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Rosalik KF, Havemann LM, Wasickanin ME, McCaulley JA, Edwards SM, Leonard KM. Vertebral artery dissection in relation to pregnancy: a case series and literature review. AJOG GLOBAL REPORTS 2023; 3:100281. [PMID: 38046533 PMCID: PMC10692729 DOI: 10.1016/j.xagr.2023.100281] [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] [Indexed: 12/05/2023] Open
Abstract
Cervical artery dissection is an uncommon condition for which pregnancy and postpartum states confer increased risk. Although the majority of patients with this condition fully recover, including resolution of the dissection on imaging, long-term sequelae include a variety of cardiovascular conditions that may be associated with high rates of morbidity and mortality. Here, we review 2 cases of vertebral artery dissection in relation to pregnancy. Our first case will review the management of a pregnant patient with a history of vertebral artery dissection; whereas our second case reviews a presentation of postpartum vertebral artery dissection. Providers should maintain a high suspicion of cervical artery dissection in pregnant and postpartum patients presenting with headache and neck pain.
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Affiliation(s)
- Kendal F. Rosalik
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Logan M. Havemann
- Department of Obstetrics and Gynecology, Carl R. Darnall Army Medical Center, Fort Hood, TX (Dr Havemann)
| | - Morgan E. Wasickanin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Jill A. McCaulley
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Sarah M. Edwards
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Katherine M. Leonard
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Womack Army Medical Center, Fort Bragg, NC (Dr Leonard)
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De Backer T. A Genetic Dissection of Vascular Risk Factors for Cervical Artery Dissection: Under Pressure. J Am Coll Cardiol 2023; 82:1424-1426. [PMID: 37758437 DOI: 10.1016/j.jacc.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Tine De Backer
- Cardiovascular Center, University Hospital Gent, Gent, Belgium.
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3
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Xie S, Ran Y, Wang X, Zhang Y, Fu Q, Ren Y, Liu J, Teng Z, Cheng J. Diagnostic potential of routine brain MRI and high-resolution, multi-contrast vessel wall imaging in the detection of internal carotid artery dissection. Front Neurol 2023; 14:1165453. [PMID: 37251240 PMCID: PMC10213939 DOI: 10.3389/fneur.2023.1165453] [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: 02/14/2023] [Accepted: 04/14/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Cervical artery dissection (CAD) is one of the major causes of stroke and most commonly occurs at the site of the extracranial internal carotid artery (ICA). This study aimed to assess the value of routine brain MRI, clinical information, and high-resolution, multi-contrast vessel wall MR imaging (hrVWI) for the timely detection of ICA dissection. Methods A total of 105 patients with CAD and 105 without CAD were recruited for this study. The lesion type in the patients was determined based on images from different modalities, including brain MRI, magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA), ultrasonography, and hrVWI and clinical information. Each lesion was reviewed to determine the type following a stepwise procedure by referring to (1) brain MRI only; (2) brain MRI and clinical information; (3) hrVWI only; and (4) hrVWI, CTA, DSA, and clinical information. Results Typical clinical presentations of patients with potential CAD include headache, neck pain, and/or Horner's syndrome. Representative imaging signs in the brain MRI included a crescentic or circular iso- or hyperintensity around the lumen, a curvilinear and isointense line crossing the lumen, or aneurysmal vessel dilation. Based on brain MRI alone, 54.3% (57/105) of the patients with CAD were correctly classified, and the accuracy increased to 73.3% (77/105) when clinical information was combined (P < 0.001) with high specificity and low sensitivity. Further analysis showed that hrVWI had the superior capability in detecting CAD, with a sensitivity and a specificity of 95.1% and 97.0%, respectively. Conclusion The combination of brain MRI and clinical information could be used for the diagnosis of CAD; however, hrVWI should be sought for uncertain cases.
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Affiliation(s)
- Shanshan Xie
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuncai Ran
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao Wang
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yong Zhang
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qichang Fu
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanan Ren
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Juanfang Liu
- Department of Intervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - Jingliang Cheng
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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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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Banayan JM. Postpartum Preeclampsia-A Diagnosis Not to Be Missed. J Cardiothorac Vasc Anesth 2023; 37:1039-1041. [PMID: 36964082 DOI: 10.1053/j.jvca.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Jennifer M Banayan
- Department of Anesthesiology, Northwestern University,Feinberg School of Medicine, Chicago, IL.
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The EZ, Lin NN, Chan CJ, Loon JCW, Tan BYQ, Seet CSR, Teoh HL, Vijayan J, Yeo LLL. Antiplatelets or anticoagulants? Secondary prevention in cervical artery dissection: an updated meta-analysis. Neurol Res Pract 2022; 4:23. [PMID: 35692052 PMCID: PMC9190132 DOI: 10.1186/s42466-022-00188-7] [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: 03/15/2022] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background Extracranial artery dissection involving either internal carotid artery or vertebral artery is a major cause of stroke in adults under 50 years of age. There is no conclusive evidence whether antiplatelets or anticoagulants are better suited in the treatment of extracranial artery dissection. Objectives To determine whether antiplatelets or anticoagulants have advantage over the other in the treatment of extracranial artery dissection for secondary prevention of recurrent ischemic events or death. Methods Present meta-analysis followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement. Database search was done in Medline, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov from inception to May 2021 using pre-defined search strategy. Additional studies were identified from reference lists from included studies, reviews and previous meta-analyses. Outcome measures were ischaemic stroke, ischaemic stroke or transient ischaemic attack (TIA), and death. Results Two RCTs and 64 observational studies were included in the meta-analysis. While the outcome measures of stroke, stroke or TIA and death were numerically higher with antiplatelet use, there were no statistically significant differences between antiplatelets and anticoagulants. Conclusion We found no significant difference between antiplatelet and anticoagulation treatment after extracranial artery dissection. The choice of treatment should be tailored to individual cases. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00188-7.
