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Sullivan-Baca E, Modiano YA, McKenney KM, Carlew AR. Pregnancy-related stroke through a neuropsychology lens. Clin Neuropsychol 2024; 38:1293-1312. [PMID: 36215407 DOI: 10.1080/13854046.2022.2131631] [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: 06/09/2022] [Accepted: 09/28/2022] [Indexed: 11/03/2022]
Abstract
Objective: Stroke represents a primary cause of morbidity and mortality in pregnant and postpartum people. While pregnancy-related stroke has drawn increased attention in certain domains of health research (e.g. obstetrics, neurology), neuropsychology has yet to contribute to this literature. Given neuropsychologists' crucial role in stroke evaluation and rehabilitation efforts, our field is poised to offer insights into this important topic. Method: This review presents facts about pregnancy-related stroke most relevant for neuropsychologists, including epidemiology, risk factors, and mechanisms, alongside clinical considerations and open areas of inquiry. Structured in the format of a traditional neuropsychological evaluation, we walk readers through factors to consider in record review, the clinical interview, and providing feedback and recommendations. Conclusions: Pregnancy-related stroke can be associated with marked functional disability and decreased quality of life, and it is notable that prevalence rates are increasing. Presenting at a time when people are experiencing adjustment to a new phase of life, and most commonly affecting women of color and other vulnerable populations, pregnancy-related stroke is a unique condition warranting special attention within the broader stroke discourse. This review aims to serve as a starting point for neuropsychologists to better understand the unique attributes of pregnancy-related stroke through a neuropsychology lens. Beyond that, it aims to promote broader meaningful discussion of neuropsychology's role in women's health.
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Affiliation(s)
| | - Yosefa A Modiano
- Vivian L Smith Department of Neurosurgery, UT Health Neurosciences, McGovern Medical School, Houston, TX, USA
| | - Kathryn M McKenney
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anne R Carlew
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
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2
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Miller EC, Kauko A, Tom SE, Laivuori H, Niiranen T, Bello NA. Risk of Midlife Stroke After Adverse Pregnancy Outcomes: The FinnGen Study. Stroke 2023; 54:1798-1805. [PMID: 37212139 PMCID: PMC10330298 DOI: 10.1161/strokeaha.123.043052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/25/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Adverse pregnancy outcomes (APO) contribute to higher risk of maternal cerebrovascular disease, but longitudinal data that include APO and stroke timing are lacking. We hypothesized that APO are associated with younger age at first stroke, with a stronger relationship in those with >1 pregnancy with APO. METHODS We analyzed longitudinal Finnish nationwide health registry data from the FinnGen Study. We included women who gave birth after 1969 when the hospital discharge registry was established. We defined APO as a pregnancy affected by gestational hypertension, preeclampsia, eclampsia, preterm birth, small for gestational age infant, or placental abruption. We defined stroke as first hospital admission for ischemic stroke or nontraumatic intracerebral or subarachnoid hemorrhage, excluding stroke during pregnancy or within 1 year postpartum. We used Kaplan-Meier survival curves and multivariable-adjusted Cox and generalized linear models to assess the relationship between APO and future stroke. RESULTS We included 144 306 women with a total of 316 789 births in the analysis sample, of whom 17.9% had at least 1 pregnancy with an APO and 2.9% experienced an APO in ≥2 pregnancies. Women with APO had more comorbidities including obesity, hypertension, heart disease, and migraine. Median age at first stroke was 58.3 years in those with no APO, 54.8 years in those with 1 APO, and 51.6 years in those with recurrent APO. In models adjusted for sociodemographic characteristics and stroke risk factors, risk of stroke was greater in women with 1 APO (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.4]) and recurrent APO (adjusted hazard ratio, 1.4 [95% CI, 1.2-1.7]) compared with those with no APO. Women with recurrent APO had more than twice the stroke risk before age 45 (adjusted odds ratio, 2.1 [95% CI, 1.5-3.1]) compared with those without APO. CONCLUSIONS Women who experience APO have earlier onset of cerebrovascular disease, with the earliest onset in those with more than 1 affected pregnancy.
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Affiliation(s)
- Eliza C Miller
- Department of Neurology, Columbia University, New York (E.C.M., S.E.T.)
| | - Anni Kauko
- Department of Internal Medicine, University of Turku, Finland (A.K., T.N.)
| | - Sarah E Tom
- Department of Neurology, Columbia University, New York (E.C.M., S.E.T.)
- Department of Epidemiology, Columbia University, New York (S.E.T.)
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Finland (H.L.)
- Center for Child, Adolescent, and Maternal Health Research, Tampere University, Finland (H.L.)
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Tampere University (H.L.)
| | - Teemu Niiranen
- Department of Internal Medicine, University of Turku, Finland (A.K., T.N.)
- Department of Health, Finnish Institute for Health and Welfare (T.N.)
| | - Natalie A Bello
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (N.A.B.)
