy that can cause significant maternal and perinatal morbidity and mortality. Hypertension and proteinuria are the keystones of the disease, though systemic end-organ dysfunction may follow. The pathogenesis is multifactorial, with known influences by placental, vascular, renal, and immunological dysfunction. This is a case of preeclampsia complicated by preterm delivery and antepartum intracerebral hemorrhage secondary to aneurysm rupture, presenting as dull headaches and blurry vision, commonly associated with severe features.
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46
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Singh SK, McCullough L. Sex Differences in the Evaluation and Treatment of Stroke. Handb Exp Pharmacol 2023; 282:77-106. [PMID: 37460659 DOI: 10.1007/164_2023_682] [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: 10/13/2023]
Abstract
There are differences in the prevalence and strength of risk factors in women, along with sex-specific risk factors such as pregnancy. Women have a higher lifetime risk of stroke compared to men, with worse outcomes including higher rates of death and disability. We have made strides in the identification of sex-specific risk factors but with the paucity of sex-specific end points in clinical trials, stroke treatment and research are hindered.
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Affiliation(s)
- Sonia K Singh
- McGovern Medical School, UTHealth Houston, Houston, TX, USA
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47
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Choudhary D, Mohan V, Varsha AS, Hegde A, Menon G. Neurosurgical emergencies during pregnancy - Management dilemmas. Surg Neurol Int 2023; 14:151. [PMID: 37151438 PMCID: PMC10159311 DOI: 10.25259/sni_1076_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Background Neurosurgical emergencies in the obstetric setting pose considerable challenges. Decision-making involves deliberations on the gestational age, critical nature of the illness, timing of surgery, maternal positioning during neurosurgery, anesthesiologic strategies, monitoring of the pregnancy during surgery, and the mode of delivery. The present study discusses the management and ethical dilemmas encountered during the management of six obstetric patients with neurosurgical emergencies. Methods A retrospective review of all neurosurgical operations performed between January 2016 and December 2022 were included in the study. Results This study includes a series of six pregnant women who presented with neurosurgical emergencies, secondary to freshly diagnosed pathologies in the period 2016-2022. The mean maternal age was 31.33 years. Four of the six patients were in the third semester and two were in the second trimester. The underlying etiologies were as follows: spontaneous intracerebral hypertensive hemorrhage (1), obstructive hydrocephalus due to shunt malfunction (1), brain tumor (02), and compressive spinal cord myelopathy due to tumors (02). Three patients who were near term underwent lower cesarean section followed by emergency neurosurgical procedure in the same sitting. Two second trimester patients continued their pregnancy after the emergency neurosurgical operation. In one patient, in whom a brain tumor was diagnosed near term, underwent neurosurgery 1 week after successful cesarean section. All the six mothers and fetus recovered well, ex3cept two patients who have persisting residual deficits. Conclusion Treatment of neurosurgical emergencies during pregnancy needs to be customized depending on the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. With careful planning, timely intervention, consultative decision making and it is possible to achieve the ultimate goal - which is to protect and safeguard the mother and preserve and deliver a viable fetus.
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Affiliation(s)
| | | | | | | | - Girish Menon
- Corresponding author: Girish Menon, Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India.
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48
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Knapp C, Bhatia K. Maternal collapse in pregnancy. Br J Hosp Med (Lond) 2022; 83:1-12. [PMID: 36594762 DOI: 10.12968/hmed.2022.0259] [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: 12/13/2022]
Abstract
Maternal collapse is a rare life-threatening event that can occur at any stage of pregnancy or up to 6 weeks postpartum. Prompt identification and timely intervention by a multidisciplinary team that includes an obstetrician, midwifery staff and an obstetric anaesthetist are essential to improve maternal and fetal outcomes. Standard adult resuscitation guidelines need to be followed with some modifications, taking into account the maternal-fetal physiology, which clinicians should be familiar with. During cardiac arrest, the emphasis is on advanced airway management, manual uterine displacement to relieve aortocaval compression and performing a resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients who are more than 20 weeks gestation to improve maternal survival. Annual multidisciplinary simulation training is recommended for all professionals involved in maternity care; this can improve teamwork, communication and emergency preparedness during maternal collapse.
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Affiliation(s)
- C Knapp
- North West School of Anaesthesia, Health Education England North West, Manchester, UK
| | - K Bhatia
- Department of Anaesthesia, St Mary's Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
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49
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Stan A, Ilut S, Dragos HM, Bota C, Hanghicel PN, Cristian A, Vlad I, Mocanu D, Strilciuc S, Panaitescu PS, Stan H, Muresanu DF. The Burden of Cerebral Venous Thrombosis in a Romanian Population across a 5-Year Period. Life (Basel) 2022; 12:life12111825. [PMID: 36362980 PMCID: PMC9693190 DOI: 10.3390/life12111825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Health policies in transitioning health systems are rarely informed by the social burden and the incidence shifts in disease epidemiology. Cerebral venous thrombosis (CVT) is a type of stroke more often affecting younger adults and women, with higher incidences being reported in recent studies. A retrospective, hospital-based population study was conducted at Cluj-Napoca Emergency County Hospital across a 5-year period between 2017 and 2021. The overall incidence and the rates in distinctive gender and age groups were assessed. Length of hospital stay (LHS), modified Rankin score (mRS) and mortality at discharge and at 3 months were calculated. Fifty-three patients were included. The median age was 45 years, and 64.2% were women. In our population of 3,043,998 person-years, 53 CVT cases resulted in an incidence of 1.74 per 100,000 (95% CI 1.30–2.27). CVT incidence was higher in women (2.13 per 100,000, 95% CI 1.47–2.07). There was a statistically significant difference in LHS between patients with different intracranial complications (Kruskal–Wallis, p = 0.008). The discharge mRS correlated with increasing age (rs = 0.334, p = 0.015), transient risk factors (Fisher’s exact test, p = 0.023) and intracranial complications (Fisher’s exact test, p = 0.022). In addition, the mRS at 3 months was statistically associated with increasing age (rs = 0.372, p = 0.006) and transient risk factors (Fisher’s exact test, p = 0.012). In-hospital mortality was 5.7%, and mortality at follow up was 7.5%, with higher rates in women (5.9% and 8.8%, respectively). Our findings may provide insight regarding the epidemiological features of certain patient groups more prone to developing CVT and its complications, informing local and central stakeholders’ efforts to improve standards of care.
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Affiliation(s)
- Adina Stan
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Silvina Ilut
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Hanna Maria Dragos
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
- Correspondence: ; Tel.: +40-773991273
| | - Claudia Bota
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Patricia Nicoleta Hanghicel
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Alexander Cristian
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Irina Vlad
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
| | - Diana Mocanu
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Stefan Strilciuc
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
| | - Paul Stefan Panaitescu
- Department of Microbiology, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
| | - Horatiu Stan
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
| | - Dafin F. Muresanu
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
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Abukhairat SM, Alyami HS, Alshammaa FA, Jamsheer FA, Baeyti NY, Aljehani MM, Al Ghadeeb M. Artery of Percheron Infarct: A Rare Case of Stroke in Pregnancy. Cureus 2022; 14:e30798. [DOI: 10.7759/cureus.30798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
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