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Greige T, Edlow JA. Managing Acute Headache in Pregnant and Postpartum Women. Ann Emerg Med 2024; 84:51-59. [PMID: 38597849 DOI: 10.1016/j.annemergmed.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Tatiana Greige
- Department of Neurology, Boston Medical Center, Boston, MA.
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Melliti M, Messelmani M, Zaouali J, Derbali H, Mrissa R. Postpartum ischemic stroke: a successful intravenous thrombolysis. Acta Neurol Belg 2023; 123:271-274. [PMID: 34661877 DOI: 10.1007/s13760-021-01789-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Maroua Melliti
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia.
| | - Meriem Messelmani
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
| | - Jamel Zaouali
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
| | - Hajer Derbali
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
| | - Ridha Mrissa
- Department of Neurology, Military Hospital of Instruction of Tunis, Tunis, Tunisia
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Impact of preeclampsia/eclampsia on hemorrhagic and ischemic stroke risk: A 17 years follow-up nationwide cohort study. PLoS One 2022; 17:e0276206. [DOI: 10.1371/journal.pone.0276206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
Background and purposes
The long-term risk of stroke in women with preeclampsia/eclampsia is a concerning issue. In this study we further investigated different stroke subtypes and differentiated follow-up time intervals.
Methods
Between 2000 and 2017, 1,384,427 pregnant women were registered in the National Health Insurance Research Database in Taiwan. After excluding women with previous stroke history and exact matching with all confounders, 6,053 women with preeclampsia/eclampsia and 24,212 controls were included in the analysis sample.
Results
Over the 17-year follow-up, the adjusted hazard ratio (aHR) for stroke in women with preeclampsia/eclampsia was 2.05 (95% confidence interval, CI = 1.67–2.52, p<0.001). The 17 years overall aHR of both ischemic and hemorrhagic stroke were 1.98 and 3.45, respectively (p<0.001). The stroke subtypes, hemorrhagic and ischemic, had different time trend risks, and hemorrhagic stroke risks kept higher than that of ischemic stroke. The aHR of ischemic stroke reached a peak during 1–3 years after childbirth (aHR = 3.09). The aHR of hemorrhagic stroke reached a peak during 3–5 years (aHR = 7.49).
Conclusions
Stroke risk persisted even after decades, for both ischemic and hemorrhagic subtypes. Women with preeclampsia/eclampsia history should be aware of the long-term risk of stroke.
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Hang S, Dixit P, Alam D, Fatima S, Madhavan R. Reversible Cerebral Vasoconstriction Syndrome and Ischemic Stroke Secondary to Peripartum Cardiomyopathy - Report a Rare Case. Cureus 2022; 14:e29640. [PMID: 36320956 PMCID: PMC9606850 DOI: 10.7759/cureus.29640] [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] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Acute cardioembolic stroke is a rare presentation of peripartum cardiomyopathy. We present an unusual case of peripartum cardiomyopathy, that subsequently developed cardioembolic ischemic stroke and reversible cerebral vasospasms. A 26-year-old G1P1 caucasian woman presented to the emergency department 10 days after a spontaneous vaginal delivery with the clinical and physical presentation of acute heart failure. Brain natriuretic peptide (BNP) level was >8000 pg/mL. Transthoracic echocardiogram (TTE) demonstrated global left ventricular hypokinesis, reduced ejection fraction (EF) 22% with grade I diastolic dysfunction and apical thrombus. On hospital day two of her heart failure exacerbation admission, a code stroke was activated for aphasia and confusion. She received an IV tissue plasminogen activator (tPA) and underwent a mechanical thrombectomy. On hospital day three, she developed worsening of neurological symptoms, and a computed tomography (CT) angiogram revealed vasospasm in the region of the left middle cerebral artery (MCA), which subsequently resulted in nimodipine therapy. Furthermore, her hospital course was complicated by persistent hypotension, and with our concern for vasospasm that was noted in the CT angiogram instead of guideline-directed therapy for heart failure, digoxin was given to control heart rate and to improve cardiac output. Ultimately, her neurological symptoms improved, and she was discharged on hospital day 10. This case highlights the combination of rare presentations - postpartum cardiomyopathy, ischemic stroke, and reversible cerebral vasospasms, which suggests that the time and size of the stroke are of the essence in terms of promptness of aggressive treatment.