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Magro I, Nurimba M, Doherty J. Headache in Pregnancy. Otolaryngol Clin North Am 2022; 55:681-696. [PMID: 35490045 DOI: 10.1016/j.otc.2022.02.013] [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: 10/18/2022]
Abstract
Headache is a common symptom in pregnancy. The differential diagnosis for headache in pregnancy is broad and includes conditions that range in acuity and severity. Most headaches in pregnancy are migraine or tension-type headaches. However, pregnant women are at an increased risk of vascular causes of headache due to hormone changes and increased hypercoagulability in pregnancy. A careful history, physical examination, and possible diagnostic workup should be performed. Treatment of headache in pregnancy varies according to the etiology, but care should be taken when performing diagnostic studies and considering pharmacologic treatments, given the possible risk to the mother and fetus.
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Affiliation(s)
- Isabelle Magro
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Margaret Nurimba
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Joni Doherty
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Alfonso F, García-Guimaraes M, Alvarado T, Sanz-Ruiz R, Roura G, Amat-Santos IJ, Abdul-Jawad Altisent O, Tizón-Marcos H, Flores-Ríos X, Masotti M, Pérez-de Prado A, Ferre GF, Ruiz-Poveda FL, Valero E, Portero-Portaz JJ, Diez-Villanueva P, Salamanca J, Bastante T, Rivero F. Clinical implications of arterial hypertension in patients with spontaneous coronary artery dissection. Coron Artery Dis 2022; 33:75-80. [PMID: 33878074 DOI: 10.1097/mca.0000000000001043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome. Many patients with SCAD have associated coronary risk factors. However, the implications of arterial hypertension in SCAD patients remain unknown. OBJECTIVE This study sought to assess the clinical implications of arterial hypertension in a nationwide cohort of patients with SCAD. METHODS The Spanish SCAD registry (NCT03607981) prospectively enrolled 318 consecutive patients. All coronary angiograms were centrally analyzed to confirm the diagnosis of SCAD. Patients were classified according to the presence of arterial hypertension. RESULTS One-hundred eighteen patients (37%) had a diagnosis of arterial hypertension. Hypertensive SCAD patients were older (60 ± 12 vs. 51 ± 9 years old) and had more frequently dyslipidemia (56 vs. 23%) and diabetes (9 vs. 3%) but were less frequently smokers (15 vs. 35%) than normotensive SCAD patients (all P < 0.05). Most patients in both groups were female (90 vs. 87%, NS) and female patients with hypertension were more frequently postmenopausal (70 vs. 47%, P < 0.05). Hypertensive SCAD patients had more severe lesions and more frequently multivessel involvement (15 vs. 7%, P < 0.05) and coronary ectasia (19 vs. 7%, P < 0.05) but showed a similar prevalence of coronary tortuosity (34 vs. 26%, NS). Revascularization requirement was similar in both groups (17 vs. 26%, NS) but procedural success was significantly lower (65 vs. 88%, P < 0.05) and procedural-related complications more frequent (65 vs. 41%, P < 0.05) in SCAD patients with hypertension. CONCLUSION Patients with SCAD and hypertension are older, more frequently postmenopausal and have more coronary risk factors than normotensive SCAD patients. During revascularization SCAD patients with hypertension obtain poorer results and have a higher risk of procedural-related complications (NCT03607981).
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Affiliation(s)
- Fernando Alfonso
- Cardiac Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBERCV, Madrid
| | - Marcos García-Guimaraes
- Cardiac Department, Hospital del Mar - Parc de Salut Mar
- Grupo de Investigación Biomédica en Enfermedades del Corazón, IMIM, Barcelona
| | - Teresa Alvarado
- Cardiac Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBERCV, Madrid
| | - Ricardo Sanz-Ruiz
- Cardiac Department, Hospital General Universitario Gregorio Marañón, IIS-GM, CIBERCV, Madrid
| | - Gerard Roura
- Cardiac Department, Hospital Universitari de Bellvitge, L´Hospitalet de Llobregat, Barcelona
| | | | | | - Helena Tizón-Marcos
- Cardiac Department, Hospital del Mar - Parc de Salut Mar
- Grupo de Investigación Biomédica en Enfermedades del Corazón, IMIM, Barcelona
| | - Xacobe Flores-Ríos
- Cardiac Department, Complexo Hospitalario Universitario de A Coruña, A Coruña
| | - Mónica Masotti
- Cardiac Department, Hospital Clinic de Barcelona, Barcelona
| | | | | | | | | | | | - Pablo Diez-Villanueva
- Cardiac Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBERCV, Madrid
| | - Jorge Salamanca
- Cardiac Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBERCV, Madrid
| | - Teresa Bastante
- Cardiac Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBERCV, Madrid
| | - Fernando Rivero
- Cardiac Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBERCV, Madrid
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Assif M, Lamy C, De Gaalon S, Caroit Y, Bourcier R, Preterre C, Guillon B. Cervical Artery Dissection in Young Women: Risk of Recurrence During Subsequent Pregnancies. Neurol Clin Pract 2022; 11:e803-e808. [PMID: 34992962 DOI: 10.1212/cpj.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/19/2021] [Indexed: 11/15/2022]
Abstract
Objectives To assess the risk of recurrence of cervical artery dissection (CAD) during pregnancy and puerperium in women with a history of CAD and then help physicians with providing medical information to women who wish to become pregnant. Methods Women aged 16-45 years who were admitted to our center for a CAD between 2005 and 2017 were identified from the hospital database, and those with spontaneous and symptomatic CAD were included. They were then contacted to answer a questionnaire that was specifically designed in regard to the recurrence of CAD and pregnancies after the primary CAD. Results Ninety-one patients satisfied our inclusion criteria, and 89 were included in the analysis. During a median follow-up of 7.0 years, 4 women (4.4%) had recurrent CAD, although none during pregnancy or puerperium. Eighteen women (20%) had a total of 20 full-term pregnancies, occurring at least 6 months after CAD. Of these 20 pregnancies, 13 (65%) were vaginal deliveries, and 7 (35%) were cesarean sections. The reason for the absence of pregnancies after the initial CAD was unrelated to the vascular event in 89% of cases, but 8% of the women had been advised by a physician to avoid any future pregnancy or they had been recommended to undergo abortion or sterilization. Conclusion In this study, there were no CAD recurrences during subsequent pregnancies or postpartum, irrespective of the type of delivery. Thus, pregnancy after a history of CAD appears to be safe.