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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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Dong J, Ma X. Uncommon Female-Predominant Etiologies of Cryptogenic Stroke. Front Neurol 2022; 13:900991. [PMID: 35812089 PMCID: PMC9263352 DOI: 10.3389/fneur.2022.900991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
The etiologies of cryptogenic stroke are complex and heterogeneous. A number of uncommon etiologies are not fully recognized, some of which predominantly affect females. Most of these etiologies are closely related to the hormonal level, reproductive factors, coagulation function, and medications of females. Moreover, once cryptogenic stroke is diagnosed, females tend to have worse outcomes. Therefore, prompt etiological recognition and treatment are crucial for good recovery. The aim of this article is to review advances in exploring uncommon female-predominant etiologies of cryptogenic stroke. These etiologies are categorized into arterial, cardiac, and venous sources. Arterial vasoconstrictive narrowing, intimal injury, and intimal developmental abnormality can cause brain ischemia or artery-to-artery cerebral embolism. Myocardial contraction dysfunction, cardiac wall injury, and developmental abnormality can induce intracardiac thrombosis and lead to cardiac embolism. In addition, cortical venous thrombosis and occult venous thromboembolism via intracardiac or extracardiac channels also account for cryptogenic stroke in females. Due to the lack of knowledge, in clinical practice, the above etiologies are seldom assessed. The low incidence rate of these etiologies can lead to missed diagnosis. This review will provide novel clinical clues for the etiological diagnosis of cryptogenic stroke and will help to improve the management and secondary prevention of stroke in the female population. In the future, more studies are needed to explore the etiology and prevention strategies of cryptogenic stroke.
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Affiliation(s)
- Jing Dong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Disorders, Beijing, China
- Clinical Center for Cardio-Cerebrovascular Disease of Capital Medical University, Beijing, China
- *Correspondence: Xin Ma
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5
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Pregnancy-Related Stroke: A Review. Obstet Gynecol Surv 2022; 77:367-378. [PMID: 35672877 DOI: 10.1097/ogx.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance The maternal risk of strokes in the United States is approximately 30/100,000 pregnancies, and strokes are the eighth leading cause of maternal death. Because of the relationship between stroke and significant neurological disability/maternal death, obstetrical health care providers must be able to identify, evaluate, diagnosis, and treat these women. Evidence Acquisition PubMed was searched using the search terms "stroke" OR "cerebrovascular accident" OR "intracranial hemorrhage" AND "pregnancy complications" OR "risk factors" OR "management" OR "outcome." The search was limited to the English language and was restricted to articles from 2000 to 2020. Results There were 319 abstracts identified, and 90 of the articles were ultimately used as the basis of this review. Presenting stroke signs and symptoms include headache, composite neurologic defects, seizures, and/or visual changes. Diagnosis is typically made with computed tomography scan using abdominal shielding or magnetic resonance imaging without contrast. Management options for an ischemic stroke include reperfusion therapy with intravenous recombinant tissue plasminogen activator catheter-based thrombolysis and/or mechanical thrombectomy. Hemorrhagic strokes are treated similarly to strokes outside of pregnancy, and that treatment is based on the severity and location of the hemorrhage. Conclusions and Relevance Early recognition and management are integral in decreasing the morbidity and mortality associated with a stroke in pregnancy. Relevance Statement This study was an evidence-based review of stroke in pregnancy and how to diagnose and mange a pregnancy complicated by a stroke.
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Newton F, Smith M, Walker J, Pradhan S. Spontaneous postpartum intracranial haemorrhage: A case report. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_81_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Postpartum Acute Basilar Artery Occlusion Secondary to Vertebral Artery Dissection. Case Report and Literature Review. J Crit Care Med (Targu Mures) 2021; 7:294-301. [PMID: 34934820 PMCID: PMC8647675 DOI: 10.2478/jccm-2021-0015] [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: 01/17/2021] [Accepted: 05/16/2021] [Indexed: 11/21/2022] Open
Abstract
Female patients in the peripartum and postpartum periods have an increased risk of stroke than nonpregnant women. Cerebrovascular complications of pregnancy represent a significant cause of maternal mortality and morbidity and are potentially disabling. Acute basilar artery occlusion secondary to spontaneous vertebral artery dissection in the postpartum period is an infrequent entity and a major diagnostic and treatment challenge. In the present case, a 37-year-old female patient, eight weeks after caesarean delivery, presented with a history of sudden cervical pain, followed by headache and dizziness. Some hours later, she was found unconscious by her family and was transferred to the emergency department, where a neurological status assessment suggested vertebrobasilar stroke. The imagistic workup revealed right vertebral artery dissection and basilar artery occlusion without constituted ischemic lesions. The patient underwent endovascular intervention with dilation of the narrowed vertebral artery and stent retriever basilar artery thrombectomy, with a favourable clinical outcome. This report first presents the details of this case and the relevant literature data on postpartum arterial dissections and the subsequent ischemic complications and available treatment options.
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Yamakawa S, Kisimoto K, Wada K, Hashimoto Y, Ueda M. [A case of antepartum reversible cerebral vasoconstriction syndrome]. Rinsho Shinkeigaku 2021; 61:681-686. [PMID: 34565754 DOI: 10.5692/clinicalneurol.cn-001627] [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: 11/05/2022]
Abstract
A 35-year-old pregnant woman with mild migraine experienced thunderclap headache at 37 weeks of gestation. Her cerebral MRA showed arterial segmental narrowing of right middle cerebral artery and bilateral posterior cerebral artery. When admitted, she had no sign of eclampsia/preeclampsia. After 4 days, she had premature rupture of the membrane and gave birth by caesarean section. Caesarean section immediately resolved the headache. The postpartum course of the patient and her baby was uneventfull. One month after her onset, her cerebral MRA showed improvement in arterial segmental narrowing of cerebral artery. We diagnosed reversible cerebral vasoconstriction syndrome (RCVS) assoiated with pregnancy. Pregnancy-related RCVS develops primarily during the puerperal period, but our case was a rare case that developed just before delivery and was successful with aggressive intervention. When antepartum RCVS develops, early cesarean section with epidural anesthesia in parallel with active treatment for headache may lead to good outcomes for both mother and child.