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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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Park Y, Cho GJ, Roh SY, Na JO, Oh MJ. Increased Cardiac Arrhythmia After Pregnancy-Induced Hypertension: A South Korean Nationwide Database Study. J Am Heart Assoc 2022; 11:e023013. [PMID: 35014853 PMCID: PMC9238534 DOI: 10.1161/jaha.121.023013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Although pregnancy‐induced hypertension (PIH) is associated with an elevated cardiovascular risk, long‐term studies or prepregnancy baseline data are scarce. Therefore, using a large nationwide cohort with prepregnancy periodic health screening data, we investigated whether clinically significant arrhythmia incidence increases after PIH. Methods and Results Data were extracted from the Korea National Health Insurance database and combined with the National Health Screening Examination database; women who gave birth between 2007 and 2015 and underwent the national health screening test within a year before pregnancy were followed up until 2016. We excluded women who had a diagnosis of arrhythmia within 1 year before pregnancy. The primary outcome was significant arrhythmia during the year after delivery. Secondary analysis included only specific diagnostic codes of arrhythmia with clinical significance. Additionally, the risk of arrhythmia was stratified by the use of magnesium sulfate. Of 2 035 684 women (PIH; n=37 297 versus normotensive pregnancy; n=1 998 387), the PIH group had a higher prepregnancy risk profile and showed a higher incidence of arrhythmia than women with normotensive pregnancies within 1 year. Women with PIH had a significantly higher risk of atrial flutter/fibrillation and atrioventricular block, but not lethal arrhythmias. Other predictors of arrhythmia development included advanced maternal age and cesarean section. Stratified analysis showed a higher risk of arrhythmia with magnesium sulfate use. Conclusions PIH was significantly associated with the development of arrhythmia within 1 year after delivery. Nevertheless, the incidence of lethal arrhythmias was not increased by PIH. Arrhythmia, especially atrial fibrillation, may largely contribute to increasing the future cardiovascular risk in women with a PIH history.
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Affiliation(s)
- Yoonjee Park
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul South Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology Korea University College of Medicine Seoul South Korea
| | - Seung-Young Roh
- Division of Cardiology Department of Internal Medicine Korea University Guro Hospital Seoul South Korea
| | - Jin Oh Na
- Division of Cardiology Department of Internal Medicine Korea University Guro Hospital Seoul South Korea
| | - Min-Jeong Oh
- Department of Obstetrics and Gynecology Korea University College of Medicine Seoul South Korea
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Bajko Z, Motataianu A, Stoian A, Barcutean L, Andone S, Maier S, Drăghici IA, Balasa R. Postpartum Cerebral Venous Thrombosis-A Single-Center Experience. Brain Sci 2021; 11:brainsci11030327. [PMID: 33806706 PMCID: PMC7998769 DOI: 10.3390/brainsci11030327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Cerebral venous thrombosis (CVT) is a rare variant of stroke in the general population, but an important subtype among pregnancy- and puerperium-related cases. Studies describing its risk factors and clinical characteristics are limited. The aim of our study is to disclose these aspects and compare with cases unrelated to pregnancy and puerperium. Materials and Methods: We performed a retrospective analysis including 88 consecutive cases from a tertiary neurology clinic with a diagnosis of CVT. Ten of the 88 cases (11.3%) appeared during the postpartum period. Results: The mean age of the puerperal CVT cases was 26.5 years. The main pregnancy-related risk factors besides puerperium were cesarean delivery (5/10), preeclampsia (2/10), and stillbirth (1/10). General risk factors for thrombosis, i.e., infection, smoking, and primary hypercoagulability, were identified in 50% of cases. Onset was in the first 3 weeks after delivery, with a mean value of 9.6 ± 5.6 days. Headache was present in 90% of postpartum CVT cases and in 76.1% of non-postpartum female cases. Seizures were more frequent in the postpartum group (60% vs. 34.8%). Onset was acute (<48 h) in 50% of postpartum cases and in 30.4% of the non-postpartum female group. The Rankin score at discharge was significantly lower in the postpartum group (0.22 vs. 0.7, p = 0.02), suggesting a more favorable short-term outcome. Conclusions: The early postpartum period represents an important risk for the development of CVT. Cesarean delivery and preeclampsia, besides general risk factors such as infection, smoking, and primary thrombophilia, contribute to enhanced risk. Puerperium-related CVT presents a more favorable outcome compared with CVT with other etiologies.