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Affiliation(s)
- Myriam Assif
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
| | - Catherine Lamy
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
| | - Solène De Gaalon
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
| | - Yolande Caroit
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
| | - Romain Bourcier
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
| | - Cécile Preterre
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
| | - Benoit Guillon
- Stroke Unit (MA, SDG, CP, BG), Nantes University Hospital; Department of Neurology (CL), Paris Descartes University, Hôpital Sainte-Anne, Paris; Department of Obstetrics and Gynecology (YC), Nantes University Hospital; Department of Neuroradiology (RB), Nantes University Hospital, France
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Kalashnikova LA, Danilova MS, Gubanova MV, Dobrynina LA. [Cervical artery dissection in women: relationships with pregnancy and postpartum period]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:7-12. [PMID: 34874648 DOI: 10.17116/jnevro20211211017] [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
OBJECTIVE To study the frequency of CeAD that developed during pregnancy or in post partum period among all CeADs in women; to study the course of pregnancy in women with prior CeAD. MATERIAL AND METHODS 162 women (mean age 37.1±4.1 years) with CeAD we examined at the Research Center of Neurology (Moscow), 98% women were studied during last 15 years. 140 women were of childbearing age (≤45 years, mean age - 35±2.8 years). All patients were interviewed whether or not CeAD occurred during pregnancy or in post partum period (CeADPPP). Obstetric history before and after CeAD was studied in 57 women of childbearing age (average age - 35.9±7.3 years at CeAD development). RESULTS CeADPPP developed in 6 out of 162 all female patients (3.7%) or of 140 childbearing age patients (4.3%). It occurred 2-6 months (4 patients) and 10 days after delivery (1 patient), or on the 25th week of pregnancy (1 patient). CeADPPP patients were younger than patients with CeAD out of pregnancy or postpartum period (29.8±8 years vs 35.1±6.7 years, p>0.05). CeADPPP in comparison with CeAD outside these periods more often involved internal carotid artery (ICA) (50% vs 35%, p=0.666), more often occurred in 2-3 arteries (50% vs 31%, p=0.386) and more often was accompanied by dissecting aneurysm development (50% vs 8%, p=0.013). After CeAD, 18 out of 57 patients in whom obstetric history was studied, including 3 patients with postpartum dissection had 29 pregnancies. The pregnancy outcomes were as follows: childbirth (17 pregnancies, 59%), fetal loss (8 pregnancies, 27%) and medical abortion (4 pregnancies, 14%). Delivery occurred on average 4.5±2.061 years after CeAD in women aged 33.0±4.25 years (cesarean section - 15 patients). Fetal loss occurred at 7.4±3.5 weeks of pregnancy in women aged 37.6±3.13 years on average 2.7±1.4 years after CeAD. Fetal loss frequency after CeAD was higher than before it (27% vs 7%, p=0.016). There were no CeAD recurrences during pregnancy and postpartum period in women who had previously undergone CeAD. CONCLUSION CeADPPP frequency among all dissections in women is 3.7-4.3%. The risk of CeAD recurrence during pregnancy or the postpartum period after prior CeAD is very low. The risk of fetal loss during 2.7±1.4 years after CeAD is higher than before it (27% vs 7%). Hormonal and growth factors associated with pregnancy and the postpartum period is suggested to contribute to cervical artery wall damage. It is possible that the prolonged action of some of these factors may disrupt the placental vessels formation, predisposing to miscarriage.
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Ruan CY, Gao BL, Pang HL, Zhang K, Zhang YH, Wei LP, Li TX, Wang ZL. Postpartum cerebral arterial dissections: Clinical features and treatment. Medicine (Baltimore) 2021; 100:e27798. [PMID: 34964745 PMCID: PMC8615341 DOI: 10.1097/md.0000000000027798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022] Open
Abstract
Postpartum cerebral arterial dissections are rare, and the clinical features, diagnosis, and treatment approaches are not clear to many physicians. This study was to investigate the clinical features, diagnosis, and treatment of postpartum cerebral arterial dissections.One patient with postpartum cerebral arterial dissections enrolled in our hospital was analyzed. All patients with postpartum cerebral arterial dissections retrieved from the PubMed were also included in this study and analyzed.A total of 45 patients with postpartum cerebral arterial dissections were retrieved including our case, with an age range of 24 to 44 years (mean 34). Thirty-six (80%) patients were older than 30 years of age (mean 35). There were 17 cases of cesarean section, 14 cases of natural labor, and 14 cases whose delivery modes were not reported. The clinical symptoms included headache in 35 cases (78%) and neck pain in 14 (31%). The symptoms occurred at a mean time of 11 days (range 0-53 days) following delivery. Among 45 patients, arterial dissections involved unilateral carotid or vertebral artery in 29 cases (64%), bilateral carotid or vertebral arteries in 8 (18%), 3 arteries in 3 (7%), and all bilateral carotid and vertebral arteries in 5 (11%). Fourteen (31%) patients were treated with antiplatelet agents, 27 (60%) with anticoagulation, 7 (16%) with both antiplatelet and anticoagulation medications, and only 2 (4%) with stent angioplasty. The prognosis was complete recovery in 30 (86%) patients and mild focal neurological symptoms in 5 (14%).Postpartum cerebral arterial dissections are rare, and correct diagnosis relies on imaging examination. Prognosis is usually favorable in patients with early diagnosis and prompt treatment.