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Affiliation(s)
| | - Kaori Kisimoto
- Department of Obstetrics and Gynecology, Kumamoto City Hospital
| | | | | | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
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Magid-Bernstein J, Omran SS, Parikh NS, Merkler AE, Navi B, Kamel H. Reversible Cerebral Vasoconstriction Syndrome: Symptoms, Incidence, and Resource Utilization in a Population-Based US Cohort. Neurology 2021; 97:e248-e253. [PMID: 34050007 PMCID: PMC8302148 DOI: 10.1212/wnl.0000000000012223] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/14/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To estimate the incidence of hospitalization for reversible cerebral vasoconstriction syndrome (RCVS), we identified RCVS-related hospital admissions across 11 US states in 2016. METHODS We tested the validity of ICD-10 code I67.841 in 79 patients with hospital admissions for RCVS or other cerebrovascular diseases at 1 academic and 1 community hospital. After determining that this code had a sensitivity of 100% (95% confidence interval [CI], 82%-100%) and a specificity of 90% (95% CI, 79%-96%), we applied it to administrative data from the Healthcare Cost and Utilization Project on all hospital admissions across 11 states. Age- and sex-standardized RCVS incidence was calculated using census data. Descriptive statistics were used to analyze associated diagnoses. RESULTS Across 5,067,250 hospital admissions in our administrative data, we identified 222 patients with a discharge diagnosis of RCVS in 2016. The estimated annual age- and sex-standardized incidence of RCVS hospitalization was 2.7 (95% CI, 2.4-3.1) cases per million adults. Many patients had concomitant neurologic diagnoses, including subarachnoid hemorrhage (37%), ischemic stroke (16%), and intracerebral hemorrhage (10%). In the 90 days before the index admission, 97 patients had an emergency department (ED) visit and 34 patients a hospital admission, most commonly for neurologic, psychiatric, and pregnancy-related diagnoses. Following discharge from the RCVS hospital admission, 58 patients had an ED visit and 31 had a hospital admission, most commonly for neurologic diagnoses. CONCLUSIONS Using population-wide data, we estimated the age- and sex-standardized incidence of hospitalization for RCVS in US adults as approximately 3 per million per year.
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Affiliation(s)
- Jessica Magid-Bernstein
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Setareh S Omran
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Neal S Parikh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Alexander E Merkler
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Babak Navi
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora.
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Liew J, Feghali J, Huang J. Intracerebral and subarachnoid hemorrhage in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 172:33-50. [PMID: 32768093 DOI: 10.1016/b978-0-444-64240-0.00002-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maternal stroke occurs in around 34 out of every 100,000 deliveries and is responsible for around 5%-12% of all maternal deaths. It is most commonly hemorrhagic, and women are at highest risk for developing pregnancy-related hemorrhage during the early postpartum period through 6 weeks following the delivery. The most common causes of hemorrhagic stroke in pregnant patients are arteriovenous malformations and cerebral aneurysms. Management is similar to that for acute hemorrhagic stroke in the nonpregnant population with standard use of computed tomography and judicious utilization of intracranial vessel imaging and contrast. The optimal delivery method is evaluated on a case-by-case basis, and cesarean delivery is not always required. As most current studies are limited by retrospective design, relatively small sample sizes, and heterogeneous study term definitions, strong and comprehensive evidence-based guidelines on the management of acute hemorrhagic stroke in pregnant patients are still lacking. In the future, multicenter registries and prospective studies with uniform definitions will help improve management strategies in this complex patient population.
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Affiliation(s)
- Jason Liew
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Hanson R, Brown P, Temple-Cooper M, Hoyt M. Puerperium Stroke and Subsequent Tissue-Type Plasminogen Activator-Induced Hemorrhage: A Case Report. A A Pract 2021; 15:e01459. [PMID: 33955867 DOI: 10.1213/xaa.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of ischemic stroke in an apparently healthy 35-year-old gravida 2 para 1 who was treated with tissue-type plasminogen activator (tPA) 9 hours after vaginal delivery that resulted in severe hemorrhage. Limited data suggest use of thrombolytics in pregnancy is safe, but there is a paucity of evidence assessing their use immediately postpartum. We describe successful combination of tPA with endovascular mechanical thrombectomy (EMT) for treatment of postpartum stroke, which was followed by extensive uterine bleeding.