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Affiliation(s)
- Zoltan Bajko
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Anca Motataianu
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Adina Stoian
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
- Department of Patophysiology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania
| | - Laura Barcutean
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Sebastian Andone
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Smaranda Maier
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
- Correspondence:
| | - Iulia-Adela Drăghici
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
| | - Rodica Balasa
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540136 Targu Mures, Romania; (Z.B.); (A.M.); (L.B.); (R.B.)
- Ist Neurology Clinic, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania; (A.S.); (S.A.); (I.-A.D.)
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[Pharmacological treatment of non-severe hypertension during pregnancy, postpartum and breastfeeding]. HIPERTENSION Y RIESGO VASCULAR 2021; 38:133-147. [PMID: 33632659 DOI: 10.1016/j.hipert.2021.01.002] [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] [Received: 12/21/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
Hypertension (HTN) in pregnancy is defined as systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg. Based on the values, it is classified as non-severe (< 160/110 mmHg) and severe (≥ 160/110 mmHg). Before starting treatment in non-severe HTN, white- coat HTN should be ruled out. If outpatient management is possible, pharmacological initiation is suggested with sustained high values, avoiding < 120/80 mmHg. Safe drugs during pregnancy are methyldopa, labetalol, and nifedipine-retard. The use of nifedipine-XL or amlodipine can be considered with a lower level of evidence of safety. Diuretics, atenolol, and other beta-blockers for antihypertensive purposes is not recommended in this period. Renin-angiotensin-aldosterone system inhibitors are strictly contraindicated. In postpartum and breastfeeding, the same therapeutic regimen used during pregnancy can be maintained, trying early withdrawal of methyldopa. During puerperium, amlodipine and enalapril are safe, with minimal excretion in breast milk.
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Gao G, Zucconi RL, Zucconi WB. Emergent Neuroimaging During Pregnancy and the Postpartum Period. Neuroimaging Clin N Am 2018; 28:419-433. [DOI: 10.1016/j.nic.2018.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Roy-O’Reilly M, McCullough LD. Age and Sex Are Critical Factors in Ischemic Stroke Pathology. Endocrinology 2018; 159:3120-3131. [PMID: 30010821 PMCID: PMC6963709 DOI: 10.1210/en.2018-00465] [Citation(s) in RCA: 208] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/04/2018] [Indexed: 02/06/2023]
Abstract
Ischemic stroke is a devastating brain injury resulting in high mortality and substantial loss of function. Understanding the pathophysiology of ischemic stroke risk, mortality, and functional loss is critical to the development of new therapies. Age and sex have a complex and interactive effect on ischemic stroke risk and pathophysiology. Aging is the strongest nonmodifiable risk factor for ischemic stroke, and aged stroke patients have higher mortality and morbidity and poorer functional recovery than their young counterparts. Importantly, patient age modifies the influence of patient sex in ischemic stroke. Early in life, the burden of ischemic stroke is higher in men, but stroke becomes more common and debilitating for women in elderly populations. The profound effects of sex and age on clinical ischemic stroke are mirrored in the results of experimental in vivo and in vitro studies. Here, we review current knowledge on the influence of age and sex in the incidence, mortality, and functional outcome of ischemic stroke in clinical populations. We also discuss the experimental evidence for sex and age differences in stroke pathophysiology and how a better understanding of these biological variables can improve clinical care and enhance development of novel therapies.