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Affiliation(s)
- Chun-Yun Ruan
- Luoyang Central Hospital, Zhengzhou University, China
| | - Bu-Lang Gao
- Henan Provincial People's Hospital, Zhengzhou University, China
| | - Hong-Li Pang
- Luoyang Central Hospital, Zhengzhou University, China
| | - Kun Zhang
- Henan Provincial People's Hospital, Zhengzhou University, China
| | - Yao-Hui Zhang
- Luoyang Central Hospital, Zhengzhou University, China
| | - Li-Ping Wei
- Luoyang Central Hospital, Zhengzhou University, China
| | - Tian-Xiao Li
- Henan Provincial People's Hospital, Zhengzhou University, China
| | - Zi-Liang Wang
- Henan Provincial People's Hospital, Zhengzhou University, China
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12
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Monari F, Busani S, Imbrogno MG, Neri I, Girardis M, Ghirardini A, Cavalleri F, Facchinetti F. Vertebral artery dissection in term pregnancy after cervical spine manipulation: a case report and review the literature. J Med Case Rep 2021; 15:530. [PMID: 34670622 PMCID: PMC8527659 DOI: 10.1186/s13256-021-03090-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/02/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, we focused on the differential diagnosis, reviewing the available evidence. CASE PRESENTATION A 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section. CONCLUSION Vertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.
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Affiliation(s)
- Francesca Monari
- Obstetrics and Gynecology Unit, Mother - Infant and Adult Department of Medical and Surgical Sciences, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124, Modena, Italy.
| | - Stefano Busani
- Department of Anaesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | - Maria Giovanna Imbrogno
- Obstetrics and Gynecology Unit, Mother - Infant and Adult Department of Medical and Surgical Sciences, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Isabella Neri
- Obstetrics and Gynecology Unit, Mother - Infant and Adult Department of Medical and Surgical Sciences, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Massimo Girardis
- Department of Anaesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | - Annamaria Ghirardini
- Department of Anaesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | - Francesca Cavalleri
- Department of Neuroradiology, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124, Modena, Italy
| | - Fabio Facchinetti
- Obstetrics and Gynecology Unit, Mother - Infant and Adult Department of Medical and Surgical Sciences, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124, Modena, Italy
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13
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Bojanowski MW, Stefanovic K, Bergeron D, Farzin B, Létourneau-Guillon L, Chaalala C. Pregnancy as a Subgroup in the Pathophysiologic Classification of Spinal Aneurysms. World Neurosurg 2021; 157:e264-e270. [PMID: 34637940 DOI: 10.1016/j.wneu.2021.10.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aneurysms of spinal arteries not associated with any known predisposing condition are referred to as isolated spinal aneurysms (SAs). In our series, an SA was found in 2 patients during the postpartum period. The goal of this study is to determine whether an occurrence of an SA may be related to puerperium. METHODS In a retrospective analysis of our consecutive series of 10 cases of SAs from 2008 to 2020, we identified 2 cases of SAs during puerperium. Patients' charts and imaging were reviewed, for potential predisposing factors. RESULTS In both cases, angiography showed fusiform aneurysms of the anterior SA with concomitant bilateral vertebral artery (VA) dissections. Serum vasculitis and inflammatory panel and genetic testing for collagen disorders were negative in both cases. Review of the literature showed that pregnancy is associated with an increased risk of arterial dissections in various locations and supports the hypothesis that hemodynamic and hormonal changes may play a role in the formation of SAs. CONCLUSIONS Pregnancy and peripartum state may be a distinct cause of the formation of SAs, possibly as a result of increased hemodynamic stress and hormonal changes that may alter the arterial wall. It would be appropriate to add pregnancy as a subgroup in the classification of SAs. In our series, both cases were associated with bilateral VA dissections; it is possible that the bilateral VA stenosis may have contributed to the formation of the SAs. It is important to recognize this possibility when considering the occlusion of a dissected VA.
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Affiliation(s)
| | | | - David Bergeron
- Division of Neurosurgery, University of Montreal, Montreal, Canada
| | - Behzad Farzin
- Department of Radiology, University of Montreal, Montreal, Canada
| | | | - Chiraz Chaalala
- Division of Neurosurgery, University of Montreal, Montreal, Canada
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14
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Azad HA, Prasad N, Shlobin NA, Mitra A, Cloney MB, Hopkins BS, Jahromi BS, Potts MB, Dahdaleh NS. Clinical Characteristics, Course, and Outcomes of Vertebral Artery Dissections in the Postpartum Period. Neurosurgery 2021; 89:792-799. [PMID: 34383947 DOI: 10.1093/neuros/nyab296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Postpartum vertebral artery dissections (ppVADs) are rare but potentially morbid conditions that occur in otherwise healthy patients. OBJECTIVE To evaluate clinical characteristics of ppVADs. METHODS Demographic, clinical, treatment, and outcome data were collected on ppVADs and are presented in a case series of 12 patients and compared to the general cohort. RESULTS In total, 12 patients had ppVADs in our cohort of 310 patients with vertebral artery dissections (VADs). They occurred 11.27 days (95% CI, -0.85 to 23.39) postdelivery. Of these, there were 5 (42%) with a hypertensive disorder of pregnancy, and 4 (33%) who had migraines. A total of 3 (25%) had ischemic strokes and 1 (8%) had a subarachnoid hemorrhage. In total, 2 patients (17%) had unfavorable modified Rankin Scale (mRS, 2-6) at discharge from hospital. Patients with ppVADs more often had bilateral VADs (42% vs 17%, P = .03), had pseudoaneurysms (50% vs 18%, P = .0068), were younger (33.83 years vs 44.32 years, P = .018), and had lower Charlson Comorbidity Index (CCI = 0 vs 0.99, P = .0038). Anticoagulant treatment was used in a similar percentage of patients. Multivariate analysis revealed 3 factors were predictive of change in mRS: CCI (OR = 1.09, 95% CI, 1.02-1.15), stroke (OR = 0.78, 95% CI, 0.65-0.95), and mRS at hospital discharge (OR = 0.80, 95% CI, 0.74-0.87). CONCLUSION There are only 15 isolated ppVADs reported in the literature; this study adds 12 patients with 17 ppVADs. Postpartum VADs occur in younger, healthier patients than in the general cohort, raising questions about mechanism of injury. The majority of ppVADs have good neurological outcomes.