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Affiliation(s)
| | - Peter Brown
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mary Temple-Cooper
- Department of Pharmacy, Hillcrest Hospital, Cleveland Clinic Health System, Mayfield Heights, Ohio
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Karjalainen L, Tikkanen M, Rantanen K, Aarnio K, Korhonen A, Saaros A, Laivuori H, Gissler M, Ijäs P. Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987-2016. Neurology 2021; 96:e2564-e2575. [PMID: 33827961 DOI: 10.1212/wnl.0000000000011990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS. METHODS We performed a retrospective population-based cohort study and nested case-control study in Finland from 1987 to 2016. The Medical Birth Register (MBR) was linked to the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period in 5-year age groups and pregnancy/postpartum period was calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors. RESULTS After chart review, 29.6% (257 of 868) of cases were PAS. The incidence of PAS was 14.5 (95% confidence interval [CI] 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987 to 1991 to 2012 to 2016 (p < 0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from 20 to 24 years to >40 years of age (p < 0.0001). During the early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable-adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95% CI 1.2-2.7), migraine (OR 16.3, 95% CI 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95% CI 2.5-6.3) were the most important risk factors for PAS. CONCLUSION PAS incidence is increasing, stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine, and hypertensive disorders of pregnancy are associated with an increased risk of PAS.
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Affiliation(s)
- Liisa Karjalainen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
| | - Minna Tikkanen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Kirsi Rantanen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Karoliina Aarnio
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Aino Korhonen
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Anna Saaros
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Hannele Laivuori
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Mika Gissler
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Petra Ijäs
- From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
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13
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Abstract
Maternal mortality rates have been steadily increasing in the United States, and cardiovascular mortality is the leading cause of death among pregnant and postpartum women. Maternal stroke accounts for a significant burden of cardiovascular mortality. Data suggest that rates of maternal stroke have been increasing in recent years. Advancing maternal age at the time of birth and the increasing prevalence of traditional cardiovascular risk factors, and other risk factors, as well, such as hypertensive disorders of pregnancy, migraine, and infections, may contribute to increased rates of maternal stroke. In this article, we provide an overview of the epidemiology of maternal stroke, explore mechanisms that may explain increasing rates of stroke among pregnant women, and identify key knowledge gaps for future investigation in this area.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha (I.Y.E.)
| | - Syed Bukhari
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (S.B., A.F.B.)
| | - Amr F Barakat
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (S.B., A.F.B.)
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville (C.J.P.)
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, MO (K.J.L.)
| | - Eliza C Miller
- Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (E.C.M.)
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14
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Wang N, Shen X, Zhang G, Gao B, Lerner A. Cerebrovascular disease in pregnancy and puerperium: perspectives from neuroradiologists. Quant Imaging Med Surg 2021; 11:838-851. [PMID: 33532282 DOI: 10.21037/qims-20-830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pregnancy-related cerebrovascular disease is a serious complication of pregnancy and puerperium. The etiology and pathological mechanisms of cerebrovascular disease are complex, involving changes in the cardiovascular, endocrine, and immune systems. Vascular risk factors during pregnancy and puerperium may cause vasospasm and endothelial cell damage leading to cerebral ischemia, hemorrhage, posterior reversible encephalopathy syndrome (PRES), and reversible cerebral vasoconstriction syndrome. Arterial or venous obstruction may damage the blood-brain barrier (BBB) and impede venous return, resulting in cerebral edema, hemorrhage, and intracranial hypertension. Pregnancy with hypercoagulability may threaten the lives of both the mother and the developing fetus. With improvements in stroke treatment during pregnancy and puerperium, neuroradiologists have gained new insights into this problem. This article reviews the pathogenesis, imaging findings, and risk factors of stroke during pregnancy and puerperium, focusing on imaging diagnosis and prognostic assessment.
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Affiliation(s)
- Naiwu Wang
- Department of Radiology, Jinan City People's Hospital, Laiwu, China
| | - Xudong Shen
- Department of Radiology, Enshi Center Hospital, Enshi, China
| | - Gang Zhang
- Department of Radiology, Yantai Yuhuangding Hospital, Yantai, China
| | - Bo Gao
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China
| | - Alexander Lerner
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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15
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Elgendy IY, Gad MM, Mahmoud AN, Keeley EC, Pepine CJ. Acute Stroke During Pregnancy and Puerperium. J Am Coll Cardiol 2020; 75:180-190. [PMID: 31948647 DOI: 10.1016/j.jacc.2019.10.056] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/17/2019] [Accepted: 10/28/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Acute stroke during pregnancy or within 6 weeks of childbirth is devastating for the mother and her family, yet data regarding incidence and contemporary trends are very limited. OBJECTIVES This study sought to investigate the incidence and outcomes of acute stroke and transient ischemic attack during pregnancy or within 6 weeks of childbirth in a large database. METHODS The National Inpatient Sample was queried to identify women age ≥18 years in the United States with pregnancy-related hospitalizations from January 1, 2007, to September 30, 2015. Temporal trends in acute stroke (ischemic and hemorrhagic)/transient ischemic attack incidence and in-hospital mortality were extracted. RESULTS Among 37,360,772 pregnancy-related hospitalizations, 16,694 (0.045%) women had an acute stroke. The rates of acute stroke did not change (42.8 per 100,000 hospitalizations in 2007 vs. 42.2 per 100,000 hospitalizations in 2015; ptrends = 0.10). Among those with acute stroke, there were increases in prevalence of obesity, smoking, hyperlipidemia, migraine, and gestational hypertension. Importantly, in-hospital mortality rates were almost 385-fold higher among those who had a stroke (42.1 per 1,000 pregnancy-related hospitalizations vs. 0.11 per 1,000 pregnancy-related hospitalizations; p < 0.0001). The rates of in-hospital mortality among pregnant women with acute stroke decreased (5.5% in 2007 vs. 2.7% in 2015; ptrends < 0.001). CONCLUSIONS In this contemporary analysis of pregnancy-related hospitalizations, acute stroke occurred in 1 of every 2,222 hospitalizations, and these rates did not decrease over approximately 9 years. The prevalence of most stroke risk factors has increased. Acute stroke during pregnancy and puerperium was associated with high maternal mortality, although it appears to be trending downward. Future studies to better identify mechanisms and approaches to prevention and management of acute stroke during pregnancy and puerperium are warranted.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Mohamed M Gad
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmed N Mahmoud
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
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16
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Abstract
PURPOSE OF REVIEW Hypertension affects approximately 10% of pregnancies and may persist in the postpartum period. Furthermore, de novo hypertension may present after delivery, but its exact prevalence is not verified. Both types of hypertension expose the mother to eventually severe complications like eclampsia, stroke, pulmonary edema, and HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome. RECENT FINDINGS Until today, there are limited data regarding the risk factors, pathogenesis, and pathophysiology of postpartum hypertensive disorders. However, there is certain evidence that preeclampsia may in large part be responsible. Women who experienced preeclampsia during pregnancy, although considered cured after delivery and elimination of the placenta, continue to present endothelial and renal dysfunction in the postpartum period. The brain and kidneys are particularly sensitive to this pathological vascular condition, and severe complications may result from their involvement. Large randomized trials are needed to give us the evidence that will allow a timely diagnosis and treatment. Until then, medical providers should increase their knowledge regarding hypertension after delivery because many times there is an underestimation of the complications that can ensue after a misdiagnosed or undertreated postpartum hypertension.