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Affiliation(s)
- Meaghan Roy-O’Reilly
- Department of Neurology, University of Texas Health Science Center, Houston, Texas
| | - Louise D McCullough
- Department of Neurology, University of Texas Health Science Center, Houston, Texas
- Correspondence: Louise D. McCullough, MD, PhD, Department of Neurology, University of Texas Health Science Center, 6431 Fannin Street, Houston, Texas 77030. E-mail:
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Clinical characteristics and prognosis of cerebral venous thrombosis in Chinese women during pregnancy and puerperium. Sci Rep 2017; 7:43866. [PMID: 28262755 PMCID: PMC5338317 DOI: 10.1038/srep43866] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/01/2017] [Indexed: 11/08/2022] Open
Abstract
Due to the specific physiology associated with pregnancy and puerperium, cerebral venous sinus thrombosis (CVT) may manifest different characteristics. This study aimed to identify the clinical manifestations and prognosis of pregnancy-associated CVT. A total of 43 pregnancy-associated CVT patients were enrolled. We analysed the clinical presentations of the disease and performed a multivariate logistic regression analysis to determine which variables were associated with prognosis. Our descriptive results showed the following: 1) the incidence was 202 per 100,000 deliveries, and the mortality rate was 11.63%; 2) the most frequent symptom was headache; 3) the most frequent abnormal laboratory findings were increased levels of fibrinogen and several serum lipoproteins (including triglyceride, cholesterol, high-density lipoprotein, low-density lipoprotein, apolipoprotein A1, and apolipoprotein B); and 4) the superior sagittal sinus and transverse sinus were the most frequently affected locations. Moreover, an increased modified Rankin Scale score was positively associated with infection, seizure, intracerebral haemorrhage (ICH) and hypertensive disorders of pregnancy (HDP). Comparably, the occurrence of death was positively and significantly associated with infection, seizure and ICH. Consequently, timely diagnosis and treatment of pregnancy-associated CVT patients with infection, seizure, ICH or HDP are needed. Patients with infection, seizure or ICH have a greater risk of death.
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Edlow AG, Edlow BL, Edlow JA. Diagnosis of Acute Neurologic Emergencies in Pregnant and Postpartum Women. Emerg Med Clin North Am 2016; 34:943-965. [PMID: 27741996 DOI: 10.1016/j.emc.2016.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute neurologic symptoms in pregnant and postpartum women may be caused by exacerbation of a preexisting neurologic condition, the initial presentation of a non-pregnancy-related problem, or a new neurologic problem. Pregnant and postpartum patients with headache and neurologic symptoms are often diagnosed with preeclampsia or eclampsia; however, other etiologies must also be considered. A team approach with close communication between emergency physicians, neurologists, maternal-fetal medicine specialists, and radiologists is the key to obtaining best outcomes. This article reviews the clinical features and differential diagnosis of acute serious neurologic conditions in pregnancy and the puerperium, focusing on diagnosis.
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Affiliation(s)
- Andrea G Edlow
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mother Infant Research Institute, Tufts Medical Center, 800 Washington Street, Box 394, Boston, MA 02111, USA
| | - Brian L Edlow
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Place, West Clinical Center, 2nd Floor, Boston, MA 02215, USA.