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Affiliation(s)
- Hooman A Azad
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nikil Prasad
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Akash Mitra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael B Cloney
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Benjamin S Hopkins
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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15
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Beyer SE, Dicks AB, Shainker SA, Feinberg L, Schermerhorn ML, Secemsky EA, Carroll BJ. Pregnancy-associated arterial dissections: a nationwide cohort study. Eur Heart J 2021; 41:4234-4242. [PMID: 32728725 DOI: 10.1093/eurheartj/ehaa497] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 12/27/2022] Open
Abstract
AIMS Pregnancy is a known risk factor for arterial dissection, which can result in significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, timing, distribution, and outcomes of arterial dissections associated with pregnancy. METHODS AND RESULTS We included all women ≥12 years of age with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010 and 2015. The primary outcome was any dissection during pregnancy, delivery, or the postpartum period (42-days post-delivery). Secondary outcomes included timing of dissection, location of dissection, and in-hospital mortality. Among 18 151 897 pregnant patients, 993 (0.005%) patients were diagnosed with a pregnancy-related dissection. Risk factors included older age (32.8 vs. 28.0 years), multiple gestation (3.6% vs. 1.9%), gestational diabetes (14.3% vs. 0.2%), gestational hypertension (6.0% vs. 0.6%), and pre-eclampsia/eclampsia (2.7% vs. 0.4%), in addition to traditional cardiovascular risk factors. Of the 993 patients with dissection, 150 (15.1%) dissections occurred in the antepartum period, 232 (23.4%) were diagnosed during the admission for delivery, and 611 (61.5%) were diagnosed in the postpartum period. The most common locations for dissections were coronary (38.2%), vertebral (22.9%), aortic (19.8%), and carotid (19.5%). In-hospital mortality was 3.7% among pregnant patients with a dissection vs. <0.001% in patients without a dissection. Deaths were isolated to patients with an aortic (8.6%), coronary (4.2%), or supra-aortic (<2.5%) dissection. CONCLUSION Arterial dissections occurred in 5.5/100 000 hospitalized pregnant or postpartum women, most frequently in the postpartum period, and were associated with high mortality risk. The coronary arteries were most commonly involved. Pregnancy-related dissections were associated with traditional risk factors, as well as pregnancy-specific conditions.
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Affiliation(s)
- Sebastian E Beyer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Andrew B Dicks
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Loryn Feinberg
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA.,Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
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17
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Manasewitsch NT, Hanfy AA, Beutler BD, Antwi-Amoabeng D, Taha M, Elnaggar M, Chahal GS. Postpartum vertebral artery dissection: case report and review of the literature. Thromb J 2020; 18:30. [PMID: 33292273 PMCID: PMC7597033 DOI: 10.1186/s12959-020-00243-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/22/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are associated with vascular complications, including ischemic stroke and cervical artery dissection. Vertebral artery dissection (VAD), however, is rare. We describe a 31-year-old female who presented with vertigo, nausea, and vomiting and was found to have a VAD. In addition, we discuss the presentation, differential diagnosis, and pathogenesis of this uncommon but clinically significant vascular event and summarize other cases of vertebral artery dissection described in the medical literature. CASE PRESENTATION A 31-year-old Hispanic woman presented 10 days postpartum with a one-day history of vertigo, nausea, vomiting, and frontal headache. The patient's pregnancy course had been complicated by preeclampsia, chorioamnionitis, and iron-deficiency anemia, and her delivery was complicated by acute hemorrhage. Physical examination was significant for left leg ataxia. Laboratory studies showed marked thrombocytosis. Emergent computed tomography (CT) scan of the head was obtained and revealed a left cerebellar ischemic large vessel stroke. Subsequent CT angiography of the head and neck showed a left VAD. Based on correlation of the clinical history and laboratory and imaging findings, a diagnosis of vertebral artery dissection secondary to reactive (secondary) thrombocytosis from overlapping iron-deficiency anemia and acute hemorrhage was established. The patient was started on a heparin infusion and experienced significant improvement after a four-day hospitalization. CONCLUSION VAD is a rare but important cause of neurologic symptoms in the postpartum period and should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women aged 30 years or older and those with a history of a hypertensive disorder of pregnancy are at particularly high risk. Prompt diagnosis and management of VAD is essential to ensure favorable outcomes.