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Affiliation(s)
- V Katsi
- Cardiology Department, Hippokration Hospital, Athens, Greece
| | - G Skalis
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece.
| | - G Vamvakou
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
| | - D Tousoulis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - T Makris
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
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17
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Abstract
Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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18
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Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:3-31. [PMID: 32768092 PMCID: PMC7528571 DOI: 10.1016/b978-0-444-64240-0.00001-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Jean Rodriguez Lopez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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19
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Burch R. Epidemiology and Treatment of Menstrual Migraine and Migraine During Pregnancy and Lactation: A Narrative Review. Headache 2019; 60:200-216. [DOI: 10.1111/head.13665] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Rebecca Burch
- John R. Graham Headache Center, Department of Neurology Brigham and Women's Hospital, Harvard Medical School Boston MA USA
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20
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Descamps R, Envain F, Kuchcinski G, Clouqueur E, Henon H, Gonzalez-Estevez M. Cesarean section under general anesthesia for antepartum reversible cerebral vasoconstriction syndrome: A case report. J Obstet Gynaecol Res 2019; 45:2461-2465. [PMID: 31463978 DOI: 10.1111/jog.14107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/14/2019] [Indexed: 12/14/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute and usually severe headache related to multifocal vasoconstriction of cerebral arteries, reversible within 3 months. About 10% of RCVS are pregnancy-related, but only three cases of antepartum RCVS have been described. We report the case of a 26-year-old pregnant woman who presented at 36 weeks gestation with antepartum RCVS. Delivery was managed by cesarean section under general anesthesia. Though she developed focal neurologic deficits on the first postoperative day, these resolved at hospital discharge. This case highlights pre- and post-partum multidisciplinary management including cesarean section under general anesthesia.
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Affiliation(s)
- Richard Descamps
- Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire de Caen, Caen, France
| | - François Envain
- Department of Obstetrics and Gynecology, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Grégory Kuchcinski
- Department of Neuroradiology, Hôpital Roger Salengro, Centre Hospitalier Universitaire de Lille and Lille University, Lille, France
| | - Elodie Clouqueur
- Department of Obstetrics and Gynecology, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Hilde Henon
- Department of Neurology and Neurovascular Medicine, Hôpital Roger Salengro, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Max Gonzalez-Estevez
- Department of Anesthesiology and Critical Care, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
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21
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Abstract
PURPOSE OF THE REVIEW Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence. RECENT FINDINGS The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.
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Affiliation(s)
- Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
- Neurological Institute of New York, 710 West 168th Street, 6th floor, New York, NY, 10032, USA.
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22
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Abstract
Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6 weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.
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23
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Bushnell CD, Chaturvedi S, Gage KR, Herson PS, Hurn PD, Jiménez MC, Kittner SJ, Madsen TE, McCullough LD, McDermott M, Reeves MJ, Rundek T. Sex differences in stroke: Challenges and opportunities. J Cereb Blood Flow Metab 2018; 38:2179-2191. [PMID: 30114967 PMCID: PMC6282222 DOI: 10.1177/0271678x18793324] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 12/19/2022]
Abstract
Biologic sex influences many variables that are important to brain health in general, and to stroke or cerebral ischemia in particular, such as general health status, cerebrovascular anatomy and function, unique risk factors such as pregnancy and preeclampsia, symptomatology, and therapeutic response. A more complete understanding of the scale and depth of sexual dimorphism in the brain and the role of more general sex-based factors is crucial to reducing the burden of stroke in women and men. This focused review highlights recent findings in stroke, including sex differences in epidemiology, risk factor reduction, comparative use of stroke therapeutics in both sexes, the importance of frailty in women, and the biologic basis for sex differences in stroke. Such findings show tremendous promise for the future of personalized medicine in stroke prevention and treatment.