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Marsh EB, Ziai WC, Llinas RH. The Need for a Rational Approach to Vasoconstrictive Syndromes: Transcranial Doppler and Calcium Channel Blockade in Reversible Cerebral Vasoconstriction Syndrome. Case Rep Neurol 2016; 8:161-171. [PMID: 27721780 PMCID: PMC5043170 DOI: 10.1159/000447626] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/14/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Reversible cerebral vasoconstriction syndrome (RCVS) typically affects young patients and left untreated can result in hemorrhage or ischemic stroke. Though the disorder has been well characterized in the literature, the most appropriate way to diagnose, treat, and evaluate therapeutic response remains unclear. In previous studies, transcranial Doppler ultrasound (TCD) has shown elevated velocities indicative of vasospasm. This imaging modality is noninvasive and inexpensive; an attractive option for diagnosis and therapeutic monitoring if it is sensitive enough to detect changes in the acute setting given that RCVS often affects the distal vessels early in the course of disease. There is also limited data that calcium channel blockade may be effective in treating vasospasm secondary to RCVS, though the agent of choice, formulation, and dose are unclear. METHODS We report a small cohort of seven patients presenting with thunderclap headache whose vascular imaging was consistent with RCVS. All were treated with calcium channel blockade and monitored with TCD performed every 1-2 days. RESULTS On presentation, TCD correlated with standard neuroimaging findings of vasospasm (on MR, CT, and conventional angiography). TCD was also able to detect improvement in velocities in the acute setting that correlated well with initiation of calcium channel blockade. Long-acting verapamil appeared to have the greatest effect on velocities compared to nimodipine and shorter-acting calcium channel blockers. CONCLUSION Though small, our cohort demonstrates potential utility of TCD to monitor RCVS, and relative superiority of extended-release verapamil over other calcium channel blockers, illustrating the need for larger randomized trials.
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Affiliation(s)
- Elisabeth B Marsh
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Md., USA
| | - Wendy C Ziai
- Department of Neurocritical Care, The Johns Hopkins University School of Medicine, Baltimore, Md., USA
| | - Rafael H Llinas
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Md., USA
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15
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Ohno Y, Terauchi M, Tamakoshi K, Shiozaki A, Saito S. The risk factors for labor onset hypertension. Hypertens Res 2015; 39:260-5. [PMID: 26490090 DOI: 10.1038/hr.2015.112] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/28/2015] [Accepted: 08/26/2015] [Indexed: 11/09/2022]
Abstract
Our aim was to clarify the perinatal outcomes of and risk factors for hypertension that is first detected after labor onset (labor onset hypertension, LOH), which may be a risk factor for eclampsia and stroke during labor. A total of 1349 parturient women who did not exhibit preeclampsia or gestational hypertension prior to labor were examined. The patients were classified into four groups: the normotensive (n=1023) (whose systolic blood pressure (SBP) remained below 140 mm Hg throughout labor), mild LOH (n=241) (whose maximum SBP during labor ranged from 140 to 159 mm Hg), severe LOH (n=66) (whose maximum SBP during labor ranged from 160 to 179 mm Hg) and emergent LOH groups (n=19) (whose maximum SBP during labor was greater than 180 mm Hg). The perinatal outcomes and patient characteristics of the four groups were compared. Twenty-four percent of the pregnant women who remained normotensive throughout pregnancy developed hypertension during labor. One of the patients in the emergent LOH group developed eclampsia. The blood pressure at delivery and frequencies of hypotensor use, interventional delivery and low Apgar scores differed significantly among the four groups. The following risk factors for severe/emergent LOH were extracted: being over 35 years old, a body mass index at delivery of >30, an SBP at 36 weeks' gestation of 130-134 mm Hg, an SBP at admission of 130-139 mm Hg, proteinuria (a score of 2+ on the dipstick test) and severe edema. The risk factors for severe/emergent LOH were identified in this study. In high risk cases, repeatedly measuring maternal blood pressure during delivery might help detect critical hypertension early.
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Affiliation(s)
| | | | - Koji Tamakoshi
- Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Arihiro Shiozaki
- Department of Obstetrics and Gynecology, Toyama University Graduate School of Medicine, Toyama, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, Toyama University Graduate School of Medicine, Toyama, Japan
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Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, Howard VJ, Lichtman JH, Lisabeth LD, Piña IL, Reeves MJ, Rexrode KM, Saposnik G, Singh V, Towfighi A, Vaccarino V, Walters MR. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:1545-88. [PMID: 24503673 PMCID: PMC10152977 DOI: 10.1161/01.str.0000442009.06663.48] [Citation(s) in RCA: 622] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura. CONCLUSIONS To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.