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Affiliation(s)
- Nicholas T Manasewitsch
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Ahmed A Hanfy
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Bryce D Beutler
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA.
| | - Daniel Antwi-Amoabeng
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Moutaz Taha
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Mohamed Elnaggar
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Gurpreet S Chahal
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
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18
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DeCarlo C, Boitano LT, Molina RL, Weinberg I, Conrad MF, Eagleton MJ, Dua A. Pregnancy and Preeclampsia Are Associated With Acute Adverse Peripheral Arterial Events. Arterioscler Thromb Vasc Biol 2020; 41:526-533. [PMID: 33054392 DOI: 10.1161/atvbaha.120.315174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Acute peripheral arterial events, such as aortic dissection, carotid artery dissection, vertebral artery dissection, and ruptured renoviseral aneurysms, have been reported during pregnancy in case series, but there is a paucity of population-based data. This study sought to establish pregnancy and preeclampsia as risk factors for acute peripheral arterial events. Approach and Results: All women who gave birth between 1998 and 2020 within a multicenter health care system were identified. Births that occurred in women <18 or >50 years of age were excluded. Primary outcome was any acute peripheral arterial event that was symptomatic or required intervention. Cox regression model was used to evaluate the association between vascular events and pregnancy as a time-varying covariate. The pregnancy exposure period was from the estimated date of conception to 3 months postpartum. There were 277 697 pregnancies (81.3% deliveries, 17.0% abortions, and 1.7% ectopics) among 176 635 women with 1.68 million patient-years of total follow-up (median, 7.9 years; interquartile range, 2.4-16.2). Preeclampsia complicated 5.3% of pregnancies; 67 790 of 225 763 (30.0%) deliveries were delivered by cesarean. Ninety-six acute arterial events occurred during follow-up, of which 24 occurred during pregnancy, including the postpartum period. Pregnancy (hazard ratio, 1.85 [95% CI, 1.01-3.38]; P=0.046) and preeclampsia (hazard ratio, 10.9 [95% CI, 5.24-22.7]; P<0.001) were significant independent predictors of acute arterial events. CONCLUSIONS While taking into account limitations from estimating conception and outcome dates, pregnancy, especially when complicated by preeclampsia, is associated with an increased risk of acute peripheral arterial events.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Laura T Boitano
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Rose L Molina
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (R.L.M.).,Division of Women's Health, Brigham and Women's Hospital, Boston, MA (R.L.M.)
| | - Ido Weinberg
- Fireman Vascular Center (I.W.), Massachusetts General Hospital, Boston.,Department of Medicine, Division of Vascular Medicine (I.W.), Massachusetts General Hospital, Boston
| | - Mark F Conrad
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Matthew J Eagleton
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Anahita Dua
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
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19
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Salehi Omran S, Parikh NS, Poisson S, Armstrong J, Merkler AE, Prabhu M, Navi BB, Riley LE, Fink ME, Kamel H. Association between Pregnancy and Cervical Artery Dissection. Ann Neurol 2020; 88:596-602. [PMID: 32525238 PMCID: PMC10001425 DOI: 10.1002/ana.25813] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We wanted to determine whether pregnancy is associated with cervical artery dissection. METHODS We performed a case-control study using claims data from all nonfederal emergency departments and acute care hospitals in New York and Florida between 2005 and 2015. Cases were women 12-42 years of age hospitalized with cervical artery dissection, defined using validated diagnosis codes for carotid/vertebral artery dissection. Controls were women 12-42 years of age with a primary diagnosis of renal colic. Cases and controls were matched 1:1 on age, race, insurance, income, state, and visit year. The exposure variable was pregnancy, defined as labor and delivery within 90 days before or 6 months after the index visit. Logistic regression was used to compare the odds of pregnancy between cases and controls. We performed a secondary cohort-crossover study comparing the risk of cervical artery dissection during pregnancy versus the same time period 1 year later. RESULTS Pregnancy was twice as common among 826 women with cervical artery dissection compared with the 826 matched controls with renal colic (odds ratio, 2.5; 95% confidence interval [CI], 1.3-4.7). In our secondary analysis, pregnancy was associated with a higher risk of cervical artery dissection (incidence rate ratio [IRR], 2.2; 95% CI, 1.3-3.5), with the heightened risk limited to the postpartum period (IRR, 5.5; 95% CI, 2.6-11.7). INTERPRETATION Pregnancy, specifically the postpartum period, was associated with hospitalization for cervical artery dissection. Although these findings might in part reflect ascertainment bias, our results suggest that arterial dissection is one mechanism by which pregnancy can lead to stroke. ANN NEUROL 2020;88:596-602.
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Affiliation(s)
- Setareh Salehi Omran
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA.,Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Sharon Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer Armstrong
- Department of Pediatrics (Neurology) and Obstetrics and Gynecology, University of Colorado Anschutz School of Medicine & Children's Hospital Colorado, Denver, CO, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Malavika Prabhu
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Matthew E Fink
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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20
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Abstract
Acute stroke in pregnancy can be devastating. Although neurologists will at some point be involved in the management, most of these patients are likely to first be evaluated by an obstetric care provider. It is, therefore, important for obstetric care providers to have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical. Once suspected, a head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component. Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]). Blood pressure (BP) control is paramount when administering tPA. During pregnancy, we recommend maintaining a BP between 140-160/90-110 mm Hg during tPA treatment. Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients. The use of therapeutic anticoagulation during the acute management of ischemic stroke is not indicated owing to an increased risk of hemorrhagic transformation. Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels. Serum glucose levels should be kept between 140 and 180 mg/dL. Antiplatelet agents are indicated for secondary prevention. The management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should overall follow same guidelines as for nonpregnant individuals.
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21
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Barghouthi T, Lemley R, Figurelle M, Bushnell C. Epidemiology of neurologic disease in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:119-141. [PMID: 32736746 DOI: 10.1016/b978-0-444-64239-4.00006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.
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Affiliation(s)
- Tamara Barghouthi
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Regan Lemley
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Morgan Figurelle
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Cheryl Bushnell
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States.