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Affiliation(s)
| | - Seemant Chaturvedi
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kathy R Gage
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado, Denver, CO, USA
| | - Patricia D Hurn
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Monik C Jiménez
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven J Kittner
- Baltimore Veterans Administration Medical Center and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, Lansing, MI, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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24
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Ladhani NNN, Swartz RH, Foley N, Nerenberg K, Smith EE, Gubitz G, Dowlatshahi D, Potts J, Ray JG, Barrett J, Bushnell C, Bal S, Chan WS, Chari R, El Amrani M, Gandhi S, Hill MD, James A, Jeerakathil T, Jin A, Kirton A, Lanthier S, Lausman A, Leffert LR, Mandzia J, Menon B, Pikula A, Poppe A, Saposnik G, Sharma M, Bhogal S, Smitko E, Lindsay MP. Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy. Int J Stroke 2018; 13:743-758. [PMID: 30021491 DOI: 10.1177/1747493018786617] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.
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Affiliation(s)
- Noor Niyar N Ladhani
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Richard H Swartz
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada
| | - Norine Foley
- 4 Department of Foods and Nutrition, Western University, London, Ontario, Canada.,5 workHORSE Consulting Group, London, Ontario, Canada
| | - Kara Nerenberg
- 6 Department of Medicine, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Gord Gubitz
- 9 Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,10 Department of Medicine (Neurology), Dalhousie University, Halifax, Canada
| | | | - Jayson Potts
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Joel G Ray
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Jon Barrett
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Cheryl Bushnell
- 14 Wake Forest Baptist Stroke Center, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - Simerpreet Bal
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Wee-Shian Chan
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Radha Chari
- 15 Faculty of Medicine & Dentistry, Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Meryem El Amrani
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Shital Gandhi
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,17 Sinai Health System, Toronto, Canada
| | - Michael D Hill
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Andra James
- 18 Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - Thomas Jeerakathil
- 19 Department of Medicine & Dentistry (Neurosciences), University of Alberta, Edmonton, Canada
| | - Albert Jin
- 20 Department of Medicine, Queen's University, Kingston, Canada
| | - Adam Kirton
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Sylvain Lanthier
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Andrea Lausman
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Lisa Rae Leffert
- 21 Department of Obstetric Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Mandzia
- 22 Department of Clinical Neurological Sciences, Western University, London, Canada
| | - Bijoy Menon
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Aleksandra Pikula
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,23 Neurovascular Unit, University Health Network/Toronto Western Hospital, Toronto, Canada
| | - Alexandre Poppe
- 24 Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Gustavo Saposnik
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,25 Stroke Research Unit, St. Michael's Hospital, Toronto, Canada
| | - Mukul Sharma
- 26 Division of Neurology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Sanjit Bhogal
- 5 workHORSE Consulting Group, London, Ontario, Canada
| | | | - M Patrice Lindsay
- 27 Heart and Stroke Foundation of Canada, Toronto, Canada.,28 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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25
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Wakefield BW, Masterson CMC, Borges MT, Hurt KJ. Pancreatic Cancer in Pregnancy Presenting with Thromboembolic Events: Case Report and Review of the Literature. Gynecol Obstet Invest 2018; 83:404-409. [PMID: 29886492 DOI: 10.1159/000487046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/19/2018] [Indexed: 11/19/2022]
Abstract
Stroke and hepatic vein thrombosis are highly associated with neoplasia but are extremely rare events in young, pregnant women. Rare and recurrent thrombotic events in pregnancy increase the suspicion for occult malignancy. We describe the case of a healthy 31-year-old G2P1 who presented with visual changes and dysarthria during pregnancy. Imaging showed cerebral infarcts. Her thrombophilia evaluation was negative. During delivery, she was diagnosed with fulminant Budd-Chiari Syndrome. Hepatic ultrasound suggested malignancy or metastasis, and postpartum CT scan and biopsy confirmed the diagnosis of Stage IV pancreatic cancer. Although rare in pregnancy, a new diagnosis of malignancy should be considered in patients with recurrent unexplained hypercoagulable complications. We propose an evidence-based algorithm for evaluation of occult malignancy in pregnancy based upon this case and review of the literature.
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Affiliation(s)
- Brian W Wakefield
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Manuel T Borges
- Department of Neuroradiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - K Joseph Hurt
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Terón I, Eng MS, Katz JM. Causes and Treatment of Acute Ischemic Stroke During Pregnancy. Curr Treat Options Neurol 2018; 20:21. [PMID: 29785465 DOI: 10.1007/s11940-018-0506-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Treatment recommendations for pregnancy associated ischemic stroke are scarce. This may be due to the fact that, in general, obstetricians tend not to make recommendations for stroke patients and neurologists are not commonly involved in the care of pregnant women. Herein, we review the multiple etiologies of ischemic stroke during pregnancy, considerations for diagnostic testing, and acute treatment and prevention options, including associated risks specific to the pregnant and puerperal state. RECENT FINDINGS Intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy have been used successfully to treat pregnant women with acute ischemic stroke. Recent national guidelines recommend considering tPA use during pregnancy for moderate and severe strokes if the potential benefits offset the risks of uterine hemorrhage. Pregnancy-associated ischemic stroke is rare, but can be devastating, and recanalization therapy should not be systematically withheld. Women who are at risk for stroke should be followed carefully, and providers caring for pregnant women should be educated regarding stroke signs and symptoms. Many of the standard post stroke diagnostic modalities may be used safely in pregnancy, and primary and secondary stroke prevention therapy must be tailored to avoid fetal toxicity.