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Ohno Y, Furuhashi M, Ishikawa K, Kondo H, Kaseki S, Kikkawa F. Results of a questionnaire survey on pregnancy-associated stroke from 2005 to 2012 in Aichi Prefecture, Japan. HYPERTENSION RESEARCH IN PREGNANCY 2014. [DOI: 10.14390/jsshp.2.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Madoka Furuhashi
- Department of Obstetrics and Gynecology, Nagoya First Red Cross Hospital
| | - Kaoru Ishikawa
- Department of Regeneration of Medicine in Kuwana District, Suzuka University of Medical Science
| | | | | | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine
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Youssoufa M, Callixte KT, Christian N. Occipital lobe epilepsy secondary to posterior reversible encephalopathy syndrome (PRES) during a post-partum eclampsia in Mali (West Africa). BMC Res Notes 2013; 6:321. [PMID: 23941365 PMCID: PMC3751096 DOI: 10.1186/1756-0500-6-321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 08/12/2013] [Indexed: 11/17/2022] Open
Abstract
Background Eclampsia is known to cause posterior reversible encephalopathy syndrome (PRES) that is often associated with an extensive neurovascular damage affecting preferably posterior regions, often leading to reversible cortical blindness. In spite the magnitude of these lesions, post eclamptic symptomatic epilepsy is rare. We therefore report a case of symptomatic occipital lobe epilepsy secondary to PRES. Case presentation A 39-year-old female right handed teacher who presented with headache of progressive onset, phosphenes, rapid decline of visual acuity to blindness, vomiting, repeated generalized tonic-clonic seizures followed by altered consciousness and very high blood pressure (HBP) of 240/120 mmHg, all of which started about 12 hours following a normal delivery. Nine months later, the patient presented with paroxysmal visual symptoms predominating in the right visual field followed by partial tonic clonic seizures with secondary generalization and recurrence of partial occipital lobe seizures. The pathophysiologic mechanism of irreversible tissue damage during PRES syndrome could result from a combination of events including the delay for early treatment, inadequate antihypertensive drugs that could worsen the brain damage by hypo perfusion, inadequate or delayed treatment for seizures or status epilepticus. Conclusion Despite its high incidence in the third world, eclampsia is not a usual cause of epilepsy. Our case is the first description of post eclamptic occipital lobe epilepsy in Africa. With this report, we draw practitioners’ attention on this rare complication.
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Affiliation(s)
- Maïga Youssoufa
- Neurology Department, CHU Gabriel Touré, Bamako, Mali and Faculty of Medicine pharmacy and Odonto-stomatology, University of Bamako, Bamako, Mali
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Semere LG, McElrath TF, Klein AM. Neuroimaging in pregnancy: a review of clinical indications and obstetric outcomes. J Matern Fetal Neonatal Med 2013; 26:1371-9. [PMID: 22862157 DOI: 10.3109/14767058.2012.713053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine indications and outcomes of pregnant women requiring neurologic imaging at a tertiary care center. METHODS We reviewed medical records of women receiving magnetic resonance (MR) head imaging during pregnancy to determine indications for such imaging and their pregnancy outcomes. RESULTS Between April 2007 and December 2008, 60 pregnant women presented to Brigham and Women's Hospital with severe headache or other acute neurologic complaint and underwent head imaging. Two patients were found to have significant findings considered to be neurologic emergencies: a right thalamic hemorrhage and a subarachnoid hemorrhage. Nine patients had abnormal findings not requiring immediate intervention but deeming further evaluation. Sixteen patients had abnormal findings determined to be incidental and unrelated to their indication for imaging. Thirty-three patients had unremarkable imaging studies. The most common presenting symptoms included headache (70%) and visual disturbances (48%). The most common imaging studies obtained were MR brain without contrast (87%) and MR angiography head without contrast (73%). The majority of patients (96%) delivered in the third trimester without significant complications. CONCLUSIONS Most women who receive head imaging in pregnancy do not have adverse findings and have good obstetrical outcomes.