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22
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van Casteren DS, van den Brink AM, Terwindt GM. Migraine and other headache disorders in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:187-199. [PMID: 32768088 DOI: 10.1016/b978-0-444-64240-0.00011-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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23
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Irving Medical Center, New York, NY
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25
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview and update on the common causes of headache attributed to arterial hypertension with a focus on secondary headache disorders. We will also highlight uncommon and recent findings in this area of research. RECENT FINDINGS There is some controversy in the relationship between chronic hypertension and headache, particularly migraine; recent research suggests that there may be a link, but it is likely complex and multifactorial. Many recent studies and case reports demonstrate that the pathophysiology underlying the onset of headache as it relates to abrupt rises in blood pressure seems to lie at the cellular level and mechanically becomes an issue with disruption of the blood-brain barrier. Although not a formally defined headache entity, carotid revascularization syndrome demonstrates this phenomenon and also has a recent set of proposed criteria that include headache and elevated blood pressure. This paper reviews the various etiologies of hypertensive headaches, mostly in regard to headache as a secondary symptom of elevated blood pressure. We will also discuss trends of hypertensive headache in pregnancy. Finally, we will touch on controversy that exists in relation to chronic hypertension and its causal relationship to headache as well as the relationship between hypertension and migraine.
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Enesi E, Rroji A, Bilaj F, Reka E, Ndroqi A, Xhumari A, Lilamani E, Petrela M. Early reappearance of disappeared ruptured small aneurysm with concomitant vertebral artery dissection. Interv Neuroradiol 2018; 24:639-642. [PMID: 29969957 DOI: 10.1177/1591019918782964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thrombosis of a previously ruptured intracranial aneurysm is a frequent event and it most commonly occurs in large or giant aneurysms. We present a dynamic short-term follow-up and management of thrombosis in a ruptured small posterior inferior cerebellar artery aneurysm with concomitant vertebral artery dissection (VAD). Clinical and radiological follow-up findings and reviewed literature on thrombosis of small ruptured aneurysms are the focus of this presentation. Early reappearance of a disappeared ruptured small cerebral aneurysm with a concomitant VAD may be attributed to the controlled ovarian hyperstimulation phase of in vitro fertilization and prolonged use of oral contraceptive pills.
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Affiliation(s)
- Eugen Enesi
- 1 Department of Neuroradiology, University of Medicine Tirana, Tirana, Albania
| | - Arben Rroji
- 1 Department of Neuroradiology, University of Medicine Tirana, Tirana, Albania
| | - Fatmir Bilaj
- 1 Department of Neuroradiology, University of Medicine Tirana, Tirana, Albania
| | - Eni Reka
- 1 Department of Neuroradiology, University of Medicine Tirana, Tirana, Albania
| | - Adrian Ndroqi
- 2 Department of Neurosurgery, University of Medicine Tirana, Tirana, Albania
| | - Artur Xhumari
- 2 Department of Neurosurgery, University of Medicine Tirana, Tirana, Albania
| | - Ejona Lilamani
- 2 Department of Neurosurgery, University of Medicine Tirana, Tirana, Albania
| | - Mentor Petrela
- 2 Department of Neurosurgery, University of Medicine Tirana, Tirana, Albania
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27
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Aljishi M, Jayathissa S. Neurogenic pulmonary oedema secondary to vertebral artery dissection while playing tennis. BMJ Case Rep 2018; 2018:bcr-2017-221753. [PMID: 29374634 DOI: 10.1136/bcr-2017-221753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We present a case of a patient who developed vertebral artery dissection (VAD) while playing tennis and presented with neurogenic pulmonary oedema. The case highlights two important points: acute pulmonary oedema as an unusual presenting feature of VAD and VAD, an important cause of stroke in young people, as being associated with playing low-impact sports such as tennis. These associations, independent of each other, are under-recognised and can lead to a delay in diagnosis.
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Affiliation(s)
- Manaf Aljishi
- Department of Internal Medicine, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Sisira Jayathissa
- Department of Internal Medicine, Hutt Valley District Health Board, Lower Hutt, New Zealand
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28
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Chang BP, Wira C, Miller J, Akhter M, Barth BE, Willey J, Nentwich L, Madsen T. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department. Acad Emerg Med 2018; 25:54-64. [PMID: 28646558 PMCID: PMC6415947 DOI: 10.1111/acem.13243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. METHODS A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. RESULTS Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. CONCLUSION Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.
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Affiliation(s)
- Bernard P. Chang
- Department of Emergency Medicine, Columbia University Medical Center
| | - Charles Wira
- Department of Emergency Medicine, Yale-New Haven Medical Center
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Medical Center
| | - Murtaza Akhter
- Department of Emergency Medicine, University of Arizona College of Medicine–Phoenix, Maricopa Integrated Health System, Phoenix, AZ
| | - Bradley E. Barth
- Department of Emergency Medicine, University of Kansas Medical Center
| | - Joshua Willey
- Department of Neurology, Stroke Service, Columbia University Medical Center
| | | | - Tracy Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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29
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Swartz RH, Ladhani NNN, Foley N, Nerenberg K, Bal S, Barrett J, Bushnell C, Chan WS, Chari R, Dowlatshahi D, Amrani ME, Gandhi S, Gubitz G, Hill MD, James A, Jeerakathil T, Jin A, Kirton A, Lanthier S, Lausman A, Leffert LR, Mandzia J, Menon B, Pikula A, Poppe A, Potts J, Ray J, Saposnik G, Sharma M, Smith EE, Bhogal S, Smitko E, Lindsay MP. Canadian stroke best practice consensus statement: Secondary stroke prevention during pregnancy. Int J Stroke 2017; 13:406-419. [PMID: 29171360 DOI: 10.1177/1747493017743801] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Canadian Stroke Best Practice Consensus Statement: Secondary Stroke Prevention during Pregnancy, is the first of a two-part series devoted to stroke in pregnancy. This document focuses on unique aspects of secondary stroke prevention in a woman with a prior history of stroke or transient ischemic attack who is, or is planning to become, pregnant. Although stroke is relatively rare in this cohort, several aspects of pregnancy can increase stroke risk during or immediately after pregnancy. The rationale for the development of this consensus statement is based on the premise that stroke in this group requires a specifically-tailored management approach. No other broad-based, stroke-specific guidelines or consensus statements exist currently. Underpinning the development of this document was the concept that maternal health is vital for fetal wellbeing; therefore, management decisions should be based on the confluence of two clinical considerations: (a) decisions that would be made if the patient was not pregnant and (b) decisions that would be made if the patient had not had a stroke. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include general management considerations for secondary stroke prevention, the use of antithrombotics, blood pressure management, lipid management, diabetes care, and management for specific ischemic stroke etiologies in pregnancy. The focus is on maternal and fetal health while minimizing risks of a recurrent stroke, through counseling, monitoring, and the safety of select pharmacotherapy. These statements are appropriate for health care professionals across all disciplines.