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Affiliation(s)
- Ina Terón
- Department of Neurology, North Shore University Hospital and Zucker School of Medicine at Hofstra/Northwell, and Feinstein Institute for Medical Research, 300 Community Drive, 9 Tower, Manhasset, NY, 11030, USA.
| | | | - Jeffrey M Katz
- Department of Neurology, North Shore University Hospital and Zucker School of Medicine at Hofstra/Northwell, and Feinstein Institute for Medical Research, 300 Community Drive, 9 Tower, Manhasset, NY, 11030, USA.,Department of Radiology, North Shore University Hospital and Zucker School of Medicine at Hofstra/Northwell, and Feinstein Institute for Medical Research, Hempstead, NY, 11549, USA
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Sanders BD, Davis MG, Holley SL, Phillippi JC. Pregnancy-Associated Stroke. J Midwifery Womens Health 2018; 63:23-32. [PMID: 29369478 DOI: 10.1111/jmwh.12720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 10/13/2017] [Accepted: 10/22/2017] [Indexed: 10/18/2022]
Abstract
Cerebrovascular accident, or stroke, is the fourth leading cause of death for all women and the eighth leading cause of pregnancy-associated death. The physiologic changes of pregnancy increase the risk of cerebrovascular accident for women. With current incidence rates, a facility with 3300 births per year can anticipate caring for one woman with a pregnancy-related stroke at least every 2 years. All maternity care providers must be able to assess women experiencing stroke-like symptoms and initiate timely care to mitigate brain tissue damage, decrease long-term morbidity, and prevent mortality. The 2 main types of stroke, ischemic and hemorrhagic, have similar presenting symptoms but very different pathophysiology and treatment. This article reviews assessment and initial treatment of pregnant and postpartum women experiencing stroke and provides guidance for subsequent maternity and primary care to assist front-line perinatal care providers who may be the first to treat affected women or may resume primary care after diagnosis.
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Neurologic Deterioration in Patients with Moyamoya Disease during Pregnancy, Delivery, and Puerperium. World Neurosurg 2017; 111:e7-e17. [PMID: 29180090 DOI: 10.1016/j.wneu.2017.11.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND We reviewed our clinical experience of patients with moyamoya disease (MMD) who gave birth and assessed characteristics of those experiencing neurologic deterioration. METHODS The patients were classified into patients diagnosed with MMD during pregnancy and puerperium (group 1) and those diagnosed before pregnancy (group 2). We retrospectively reviewed patient characteristics, MMD treatment, neurologic symptoms before and during pregnancy and/after puerperium, obstetrical history, and delivery type in groups 1 and 2. RESULTS Group 1 included 2 patients with deterioration of pre-existing transient ischemic attacks (TIAs) and acute cerebral infarction and 1 patient with seizures and newly developed TIAs during pregnancy and/or puerperium. Group 2 included 20 patients with 23 pregnancies. In group 2, 4 patients had deterioration of TIAs during pregnancy and puerperium. There were significant differences between the cases without neurologic deterioration and with deterioration in group 2 (TIAs ≥10 before pregnancy, 0% vs. 75%, P = 0.002; severely reduced regional cerebrovascular reserve on single-photon emission computed tomography, 10.5% vs. 100%, P = 0.002; and surgical revascularization before pregnancy, 75% vs. 15.8%, P = 0.04). In groups 1 and 2, 6 of the 7 cases in which TIAs occurred or worsened during pregnancy or puerperium recovered to prepregnancy TIA levels after puerperium. CONCLUSIONS Patients with severely reduced regional cerebrovascular reserve on single-photon emission computed tomography and frequent TIAs before pregnancy may experience neurologic deterioration during pregnancy, delivery, and puerperium. Surgical revascularization before pregnancy may decrease neurologic deterioration during these periods.
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Cohen H, Rossignol M. [Maternal death by stroke. Results from the French enquiry into maternal deaths, 2010-2012]. ACTA ACUST UNITED AC 2017; 45:S65-S70. [PMID: 29153848 DOI: 10.1016/j.gofs.2017.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Indexed: 10/18/2022]
Abstract
Stroke is a rare event during pregnancy (10/100,000) and can be ischemic (24%), hemorrhagic (74%) or both (2%). Pregnancy probably increases the risk even if it is discussed for arteriovenous malformation (AVM), aneurismal subarachnoid hemorrhage (SAH) and cavernomas. Between 2010 and 2012, 31 maternal deaths were associated with stroke. In 22 cases, stroke was the direct cause of death giving a maternal mortality ratio of 0,9/100,000 witch is not different from the former report (2007-2009). There were 2 cerebral thrombophlebitis, 2 ischemic strokes and 18 hemorrhagic strokes (4 SAH, 2 AVM). These deaths occurred during ongoing pregnancy in 5 cases (25%), after miscarriage in 1 case (5%) and in the post-partum period in 14 cases (70%). In this last situation, stroke occurred before delivery in 4 cases and during the post-partum period in 9 cases (1 to 9 days) (1 unknown). There were 7 vaginal deliveries (50%) and 6 emergency cesarean sections (43%) (1 unknown). Most of those deaths were considered to be unavoidable (13/17, 76%). Four deaths were considered by the experts as being possibly avoidable (delay diagnosis, diagnostic error, inadequate treatment, lake of interruption of the pregnancy). Analyzing those deaths remind that any sudden, severe and unusual headache must be explored and that pregnancy does not contraindicate any of the diagnostic examinations (TDM, angio-TDM, MRI) or invasive treatments (surgery, arterio-embolization, fibrinolysis) necessary for its management. Furthermore, the diagnosis of postdural puncture headache should not be establishedwithout imaging when the symptomatology is not absolutely typical.