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Affiliation(s)
- Luwam G Semere
- Department of Obstetrics and Gynecology, Department of Medicine, Division of General Internal Medicine, University of California, Los Angeles Robert Wood Johnson Foundation Clinical Scholars Program, Los Angeles, CA, USA
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Hakim J, Senterman MK, Hakim AM. Preeclampsia is a biomarker for vascular disease in both mother and child: the need for a medical alert system. Int J Pediatr 2013; 2013:953150. [PMID: 23690796 PMCID: PMC3652204 DOI: 10.1155/2013/953150] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 03/28/2013] [Indexed: 11/17/2022] Open
Abstract
This paper reviews the literature pertaining to the impact of preeclampsia not only on the mother but particularly on the children. The review points to the higher blood pressure in children born to preeclamptic mothers compared to controls, their increased tendency to suffer strokes, the reduction in their cognitive ability, and their vulnerability to depression. Mechanisms that may induce these changes are emphasized, particularly the placental vascular insufficiency and the resulting hypoxic and proinflammatory environments in which the fetus develops. The hypothesis proposed is that these changes in the fetal-placental environment result in epigenetic programming of the child towards a higher propensity for vascular disease. The review's main recommendation is that, within ethical boundaries, the medical records of individuals born to preeclamptic mothers should clearly indicate this event and should be made available to the affected individuals so that preventive measures against vascular complications and lifestyle changes that may mitigate the latter can be instituted.
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Affiliation(s)
- Julie Hakim
- Department of Obstetrics and Gynecology, The Ottawa Hospital and the University of Ottawa, General Campus, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
| | - Mary K. Senterman
- Departments of Pathology & Laboratory Medicine and Obstetrics & Gynecology,
The Ottawa Hospital and the University of Ottawa, General Campus, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
| | - Antoine M. Hakim
- Division of Neurology, The Ottawa Hospital and the University of Ottawa, Ottawa, ON, Canada K1H 8M5
- Neuroscience Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada K1Y 4E9
- Canadian Stroke Network, Ottawa, ON, Canada K1G 5Z3
- Brain and Mind Research Institute, University of Ottawa, 2413-451 Smyth Road, Ottawa, ON, Canada K1H 8M5
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Ohno Y, Ishikawa K, Kaseki S, Kikkawa F. Questionnaire-based study of cerebrovascular complications during pregnancy in Aichi Prefecture, Japan. HYPERTENSION RESEARCH IN PREGNANCY 2013. [DOI: 10.14390/jsshp.1.40] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Kaoru Ishikawa
- Department of Regeneration of Medicine in Kuwana District, Suzuka University of Medical Science
| | | | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine
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OHNO Y, KAWAI M, MORIKAWA S, SAKAKIBARA K, TANAKA K, ISHIKAWA K, KIKKAWA F. Management of Eclampsia and Stroke During Pregnancy. Neurol Med Chir (Tokyo) 2013; 53:513-9. [DOI: 10.2176/nmc.53.513] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Michiyasu KAWAI
- Department of Obstetrics and Gynecology, Toyohashi Municipal Hospital
| | | | | | - Kanji TANAKA
- Department of Obstetrics and Gynecology, Hirosaki University Graduate School of Medicine
| | - Kaoru ISHIKAWA
- Department of Regenerative Medicine, Suzuka University of Medical Science
| | - Fumitaka KIKKAWA
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine
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Reversible cerebral vasoconstriction syndrome: an important cause of acute severe headache. Emerg Med Int 2012; 2012:303152. [PMID: 22830030 PMCID: PMC3399374 DOI: 10.1155/2012/303152] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 04/30/2012] [Accepted: 05/10/2012] [Indexed: 11/18/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of acute headache. The majority of these patients develop potentially serious neurological complications. Rigorous investigation is required to exclude other significant differential diagnoses. Differentiating RCVS from subarachnoid haemorrhage (SAH) and primary angiitis of the central nervous system (PACNS) may be difficult but has important therapeutic implications. This paper describes what is currently known about the epidemiology, pathophysiology, clinical, and diagnostic features of the syndrome, an approach to investigation, a summary of treatments, and what is known of prognosis.
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