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Affiliation(s)
- Richard H Swartz
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 12366 Faculty of Medicine (Neurology), University of Toronto , Canada
| | - Noor Niyar N Ladhani
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada
| | - Norine Foley
- 4 Department of Foods and Nutrition, Western University, London, ON, Canada.,5 workHORSE Consulting Group, London, ON, Canada
| | - Kara Nerenberg
- 6 Department of Medicine, 70401 University of Calgary , Canada
| | - Simerpreet Bal
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada
| | - Jon Barrett
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada
| | - Cheryl Bushnell
- 8 Wake Forest Baptist Stroke Center, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - Wee-Shian Chan
- 9 Department of Obstetric General Internal Medicine, 8163 British Columbia Women's Hospital , Vancouver, Canada
| | - Radha Chari
- 10 Department of Medicine & Dentistry, Obstetrics and Gynecology, 215465 University of Alberta , Canada
| | | | - Meryem El Amrani
- 12 Hôpital du Sacré-Coeur de Montréal, Neurology, Montreal, Canada
| | - Shital Gandhi
- 3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada.,13 Sinai Health System, Toronto, Canada
| | - Gord Gubitz
- 14 Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,15 Department of Medicine (Neurology), Dalhousie University, Canada
| | - Michael D Hill
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | - Andra James
- 17 Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - Thomas Jeerakathil
- 18 Department of Medicine & Dentistry (Neurosciences), 215465 University of Alberta , Canada
| | - Albert Jin
- 19 Department of Medicine, Queen's University, Canada
| | - Adam Kirton
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | - Sylvain Lanthier
- 12 Hôpital du Sacré-Coeur de Montréal, Neurology, Montreal, Canada
| | - Andrea Lausman
- 3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada.,20 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Canada
| | - Lisa Rae Leffert
- 21 Department of Obstetric Anesthesia, 2348 Massachusetts General Hospital , Boston, MA, USA
| | - Jennifer Mandzia
- 22 Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Bijoy Menon
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | - Aleksandra Pikula
- 2 12366 Faculty of Medicine (Neurology), University of Toronto , Canada.,23 Neurovascular Unit, UHN/Toronto Western Hospital, Toronto, ON, Canada
| | - Alexandre Poppe
- 24 Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Jayson Potts
- 9 Department of Obstetric General Internal Medicine, 8163 British Columbia Women's Hospital , Vancouver, Canada
| | - Joel Ray
- 3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada.,20 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Canada
| | - Gustavo Saposnik
- 2 12366 Faculty of Medicine (Neurology), University of Toronto , Canada.,25 St. Michael's Hospital Stroke Research Unit, Toronto, ON, Canada
| | - Mukul Sharma
- 26 Department of Medicine, Division of Neurology, McMaster University, Hamilton, ON, Canada
| | - Eric E Smith
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | | | - Elisabeth Smitko
- 27 282184 Heart and Stroke Foundation of Canada , Toronto, ON, Canada
| | - M Patrice Lindsay
- 27 282184 Heart and Stroke Foundation of Canada , Toronto, ON, Canada.,28 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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30
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Negro A, Delaruelle Z, Ivanova TA, Khan S, Ornello R, Raffaelli B, Terrin A, Reuter U, Mitsikostas DD. Headache and pregnancy: a systematic review. J Headache Pain 2017; 18:106. [PMID: 29052046 PMCID: PMC5648730 DOI: 10.1186/s10194-017-0816-0] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 10/11/2017] [Indexed: 02/06/2023] Open
Abstract
This systematic review summarizes the existing data on headache and pregnancy with a scope on clinical headache phenotypes, treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding, headache related complications, and diagnostics of headache in pregnancy. Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. Data regarding other primary headache conditions are still scarce. Early diagnostics of the disease manifested by headache is important for mother and fetus life. It is especially important to identify “red flag symptoms” suggesting that headache is a symptom of a serious disease. In order to exclude a secondary headache additional studies can be necessary: electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture. During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one. Treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.
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Affiliation(s)
- A Negro
- Department of Clinical and Molecular Medicine, Regional Referral Headache Centre, Sapienza University of Rome, Sant'Andrea Hospital, 00189, Rome, Italy.
| | - Z Delaruelle
- Department of Neurology, Ghent University Hospital, 9000, Ghent, Belgium
| | - T A Ivanova
- Institute of Professional Education, Chair of Neurology. I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - S Khan
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, -2600, Glostrup, DK, Denmark
| | - R Ornello
- Department of Neurology, University of L'Aquila, 67100, L'Aquila, Italy
| | - B Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - A Terrin
- Department of Neurosciences, Headache Centre, University of Padua, 35128, Padua, Italy
| | - U Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - D D Mitsikostas
- Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11528, Athens, Greece
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