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Affiliation(s)
- H Cohen
- Service de gynécologie-obstétrique, institut mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France
| | - M Rossignol
- Département d'anesthésie-réanimation-SMUR, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France.
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Abstract
Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke - including diabetes mellitus and atrial fibrillation - are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials - despite governmental actions highlighting the need to include both men and women in clinical trials - resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women.
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Holanda Peña M, Chicote Álvarez E, Vázquez Higuera JL. Fulminant reversible cerebral vasoconstriction syndrome. Med Clin (Barc) 2017; 149:417-418. [PMID: 28587853 DOI: 10.1016/j.medcli.2017.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 04/07/2017] [Accepted: 04/20/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Marisol Holanda Peña
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España.
| | - Enrique Chicote Álvarez
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
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Hemolysis, Elevated Liver Enzymes, and Low Platelets, Severe Fetal Growth Restriction, Postpartum Subarachnoid Hemorrhage, and Craniotomy: A Rare Case Report and Systematic Review. Case Rep Obstet Gynecol 2017; 2017:8481290. [PMID: 28567318 PMCID: PMC5439246 DOI: 10.1155/2017/8481290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/22/2017] [Accepted: 04/04/2017] [Indexed: 01/29/2023] Open
Abstract
Introduction. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a relatively uncommon but traumatic condition occurring in the later stage of pregnancy as a complication of severe preeclampsia or eclampsia. Prompt brain computed tomography (CT) or magnetic resonance imaging (MRI) and a multidisciplinary management approach are required to improve perinatal outcome. Case. A 37-year-old, Gravida 6, Para 1-0-4-1, Hispanic female with a history of chronic hypertension presented at 26 weeks and 6 days of gestational age. She was noted to have hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome accompanied by fetal growth restriction (FGR), during ultrasound evaluation, warranting premature delivery. The infant was delivered in stable condition suffering no permanent neurological deficit. Conclusion. HELLP syndrome is an uncommon and traumatic obstetric event which can lead to neurological deficits if not managed in a responsive and rapid manner. The central aggravating factor seems to be hypertension induced preeclamptic or eclamptic episode and complications thereof. The syndrome itself is manifested by hemolytic anemia, increased liver enzymes, and decreasing platelet counts with a majority of neurological defects resulting from hemorrhagic stroke or subarachnoid hemorrhage (SAH). To minimize adverse perinatal outcomes, obstetric management of this medical complication must include rapid clinical assessment, diagnostic examination, and neurosurgery consultation.
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Cheng CA, Lee JT, Lin HC, Lin HC, Chung CH, Lin FH, Tsao CH, Wu YF, Chien WC, Chiu HW. Pregnancy increases stroke risk up to 1 year postpartum and reduces long-term risk. QJM 2017; 110:355-360. [PMID: 28069909 DOI: 10.1093/qjmed/hcw222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND : The incidence of stroke in pregnant women is low but trending upward. There are few studies of the topic in women of Asian ethnicity. AIM We aim to evaluate stroke risk in Asian women during and after pregnancy. DESIGN : Using the Taiwan National Health Insurance database, we designed a retrospective study that included 18-45-year-old pregnant women between the years 2000 and 2010. We selected a 1:1 age-matched control group of non-pregnant women. The endpoint was any type of stroke during pregnancy or the postpartum period; otherwise, the patients were tracked until 31 December 2010. METHODS : The risk factors for stroke were found using Cox proportional regression to calculate the hazard ratio (HR) with a 95% CI compared with the control group. RESULTS : The incidence of stroke within 1 year postpartum was 71/100,000. The risk of postpartum stroke within 1 year was an HR of 1.208 (95% CI: 1.001-5.129). The occurrence of stroke was associated with hypertension, diabetes mellitus, coagulation disorders, migraine, obesity, cerebrovascular malformation and parity. Women with third and fourth parity carried increased risks of 13.3% and 2.5%, respectively, compared with first parity women. In long-term follow-ups, stroke risk was significantly lower, with an adjusted HR of 0.362 (95% CI: 0.269-0.489). CONCLUSION The risk of stroke was elevated during the first year postpartum, but lower in subsequent years. Stroke risk increased in multiparous (≥3) women. Physicians should be on alert for pregnancy complications and ensure appropriate management to prevent postpartum stroke.
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Affiliation(s)
- Chun-An Cheng
- From the Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
| | - Jiunn-Tay Lee
- From the Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hung-Che Lin
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hui-Chen Lin
- From the Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Health Duties and Chronic Epidemiology, School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Fu-Huang Lin
- Department of Health Duties and Chronic Epidemiology, School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chang-Huei Tsao
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Fu Wu
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Health Duties and Chronic Epidemiology, School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Hung-Wen Chiu
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
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